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apc_fee_Schedule06192006

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					State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                  Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                    from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                  4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                     Schedule
                                           (FYI Only)                                                                     Fee

00100    Anesth, salivary gland                N             N         0000       0.0000        0.00         0.00         0.00
00102    Anesth, repair of cleft lip           N             N         0000       0.0000        0.00         0.00         0.00
00103    Anesth, blepharoplasty                N             N         0000       0.0000        0.00         0.00         0.00
00104    Anesth, electroshock                  N             N         0000       0.0000        0.00         0.00         0.00
00120    Anesth, ear surgery                   N             N         0000       0.0000        0.00         0.00         0.00
00124    Anesth, ear exam                      N             N         0000       0.0000        0.00         0.00         0.00
00126    Anesth, tympanotomy                   N             N         0000       0.0000        0.00         0.00         0.00
00140    Anesth, procedures on eye             N             N         0000       0.0000        0.00         0.00         0.00
00142    Anesth, lens surgery                  N             N         0000       0.0000        0.00         0.00         0.00
00144    Anesth, corneal transplant            N             N         0000       0.0000        0.00         0.00         0.00
00145    Anesth, vitreoretinal surg            N             N         0000       0.0000        0.00         0.00         0.00
00147    Anesth, iridectomy                    N             N         0000       0.0000        0.00         0.00         0.00
00148    Anesth, eye exam                      N             N         0000       0.0000        0.00         0.00         0.00
00160    Anesth, nose/sinus surgery            N             N         0000       0.0000        0.00         0.00         0.00
00162    Anesth, nose/sinus surgery            N             N         0000       0.0000        0.00         0.00         0.00
00164    Anesth, biopsy of nose                N             N         0000       0.0000        0.00         0.00         0.00
00170    Anesth, procedure on mouth            N             N         0000       0.0000        0.00         0.00         0.00
00172    Anesth, cleft palate repair           N             N         0000       0.0000        0.00         0.00         0.00
00174    Anesth, pharyngeal surgery            N             N         0000       0.0000        0.00         0.00         0.00
00176    Anesth, pharyngeal surgery            C             C         0000       0.0000        0.00         0.00         0.00
00190    Anesth, face/skull bone surg          N             N         0000       0.0000        0.00         0.00         0.00
00192    Anesth, facial bone surgery           C             C         0000       0.0000        0.00         0.00         0.00
00210    Anesth, open head surgery             N             N         0000       0.0000        0.00         0.00         0.00
00212    Anesth, skull drainage                N             N         0000       0.0000        0.00         0.00         0.00
00214    Anesth, skull drainage                C             C         0000       0.0000        0.00         0.00         0.00
00215    Anesth, skull repair/fract            C             C         0000       0.0000        0.00         0.00         0.00
00216    Anesth, head vessel surgery           N             N         0000       0.0000        0.00         0.00         0.00
00218    Anesth, special head surgery          N             N         0000       0.0000        0.00         0.00         0.00
00220    Anesth, intrcrn nerve                 N             N         0000       0.0000        0.00         0.00         0.00
00222    Anesth, head nerve surgery            N             N         0000       0.0000        0.00         0.00         0.00
00300    Anesth, head/neck/ptrunk              N             N         0000       0.0000        0.00         0.00         0.00
00320    Anesth, neck organ, 1 & over          N             N         0000       0.0000        0.00         0.00         0.00
00322    Anesth, biopsy of thyroid             N             N         0000       0.0000        0.00         0.00         0.00
00326    Anesth, larynx/trach, < 1 yr          N             N         0000       0.0000        0.00         0.00         0.00
00350    Anesth, neck vessel surgery           N             N         0000       0.0000        0.00         0.00         0.00
00352    Anesth, neck vessel surgery           N             N         0000       0.0000        0.00         0.00         0.00
00400    Anesth, skin, ext/per/atrunk          N             N         0000       0.0000        0.00         0.00         0.00
00402    Anesth, surgery of breast             N             N         0000       0.0000        0.00         0.00         0.00
00404    Anesth, surgery of breast             C             C         0000       0.0000        0.00         0.00         0.00
00406    Anesth, surgery of breast             C             C         0000       0.0000        0.00         0.00         0.00
00410    Anesth, correct heart rhythm          N             N         0000       0.0000        0.00         0.00         0.00
00450    Anesth, surgery of shoulder           N             N         0000       0.0000        0.00         0.00         0.00
00452    Anesth, surgery of shoulder           C             C         0000       0.0000        0.00         0.00         0.00
00454    Anesth, collar bone biopsy            N             N         0000       0.0000        0.00         0.00         0.00
00470    Anesth, removal of rib                N             N         0000       0.0000        0.00         0.00         0.00
00472    Anesth, chest wall repair             N             N         0000       0.0000        0.00         0.00         0.00
00474    Anesth, surgery of rib(s)             C             C         0000       0.0000        0.00         0.00         0.00
00500    Anesth, esophageal surgery            N             N         0000       0.0000        0.00         0.00         0.00
00520    Anesth, chest procedure               N             N         0000       0.0000        0.00         0.00         0.00
00522    Anesth, chest lining biopsy           N             N         0000       0.0000        0.00         0.00         0.00
00524    Anesth, chest drainage                C             C         0000       0.0000        0.00         0.00         0.00
00528    Anesth, chest partition view          N             N         0000       0.0000        0.00         0.00         0.00
00529    Anesth, chest partition view          N             N         0000       0.0000        0.00         0.00         0.00
00530    Anesth, pacemaker insertion           N             N         0000       0.0000        0.00         0.00         0.00
00532    Anesth, vascular access               N             N         0000       0.0000        0.00         0.00         0.00
00534    Anesth, cardioverter/defib            N             N         0000       0.0000        0.00         0.00         0.00
00537    Anesth, cardiac electrophys           N             N         0000       0.0000        0.00         0.00         0.00
00539    Anesth, trach-bronch reconst          N             N         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                      1 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                  Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                    from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                  4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                     Schedule
                                           (FYI Only)                                                                     Fee

00540    Anesth, chest surgery                 C             C         0000       0.0000        0.00         0.00         0.00
00541    Anesth, one lung ventilation          N             N         0000       0.0000        0.00         0.00         0.00
00542    Anesth, release of lung               C             C         0000       0.0000        0.00         0.00         0.00
00546    Anesth, lung,chest wall surg          C             C         0000       0.0000        0.00         0.00         0.00
00548    Anesth, trachea,bronchi surg          N             N         0000       0.0000        0.00         0.00         0.00
00550    Anesth, sternal debridement           N             N         0000       0.0000        0.00         0.00         0.00
00560    Anesth, heart surg w/o pump           C             C         0000       0.0000        0.00         0.00         0.00
00561    Anesth, heart surg < age 1            C             C         0000       0.0000        0.00         0.00         0.00
00562    Anesth, heart surg w/pump             C             C         0000       0.0000        0.00         0.00         0.00
00563    Anesth, heart surg w/arrest           N             N         0000       0.0000        0.00         0.00         0.00
00566    Anesth, cabg w/o pump                 N             N         0000       0.0000        0.00         0.00         0.00
00580    Anesth, heart/lung transplnt          C             C         0000       0.0000        0.00         0.00         0.00
00600    Anesth, spine, cord surgery           N             N         0000       0.0000        0.00         0.00         0.00
00604    Anesth, sitting procedure             C             C         0000       0.0000        0.00         0.00         0.00
00620    Anesth, spine, cord surgery           N             N         0000       0.0000        0.00         0.00         0.00
00622    Anesth, removal of nerves             C             C         0000       0.0000        0.00         0.00         0.00
00630    Anesth, spine, cord surgery           N             N         0000       0.0000        0.00         0.00         0.00
00632    Anesth, removal of nerves             C             C         0000       0.0000        0.00         0.00         0.00
00634    Anesth for chemonucleolysis           N             N         0000       0.0000        0.00         0.00         0.00
00635    Anesth, lumbar puncture               N             N         0000       0.0000        0.00         0.00         0.00
00640    Anesth, spine manipulation            N             N         0000       0.0000        0.00         0.00         0.00
00670    Anesth, spine, cord surgery           C             C         0000       0.0000        0.00         0.00         0.00
00700    Anesth, abdominal wall surg           N             N         0000       0.0000        0.00         0.00         0.00
00702    Anesth, for liver biopsy              N             N         0000       0.0000        0.00         0.00         0.00
00730    Anesth, abdominal wall surg           N             N         0000       0.0000        0.00         0.00         0.00
00740    Anesth, upper gi visualize            N             N         0000       0.0000        0.00         0.00         0.00
00750    Anesth, repair of hernia              N             N         0000       0.0000        0.00         0.00         0.00
00752    Anesth, repair of hernia              N             N         0000       0.0000        0.00         0.00         0.00
00754    Anesth, repair of hernia              N             N         0000       0.0000        0.00         0.00         0.00
00756    Anesth, repair of hernia              N             N         0000       0.0000        0.00         0.00         0.00
00770    Anesth, blood vessel repair           N             N         0000       0.0000        0.00         0.00         0.00
00790    Anesth, surg upper abdomen            N             N         0000       0.0000        0.00         0.00         0.00
00792    Anesth, hemorr/excise liver           C             C         0000       0.0000        0.00         0.00         0.00
00794    Anesth, pancreas removal              C             C         0000       0.0000        0.00         0.00         0.00
00796    Anesth, for liver transplant          C             C         0000       0.0000        0.00         0.00         0.00
00797    Anesth, surgery for obesity           N             N         0000       0.0000        0.00         0.00         0.00
00800    Anesth, abdominal wall surg           N             N         0000       0.0000        0.00         0.00         0.00
00802    Anesth, fat layer removal             C             C         0000       0.0000        0.00         0.00         0.00
00810    Anesth, low intestine scope           N             N         0000       0.0000        0.00         0.00         0.00
00820    Anesth, abdominal wall surg           N             N         0000       0.0000        0.00         0.00         0.00
00830    Anesth, repair of hernia              N             N         0000       0.0000        0.00         0.00         0.00
00832    Anesth, repair of hernia              N             N         0000       0.0000        0.00         0.00         0.00
00834    Anesth, hernia repair< 1 yr           N             N         0000       0.0000        0.00         0.00         0.00
00836    Anesth hernia repair preemie          N             N         0000       0.0000        0.00         0.00         0.00
00840    Anesth, surg lower abdomen            N             N         0000       0.0000        0.00         0.00         0.00
00842    Anesth, amniocentesis                 N             N         0000       0.0000        0.00         0.00         0.00
00844    Anesth, pelvis surgery                C             C         0000       0.0000        0.00         0.00         0.00
00846    Anesth, hysterectomy                  C             C         0000       0.0000        0.00         0.00         0.00
00848    Anesth, pelvic organ surg             C             C         0000       0.0000        0.00         0.00         0.00
00851    Anesth, tubal ligation                N             N         0000       0.0000        0.00         0.00         0.00
00860    Anesth, surgery of abdomen            N             N         0000       0.0000        0.00         0.00         0.00
00862    Anesth, kidney/ureter surg            N             N         0000       0.0000        0.00         0.00         0.00
00864    Anesth, removal of bladder            C             C         0000       0.0000        0.00         0.00         0.00
00865    Anesth, removal of prostate           C             C         0000       0.0000        0.00         0.00         0.00
00866    Anesth, removal of adrenal            C             C         0000       0.0000        0.00         0.00         0.00
00868    Anesth, kidney transplant             C             C         0000       0.0000        0.00         0.00         0.00
00870    Anesth, bladder stone surg            N             N         0000       0.0000        0.00         0.00         0.00
00872    Anesth kidney stone destruct          N             N         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                      2 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                  Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                    from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                  4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                     Schedule
                                           (FYI Only)                                                                     Fee

00873    Anesth kidney stone destruct          N             N         0000       0.0000        0.00         0.00         0.00
00880    Anesth, abdomen vessel surg           N             N         0000       0.0000        0.00         0.00         0.00
00882    Anesth, major vein ligation           C             C         0000       0.0000        0.00         0.00         0.00
00902    Anesth, anorectal surgery             N             N         0000       0.0000        0.00         0.00         0.00
00904    Anesth, perineal surgery              C             C         0000       0.0000        0.00         0.00         0.00
00906    Anesth, removal of vulva              N             N         0000       0.0000        0.00         0.00         0.00
00908    Anesth, removal of prostate           C             C         0000       0.0000        0.00         0.00         0.00
00910    Anesth, bladder surgery               N             N         0000       0.0000        0.00         0.00         0.00
00912    Anesth, bladder tumor surg            N             N         0000       0.0000        0.00         0.00         0.00
00914    Anesth, removal of prostate           N             N         0000       0.0000        0.00         0.00         0.00
00916    Anesth, bleeding control              N             N         0000       0.0000        0.00         0.00         0.00
00918    Anesth, stone removal                 N             N         0000       0.0000        0.00         0.00         0.00
00920    Anesth, genitalia surgery             N             N         0000       0.0000        0.00         0.00         0.00
00921    Anesth, vasectomy                     N             N         0000       0.0000        0.00         0.00         0.00
00922    Anesth, sperm duct surgery            N             N         0000       0.0000        0.00         0.00         0.00
00924    Anesth, testis exploration            N             N         0000       0.0000        0.00         0.00         0.00
00926    Anesth, removal of testis             N             N         0000       0.0000        0.00         0.00         0.00
00928    Anesth, removal of testis             N             N         0000       0.0000        0.00         0.00         0.00
00930    Anesth, testis suspension             N             N         0000       0.0000        0.00         0.00         0.00
00932    Anesth, amputation of penis           C             C         0000       0.0000        0.00         0.00         0.00
00934    Anesth, penis, nodes removal          C             C         0000       0.0000        0.00         0.00         0.00
00936    Anesth, penis, nodes removal          C             C         0000       0.0000        0.00         0.00         0.00
00938    Anesth, insert penis device           N             N         0000       0.0000        0.00         0.00         0.00
00940    Anesth, vaginal procedures            N             N         0000       0.0000        0.00         0.00         0.00
00942    Anesth, surg on vag/urethral          N             N         0000       0.0000        0.00         0.00         0.00
00944    Anesth, vaginal hysterectomy          C             C         0000       0.0000        0.00         0.00         0.00
00948    Anesth, repair of cervix              N             N         0000       0.0000        0.00         0.00         0.00
00950    Anesth, vaginal endoscopy             N             N         0000       0.0000        0.00         0.00         0.00
00952    Anesth, hysteroscope/graph            N             N         0000       0.0000        0.00         0.00         0.00
01112    Anesth, bone aspirate/bx              N             N         0000       0.0000        0.00         0.00         0.00
01120    Anesth, pelvis surgery                N             N         0000       0.0000        0.00         0.00         0.00
01130    Anesth, body cast procedure           N             N         0000       0.0000        0.00         0.00         0.00
01140    Anesth, amputation at pelvis          C             C         0000       0.0000        0.00         0.00         0.00
01150    Anesth, pelvic tumor surgery          C             C         0000       0.0000        0.00         0.00         0.00
01160    Anesth, pelvis procedure              N             N         0000       0.0000        0.00         0.00         0.00
01170    Anesth, pelvis surgery                N             N         0000       0.0000        0.00         0.00         0.00
01173    Anesth, fx repair, pelvis             N             N         0000       0.0000        0.00         0.00         0.00
01180    Anesth, pelvis nerve removal          N             N         0000       0.0000        0.00         0.00         0.00
01190    Anesth, pelvis nerve removal          N             N         0000       0.0000        0.00         0.00         0.00
01200    Anesth, hip joint procedure           N             N         0000       0.0000        0.00         0.00         0.00
01202    Anesth, arthroscopy of hip            N             N         0000       0.0000        0.00         0.00         0.00
01210    Anesth, hip joint surgery             N             N         0000       0.0000        0.00         0.00         0.00
01212    Anesth, hip disarticulation           C             C         0000       0.0000        0.00         0.00         0.00
01214    Anesth, hip arthroplasty              C             C         0000       0.0000        0.00         0.00         0.00
01215    Anesth, revise hip repair             N             N         0000       0.0000        0.00         0.00         0.00
01220    Anesth, procedure on femur            N             N         0000       0.0000        0.00         0.00         0.00
01230    Anesth, surgery of femur              N             N         0000       0.0000        0.00         0.00         0.00
01232    Anesth, amputation of femur           C             C         0000       0.0000        0.00         0.00         0.00
01234    Anesth, radical femur surg            C             C         0000       0.0000        0.00         0.00         0.00
01250    Anesth, upper leg surgery             N             N         0000       0.0000        0.00         0.00         0.00
01260    Anesth, upper leg veins surg          N             N         0000       0.0000        0.00         0.00         0.00
01270    Anesth, thigh arteries surg           N             N         0000       0.0000        0.00         0.00         0.00
01272    Anesth, femoral artery surg           C             C         0000       0.0000        0.00         0.00         0.00
01274    Anesth, femoral embolectomy           C             C         0000       0.0000        0.00         0.00         0.00
01320    Anesth, knee area surgery             N             N         0000       0.0000        0.00         0.00         0.00
01340    Anesth, knee area procedure           N             N         0000       0.0000        0.00         0.00         0.00
01360    Anesth, knee area surgery             N             N         0000       0.0000        0.00         0.00         0.00
01380    Anesth, knee joint procedure          N             N         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                      3 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                  Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                    from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                  4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                     Schedule
                                           (FYI Only)                                                                     Fee

01382    Anesth, dx knee arthroscopy           N             N         0000       0.0000        0.00         0.00         0.00
01390    Anesth, knee area procedure           N             N         0000       0.0000        0.00         0.00         0.00
01392    Anesth, knee area surgery             N             N         0000       0.0000        0.00         0.00         0.00
01400    Anesth, knee joint surgery            N             N         0000       0.0000        0.00         0.00         0.00
01402    Anesth, knee arthroplasty             C             C         0000       0.0000        0.00         0.00         0.00
01404    Anesth, amputation at knee            C             C         0000       0.0000        0.00         0.00         0.00
01420    Anesth, knee joint casting            N             N         0000       0.0000        0.00         0.00         0.00
01430    Anesth, knee veins surgery            N             N         0000       0.0000        0.00         0.00         0.00
01432    Anesth, knee vessel surg              N             N         0000       0.0000        0.00         0.00         0.00
01440    Anesth, knee arteries surg            N             N         0000       0.0000        0.00         0.00         0.00
01442    Anesth, knee artery surg              C             C         0000       0.0000        0.00         0.00         0.00
01444    Anesth, knee artery repair            C             C         0000       0.0000        0.00         0.00         0.00
01462    Anesth, lower leg procedure           N             N         0000       0.0000        0.00         0.00         0.00
01464    Anesth, ankle/ft arthroscopy          N             N         0000       0.0000        0.00         0.00         0.00
01470    Anesth, lower leg surgery             N             N         0000       0.0000        0.00         0.00         0.00
01472    Anesth, achilles tendon surg          N             N         0000       0.0000        0.00         0.00         0.00
01474    Anesth, lower leg surgery             N             N         0000       0.0000        0.00         0.00         0.00
01480    Anesth, lower leg bone surg           N             N         0000       0.0000        0.00         0.00         0.00
01482    Anesth, radical leg surgery           N             N         0000       0.0000        0.00         0.00         0.00
01484    Anesth, lower leg revision            N             N         0000       0.0000        0.00         0.00         0.00
01486    Anesth, ankle replacement             C             C         0000       0.0000        0.00         0.00         0.00
01490    Anesth, lower leg casting             N             N         0000       0.0000        0.00         0.00         0.00
01500    Anesth, leg arteries surg             N             N         0000       0.0000        0.00         0.00         0.00
01502    Anesth, lwr leg embolectomy           C             C         0000       0.0000        0.00         0.00         0.00
01520    Anesth, lower leg vein surg           N             N         0000       0.0000        0.00         0.00         0.00
01522    Anesth, lower leg vein surg           N             N         0000       0.0000        0.00         0.00         0.00
01610    Anesth, surgery of shoulder           N             N         0000       0.0000        0.00         0.00         0.00
01620    Anesth, shoulder procedure            N             N         0000       0.0000        0.00         0.00         0.00
01622    Anes dx shoulder arthroscopy          N             N         0000       0.0000        0.00         0.00         0.00
01630    Anesth, surgery of shoulder           N             N         0000       0.0000        0.00         0.00         0.00
01632    Anesth, surgery of shoulder           C             C         0000       0.0000        0.00         0.00         0.00
01634    Anesth, shoulder joint amput          C             C         0000       0.0000        0.00         0.00         0.00
01636    Anesth, forequarter amput             C             C         0000       0.0000        0.00         0.00         0.00
01638    Anesth, shoulder replacement          C             C         0000       0.0000        0.00         0.00         0.00
01650    Anesth, shoulder artery surg          N             N         0000       0.0000        0.00         0.00         0.00
01652    Anesth, shoulder vessel surg          C             C         0000       0.0000        0.00         0.00         0.00
01654    Anesth, shoulder vessel surg          C             C         0000       0.0000        0.00         0.00         0.00
01656    Anesth, arm-leg vessel surg           C             C         0000       0.0000        0.00         0.00         0.00
01670    Anesth, shoulder vein surg            N             N         0000       0.0000        0.00         0.00         0.00
01680    Anesth, shoulder casting              N             N         0000       0.0000        0.00         0.00         0.00
01682    Anesth, airplane cast                 N             N         0000       0.0000        0.00         0.00         0.00
01710    Anesth, elbow area surgery            N             N         0000       0.0000        0.00         0.00         0.00
01712    Anesth, uppr arm tendon surg          N             N         0000       0.0000        0.00         0.00         0.00
01714    Anesth, uppr arm tendon surg          N             N         0000       0.0000        0.00         0.00         0.00
01716    Anesth, biceps tendon repair          N             N         0000       0.0000        0.00         0.00         0.00
01730    Anesth, uppr arm procedure            N             N         0000       0.0000        0.00         0.00         0.00
01732    Anesth, dx elbow arthroscopy          N             N         0000       0.0000        0.00         0.00         0.00
01740    Anesth, upper arm surgery             N             N         0000       0.0000        0.00         0.00         0.00
01742    Anesth, humerus surgery               N             N         0000       0.0000        0.00         0.00         0.00
01744    Anesth, humerus repair                N             N         0000       0.0000        0.00         0.00         0.00
01756    Anesth, radical humerus surg          C             C         0000       0.0000        0.00         0.00         0.00
01758    Anesth, humeral lesion surg           N             N         0000       0.0000        0.00         0.00         0.00
01760    Anesth, elbow replacement             N             N         0000       0.0000        0.00         0.00         0.00
01770    Anesth, uppr arm artery surg          N             N         0000       0.0000        0.00         0.00         0.00
01772    Anesth, uppr arm embolectomy          N             N         0000       0.0000        0.00         0.00         0.00
01780    Anesth, upper arm vein surg           N             N         0000       0.0000        0.00         0.00         0.00
01782    Anesth, uppr arm vein repair          N             N         0000       0.0000        0.00         0.00         0.00
01810    Anesth, lower arm surgery             N             N         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                      4 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

01820    Anesth, lower arm procedure           N             N         0000       0.0000        0.00         0.00         0.00
01829    Anesth, dx wrist arthroscopy          N             N         0000       0.0000        0.00         0.00         0.00
01830    Anesth, lower arm surgery             N             N         0000       0.0000        0.00         0.00         0.00
01832    Anesth, wrist replacement             N             N         0000       0.0000        0.00         0.00         0.00
01840    Anesth, lwr arm artery surg           N             N         0000       0.0000        0.00         0.00         0.00
01842    Anesth, lwr arm embolectomy           N             N         0000       0.0000        0.00         0.00         0.00
01844    Anesth, vascular shunt surg           N             N         0000       0.0000        0.00         0.00         0.00
01850    Anesth, lower arm vein surg           N             N         0000       0.0000        0.00         0.00         0.00
01852    Anesth, lwr arm vein repair           N             N         0000       0.0000        0.00         0.00         0.00
01860    Anesth, lower arm casting             N             N         0000       0.0000        0.00         0.00         0.00
01905    Anes, spine inject, x-ray/re          N             N         0000       0.0000        0.00         0.00         0.00
01916    Anesth, dx arteriography              N             N         0000       0.0000        0.00         0.00         0.00
01920    Anesth, catheterize heart             N             N         0000       0.0000        0.00         0.00         0.00
01922    Anesth, cat or MRI scan               N             N         0000       0.0000        0.00         0.00         0.00
01924    Anes, ther interven rad, art          N             N         0000       0.0000        0.00         0.00         0.00
01925    Anes, ther interven rad, car          N             N         0000       0.0000        0.00         0.00         0.00
01926    Anes, tx interv rad hrt/cran          N             N         0000       0.0000        0.00         0.00         0.00
01930    Anes, ther interven rad, vei          N             N         0000       0.0000        0.00         0.00         0.00
01931    Anes, ther interven rad, tip          N             N         0000       0.0000        0.00         0.00         0.00
01932    Anes, tx interv rad, th vein          N             N         0000       0.0000        0.00         0.00         0.00
01933    Anes, tx interv rad, cran v           N             N         0000       0.0000        0.00         0.00         0.00
01951    Anesth, burn, less 4 percent          N             N         0000       0.0000        0.00         0.00         0.00
01952    Anesth, burn, 4-9 percent             N             N         0000       0.0000        0.00         0.00         0.00
01953    Anesth, burn, each 9 percent          N             N         0000       0.0000        0.00         0.00         0.00
01958    Anesth, antepartum manipul            N             N         0000       0.0000        0.00         0.00         0.00
01960    Anesth, vaginal delivery              N             N         0000       0.0000        0.00         0.00         0.00
01961    Anesth, cs delivery                   N             N         0000       0.0000        0.00         0.00         0.00
01962    Anesth, emer hysterectomy             N             N         0000       0.0000        0.00         0.00         0.00
01963    Anesth, cs hysterectomy               N             N         0000       0.0000        0.00         0.00         0.00
01965    Anesth, inc/missed ab proc            N             N         0000       0.0000        0.00         0.00         0.00
01966    Anesth, induced ab procedure          N             N         0000       0.0000        0.00         0.00         0.00
01967    Anesth/analg, vag delivery            N             N         0000       0.0000        0.00         0.00         0.00
01968    Anes/analg cs deliver add-on          N             N         0000       0.0000        0.00         0.00         0.00
01969    Anesth/analg cs hyst add-on           N             N         0000       0.0000        0.00         0.00         0.00
01990    Support for organ donor               C             C         0000       0.0000        0.00         0.00         0.00
01991    Anesth, nerve block/inj               N             N         0000       0.0000        0.00         0.00         0.00
01992    Anesth, n block/inj, prone            N             N         0000       0.0000        0.00         0.00         0.00
01995    Regional anesthesia limb              N             N         0000       0.0000        0.00         0.00         0.00
01996    Hosp manage cont drug admin           N             N         0000       0.0000        0.00         0.00         0.00
01999    Unlisted anesth procedure             N             1         0000       0.0000        0.00         0.00         0.00
10021    Fna w/o image                         T             T         0002       0.9357        41.43       95.21        109.10
10022    Fna w/image                           T             T         0036       2.1838        96.70       222.20       254.63
10040    Acne surgery                          T             T         0010       0.5923        26.23       60.27        69.06
10060    Drainage of skin abscess              T             T         0006       1.5100        66.86       153.64       176.07
10061    Drainage of skin abscess              T             T         0006       1.5100        66.86       153.64       176.07
10080    Drainage of pilonidal cyst            T             T         0006       1.5100        66.86       153.64       176.07
10081    Drainage of pilonidal cyst            T             T         0007      11.6717       516.82      1,187.60     1,360.92
10120    Remove foreign body                   T             T         0006       1.5100        66.86       153.64       176.07
10121    Remove foreign body                   T             T         0021      14.9984       664.13      1,526.09     1,748.81
10140    Drainage of hematoma/fluid            T             T         0007      11.6717       516.82      1,187.60     1,360.92
10160    Puncture drainage of lesion           T             T         0018       1.1010        48.75       112.03       128.38
10180    Complex drainage, wound               T             T         0008      16.2953       721.56      1,658.05     1,900.03
11000    Debride infected skin                 T             T         0013       1.0603        46.95       107.89       123.63
11001    Debride infected skin add-on          T             T         0012       0.8477        37.54       86.25        98.84
11004    Debride genitalia & perineum          C             C         0000       0.0000        0.00         0.00         0.00
11005    Debride abdom wall                    C             C         0000       0.0000        0.00         0.00         0.00
11006    Debride genit/per/abdom wall          C             C         0000       0.0000        0.00         0.00         0.00
11008    Remove mesh from abd wall             C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                   5 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

11010    Debride skin, fx                      T             T         0019       4.1481       183.68       422.07       483.67
11011    Debride skin/muscle, fx               T             T         0019       4.1481       183.68       422.07       483.67
11012    Debride skin/muscle/bone, fx          T             T         0019       4.1481       183.68       422.07       483.67
11040    Debride skin, partial                 T             T         0015       1.6338        72.34       166.24       190.50
11041    Debride skin, full                    T             T         0015       1.6338        72.34       166.24       190.50
11042    Debride skin/tissue                   T             T         0016       2.5080       111.05       255.19       292.43
11043    Debride tissue/muscle                 T             T         0016       2.5080       111.05       255.19       292.43
11044    Debride tissue/muscle/bone            T             T         0682       6.7313       298.06       684.91       784.87
11055    Trim skin lesion                      T             T         0012       0.8477        37.54       86.25        98.84
11056    Trim skin lesions, 2 to 4             T             T         0012       0.8477        37.54       86.25        98.84
11057    Trim skin lesions, over 4             T             T         0013       1.0603        46.95       107.89       123.63
11100    Biopsy, skin lesion                   T             T         0018       1.1010        48.75       112.03       128.38
11101    Biopsy, skin add-on                   T             T         0018       1.1010        48.75       112.03       128.38
11200    Removal of skin tags                  T             T         0013       1.0603        46.95       107.89       123.63
11201    Remove skin tags add-on               T             T         0015       1.6338        72.34       166.24       190.50
11300    Shave skin lesion                     T             T         0012       0.8477        37.54       86.25        98.84
11301    Shave skin lesion                     T             T         0012       0.8477        37.54       86.25        98.84
11302    Shave skin lesion                     T             T         0013       1.0603        46.95       107.89       123.63
11303    Shave skin lesion                     T             T         0015       1.6338        72.34       166.24       190.50
11305    Shave skin lesion                     T             T         0013       1.0603        46.95       107.89       123.63
11306    Shave skin lesion                     T             T         0013       1.0603        46.95       107.89       123.63
11307    Shave skin lesion                     T             T         0013       1.0603        46.95       107.89       123.63
11308    Shave skin lesion                     T             T         0013       1.0603        46.95       107.89       123.63
11310    Shave skin lesion                     T             T         0013       1.0603        46.95       107.89       123.63
11311    Shave skin lesion                     T             T         0013       1.0603        46.95       107.89       123.63
11312    Shave skin lesion                     T             T         0013       1.0603        46.95       107.89       123.63
11313    Shave skin lesion                     T             T         0016       2.5080       111.05       255.19       292.43
11400    Exc tr-ext b9+marg 0.5 < cm           T             T         0019       4.1481       183.68       422.07       483.67
11401    Exc tr-ext b9+marg 0.6-1 cm           T             T         0019       4.1481       183.68       422.07       483.67
11402    Exc tr-ext b9+marg 1.1-2 cm           T             T         0019       4.1481       183.68       422.07       483.67
11403    Exc tr-ext b9+marg 2.1-3 cm           T             T         0020       6.9410       307.35       706.25       809.32
11404    Exc tr-ext b9+marg 3.1-4 cm           T             T         0021      14.9984       664.13      1,526.09     1,748.81
11406    Exc tr-ext b9+marg > 4.0 cm           T             T         0021      14.9984       664.13      1,526.09     1,748.81
11420    Exc h-f-nk-sp b9+marg 0.5 <           T             T         0020       6.9410       307.35       706.25       809.32
11421    Exc h-f-nk-sp b9+marg 0.6-1           T             T         0020       6.9410       307.35       706.25       809.32
11422    Exc h-f-nk-sp b9+marg 1.1-2           T             T         0020       6.9410       307.35       706.25       809.32
11423    Exc h-f-nk-sp b9+marg 2.1-3           T             T         0021      14.9984       664.13      1,526.09     1,748.81
11424    Exc h-f-nk-sp b9+marg 3.1-4           T             T         0021      14.9984       664.13      1,526.09     1,748.81
11426    Exc h-f-nk-sp b9+marg > 4 cm          T             T         0022      19.5716       866.63      1,991.41     2,282.05
11440    Exc face-mm b9+marg 0.5 < cm          T             T         0019       4.1481       183.68       422.07       483.67
11441    Exc face-mm b9+marg 0.6-1 cm          T             T         0019       4.1481       183.68       422.07       483.67
11442    Exc face-mm b9+marg 1.1-2 cm          T             T         0020       6.9410       307.35       706.25       809.32
11443    Exc face-mm b9+marg 2.1-3 cm          T             T         0020       6.9410       307.35       706.25       809.32
11444    Exc face-mm b9+marg 3.1-4 cm          T             T         0020       6.9410       307.35       706.25       809.32
11446    Exc face-mm b9+marg > 4 cm            T             T         0022      19.5716       866.63      1,991.41     2,282.05
11450    Removal, sweat gland lesion           T             T         0022      19.5716       866.63      1,991.41     2,282.05
11451    Removal, sweat gland lesion           T             T         0022      19.5716       866.63      1,991.41     2,282.05
11462    Removal, sweat gland lesion           T             T         0022      19.5716       866.63      1,991.41     2,282.05
11463    Removal, sweat gland lesion           T             T         0022      19.5716       866.63      1,991.41     2,282.05
11470    Removal, sweat gland lesion           T             T         0022      19.5716       866.63      1,991.41     2,282.05
11471    Removal, sweat gland lesion           T             T         0022      19.5716       866.63      1,991.41     2,282.05
11600    Exc tr-ext mlg+marg 0.5 < cm          T             T         0019       4.1481       183.68       422.07       483.67
11601    Exc tr-ext mlg+marg 0.6-1 cm          T             T         0019       4.1481       183.68       422.07       483.67
11602    Exc tr-ext mlg+marg 1.1-2 cm          T             T         0019       4.1481       183.68       422.07       483.67
11603    Exc tr-ext mlg+marg 2.1-3 cm          T             T         0020       6.9410       307.35       706.25       809.32
11604    Exc tr-ext mlg+marg 3.1-4 cm          T             T         0020       6.9410       307.35       706.25       809.32
11606    Exc tr-ext mlg+marg > 4 cm            T             T         0021      14.9984       664.13      1,526.09     1,748.81
11620    Exc h-f-nk-sp mlg+marg 0.5 <          T             T         0020       6.9410       307.35       706.25       809.32


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                   6 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

11621    Exc h-f-nk-sp mlg+marg 0.6-1          T             T         0019       4.1481       183.68       422.07       483.67
11622    Exc h-f-nk-sp mlg+marg 1.1-2          T             T         0020       6.9410       307.35       706.25       809.32
11623    Exc h-f-nk-sp mlg+marg 2.1-3          T             T         0021      14.9984       664.13      1,526.09     1,748.81
11624    Exc h-f-nk-sp mlg+marg 3.1-4          T             T         0021      14.9984       664.13      1,526.09     1,748.81
11626    Exc h-f-nk-sp mlg+mar > 4 cm          T             T         0022      19.5716       866.63      1,991.41     2,282.05
11640    Exc face-mm malig+marg 0.5 <          T             T         0020       6.9410       307.35       706.25       809.32
11641    Exc face-mm malig+marg 0.6-1          T             T         0020       6.9410       307.35       706.25       809.32
11642    Exc face-mm malig+marg 1.1-2          T             T         0020       6.9410       307.35       706.25       809.32
11643    Exc face-mm malig+marg 2.1-3          T             T         0020       6.9410       307.35       706.25       809.32
11644    Exc face-mm malig+marg 3.1-4          T             T         0021      14.9984       664.13      1,526.09     1,748.81
11646    Exc face-mm mlg+marg > 4 cm           T             T         0022      19.5716       866.63      1,991.41     2,282.05
11719    Trim nail(s)                          T             T         0009       0.7513        33.27       76.44        87.60
11720    Debride nail, 1-5                     T             T         0009       0.7513        33.27       76.44        87.60
11721    Debride nail, 6 or more               T             T         0009       0.7513        33.27       76.44        87.60
11730    Removal of nail plate                 T             T         0013       1.0603        46.95       107.89       123.63
11732    Remove nail plate, add-on             T             T         0012       0.8477        37.54       86.25        98.84
11740    Drain blood from under nail           T             T         0009       0.7513        33.27       76.44        87.60
11750    Removal of nail bed                   T             T         0019       4.1481       183.68       422.07       483.67
11752    Remove nail bed/finger tip            T             T         0022      19.5716       866.63      1,991.41     2,282.05
11755    Biopsy, nail unit                     T             T         0019       4.1481       183.68       422.07       483.67
11760    Repair of nail bed                    T             T         0024       1.5513        68.69       157.84       180.88
11762    Reconstruction of nail bed            T             T         0024       1.5513        68.69       157.84       180.88
11765    Excision of nail fold, toe            T             T         0015       1.6338        72.34       166.24       190.50
11770    Removal of pilonidal lesion           T             T         0022      19.5716       866.63      1,991.41     2,282.05
11771    Removal of pilonidal lesion           T             T         0022      19.5716       866.63      1,991.41     2,282.05
11772    Removal of pilonidal lesion           T             T         0022      19.5716       866.63      1,991.41     2,282.05
11900    Injection into skin lesions           T             T         0012       0.8477        37.54       86.25        98.84
11901    Added skin lesions injection          T             T         0012       0.8477        37.54       86.25        98.84
11920    Correct skin color defects            T             1         0000       0.0000        0.00         0.00         0.00
11921    Correct skin color defects            T             1         0000       0.0000        0.00         0.00         0.00
11922    Correct skin color defects            T             1         0000       0.0000        0.00         0.00         0.00
11950    Therapy for contour defects           T             1         0000       0.0000        0.00         0.00         0.00
11951    Therapy for contour defects           T             1         0000       0.0000        0.00         0.00         0.00
11952    Therapy for contour defects           T             1         0000       0.0000        0.00         0.00         0.00
11954    Therapy for contour defects           T             1         0000       0.0000        0.00         0.00         0.00
11960    Insert tissue expander(s)             T             T         0027      18.1956       805.70      1,851.40     2,121.61
11970    Replace tissue expander               T             T         0027      18.1956       805.70      1,851.40     2,121.61
11971    Remove tissue expander(s)             T             T         0022      19.5716       866.63      1,991.41     2,282.05
11975    Insert contraceptive cap              E             3         0000       0.0000         M01         M01          M01
11976    Removal of contraceptive cap          T             T         0019       4.1481       183.68       422.07       483.67
11977    Removal/reinsert contra cap           E             3         0000       0.0000         M01         M01          M01
11980    Implant hormone pellet(s)             X             X         0340       0.6137        27.17       62.44        71.56
11981    Insert drug implant device            X             X         0340       0.6137        27.17       62.44        71.56
11982    Remove drug implant device            X             X         0340       0.6137        27.17       62.44        71.56
11983    Remove/insert drug implant            X             X         0340       0.6137        27.17       62.44        71.56
12001    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12002    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12004    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12005    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12006    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12007    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12011    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12013    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12014    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12015    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12016    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12017    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88
12018    Repair superficial wound(s)           T             T         0024       1.5513        68.69       157.84       180.88


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                   7 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

12020    Closure of split wound                T             T         0024       1.5513        68.69       157.84       180.88
12021    Closure of split wound                T             T         0024       1.5513        68.69       157.84       180.88
12031    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12032    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12034    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12035    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12036    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12037    Layer closure of wound(s)             T             T         0025       5.3051       234.91       539.79       618.57
12041    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12042    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12044    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12045    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12046    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12047    Layer closure of wound(s)             T             T         0025       5.3051       234.91       539.79       618.57
12051    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12052    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12053    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12054    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12055    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12056    Layer closure of wound(s)             T             T         0024       1.5513        68.69       157.84       180.88
12057    Layer closure of wound(s)             T             T         0025       5.3051       234.91       539.79       618.57
13100    Repair of wound or lesion             T             T         0025       5.3051       234.91       539.79       618.57
13101    Repair of wound or lesion             T             T         0025       5.3051       234.91       539.79       618.57
13102    Repair wound/lesion add-on            T             T         0024       1.5513        68.69       157.84       180.88
13120    Repair of wound or lesion             T             T         0024       1.5513        68.69       157.84       180.88
13121    Repair of wound or lesion             T             T         0024       1.5513        68.69       157.84       180.88
13122    Repair wound/lesion add-on            T             T         0024       1.5513        68.69       157.84       180.88
13131    Repair of wound or lesion             T             T         0024       1.5513        68.69       157.84       180.88
13132    Repair of wound or lesion             T             T         0024       1.5513        68.69       157.84       180.88
13133    Repair wound/lesion add-on            T             T         0024       1.5513        68.69       157.84       180.88
13150    Repair of wound or lesion             T             T         0025       5.3051       234.91       539.79       618.57
13151    Repair of wound or lesion             T             T         0024       1.5513        68.69       157.84       180.88
13152    Repair of wound or lesion             T             T         0025       5.3051       234.91       539.79       618.57
13153    Repair wound/lesion add-on            T             T         0024       1.5513        68.69       157.84       180.88
13160    Late closure of wound                 T             T         0027      18.1956       805.70      1,851.40     2,121.61
14000    Skin tissue rearrangement             T             T         0686      13.4973       597.66      1,373.35     1,573.79
14001    Skin tissue rearrangement             T             T         0027      18.1956       805.70      1,851.40     2,121.61
14020    Skin tissue rearrangement             T             T         0686      13.4973       597.66      1,373.35     1,573.79
14021    Skin tissue rearrangement             T             T         0027      18.1956       805.70      1,851.40     2,121.61
14040    Skin tissue rearrangement             T             T         0686      13.4973       597.66      1,373.35     1,573.79
14041    Skin tissue rearrangement             T             T         0027      18.1956       805.70      1,851.40     2,121.61
14060    Skin tissue rearrangement             T             T         0027      18.1956       805.70      1,851.40     2,121.61
14061    Skin tissue rearrangement             T             T         0686      13.4973       597.66      1,373.35     1,573.79
14300    Skin tissue rearrangement             T             T         0027      18.1956       805.70      1,851.40     2,121.61
14350    Skin tissue rearrangement             T             T         0027      18.1956       805.70      1,851.40     2,121.61
15000    Skin graft                            T             T         0025       5.3051       234.91       539.79       618.57
15001    Skin graft add-on                     T             T         0025       5.3051       234.91       539.79       618.57
15040    Harvest cultured skin graft           T             T         0024       1.5513        68.69       157.84       180.88
15050    Skin pinch graft                      T             T         0025       5.3051       234.91       539.79       618.57
15100    Skin split graft                      T             T         0027      18.1956       805.70      1,851.40     2,121.61
15101    Skin split graft add-on               T             T         0027      18.1956       805.70      1,851.40     2,121.61
15110    Epidrm autogrft trnk/arm/leg          T             T         0027      18.1956       805.70      1,851.40     2,121.61
15111    Epidrm autogrft t/a/l add-on          T             T         0027      18.1956       805.70      1,851.40     2,121.61
15115    Epidrm a-grft face/nck/hf/g           T             T         0027      18.1956       805.70      1,851.40     2,121.61
15116    Epidrm a-grft f/n/hf/g addl           T             T         0027      18.1956       805.70      1,851.40     2,121.61
15120    Skin split graft                      T             T         0027      18.1956       805.70      1,851.40     2,121.61
15121    Skin split graft add-on               T             T         0027      18.1956       805.70      1,851.40     2,121.61
15130    Derm autograft, trnk/arm/leg          T             T         0027      18.1956       805.70      1,851.40     2,121.61


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                   8 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

15131    Derm autograft t/a/l add-on           T             T         0027      18.1956       805.70      1,851.40     2,121.61
15135    Derm autograft face/nck/hf/g          T             T         0027      18.1956       805.70      1,851.40     2,121.61
15136    Derm autograft, f/n/hf/g add          T             T         0027      18.1956       805.70      1,851.40     2,121.61
15150    Cult epiderm grft t/arm/leg           T             T         0027      18.1956       805.70      1,851.40     2,121.61
15151    Cult epiderm grft t/a/l addl          T             T         0027      18.1956       805.70      1,851.40     2,121.61
15152    Cult epiderm graft t/a/l +%           T             T         0027      18.1956       805.70      1,851.40     2,121.61
15155    Cult epiderm graft, f/n/hf/g          T             T         0027      18.1956       805.70      1,851.40     2,121.61
15156    Cult epidrm grft f/n/hfg add          T             T         0027      18.1956       805.70      1,851.40     2,121.61
15157    Cult epiderm grft f/n/hfg +%          T             T         0027      18.1956       805.70      1,851.40     2,121.61
15170    Acell graft trunk/arms/legs           T             T         0024       1.5513        68.69       157.84       180.88
15171    Acell graft t/arm/leg add-on          T             T         0024       1.5513        68.69       157.84       180.88
15175    Acellular graft, f/n/hf/g             T             T         0024       1.5513        68.69       157.84       180.88
15176    Acell graft, f/n/hf/g add-on          T             T         0024       1.5513        68.69       157.84       180.88
15200    Skin full graft                       T             T         0027      18.1956       805.70      1,851.40     2,121.61
15201    Skin full graft add-on                T             T         0025       5.3051       234.91       539.79       618.57
15220    Skin full graft                       T             T         0027      18.1956       805.70      1,851.40     2,121.61
15221    Skin full graft add-on                T             T         0025       5.3051       234.91       539.79       618.57
15240    Skin full graft                       T             T         0686      13.4973       597.66      1,373.35     1,573.79
15241    Skin full graft add-on                T             T         0025       5.3051       234.91       539.79       618.57
15260    Skin full graft                       T             T         0686      13.4973       597.66      1,373.35     1,573.79
15261    Skin full graft add-on                T             T         0025       5.3051       234.91       539.79       618.57
15300    Apply skinallogrft, t/arm/lg          T             T         0027      18.1956       805.70      1,851.40     2,121.61
15301    Apply sknallogrft t/a/l addl          T             T         0025       5.3051       234.91       539.79       618.57
15320    Apply skin allogrft f/n/hf/g          T             T         0025       5.3051       234.91       539.79       618.57
15321    Aply sknallogrft f/n/hfg add          T             T         0025       5.3051       234.91       539.79       618.57
15330    Aply acell alogrft t/arm/leg          T             T         0025       5.3051       234.91       539.79       618.57
15331    Aply acell grft t/a/l add-on          T             T         0025       5.3051       234.91       539.79       618.57
15335    Apply acell graft, f/n/hf/g           T             T         0025       5.3051       234.91       539.79       618.57
15336    Aply acell grft f/n/hf/g add          T             T         0025       5.3051       234.91       539.79       618.57
15340    Apply cult skin substitute            T             T         0024       1.5513        68.69       157.84       180.88
15341    Apply cult skin sub add-on            T             T         0024       1.5513        68.69       157.84       180.88
15360    Apply cult derm sub, t/a/l            T             T         0024       1.5513        68.69       157.84       180.88
15361    Aply cult derm sub t/a/l add          T             T         0024       1.5513        68.69       157.84       180.88
15365    Apply cult derm sub f/n/hf/g          T             T         0024       1.5513        68.69       157.84       180.88
15366    Apply cult derm f/hf/g add            T             T         0024       1.5513        68.69       157.84       180.88
15400    Skin heterograft                      T             T         0025       5.3051       234.91       539.79       618.57
15401    Skin heterograft add-on               T             T         0025       5.3051       234.91       539.79       618.57
15420    Apply skin xgraft, f/n/hf/g           T             T         0025       5.3051       234.91       539.79       618.57
15421    Apply skn xgrft f/n/hf/g add          T             T         0025       5.3051       234.91       539.79       618.57
15430    Apply acellular xenograft             T             T         0025       5.3051       234.91       539.79       618.57
15431    Apply acellular xgraft add            T             T         0025       5.3051       234.91       539.79       618.57
15570    Form skin pedicle flap                T             T         0027      18.1956       805.70      1,851.40     2,121.61
15572    Form skin pedicle flap                T             T         0027      18.1956       805.70      1,851.40     2,121.61
15574    Form skin pedicle flap                T             T         0027      18.1956       805.70      1,851.40     2,121.61
15576    Form skin pedicle flap                T             T         0686      13.4973       597.66      1,373.35     1,573.79
15600    Skin graft                            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15610    Skin graft                            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15620    Skin graft                            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15630    Skin graft                            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15650    Transfer skin pedicle flap            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15732    Muscle-skin graft, head/neck          T             T         0027      18.1956       805.70      1,851.40     2,121.61
15734    Muscle-skin graft, trunk              T             T         0027      18.1956       805.70      1,851.40     2,121.61
15736    Muscle-skin graft, arm                T             T         0027      18.1956       805.70      1,851.40     2,121.61
15738    Muscle-skin graft, leg                T             T         0027      18.1956       805.70      1,851.40     2,121.61
15740    Island pedicle flap graft             T             T         0686      13.4973       597.66      1,373.35     1,573.79
15750    Neurovascular pedicle graft           T             T         0027      18.1956       805.70      1,851.40     2,121.61
15756    Free myo/skin flap microvasc          C             C         0000       0.0000        0.00         0.00         0.00
15757    Free skin flap, microvasc             C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                   9 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

15758    Free fascial flap, microvasc          C             C         0000       0.0000        0.00         0.00         0.00
15760    Composite skin graft                  T             T         0027      18.1956       805.70      1,851.40     2,121.61
15770    Derma-fat-fascia graft                T             T         0027      18.1956       805.70      1,851.40     2,121.61
15775    Hair transplant punch grafts          T             1         0000       0.0000        0.00         0.00         0.00
15776    Hair transplant punch grafts          T             1         0000       0.0000        0.00         0.00         0.00
15780    Abrasion treatment of skin            T             T         0022      19.5716       866.63      1,991.41     2,282.05
15781    Abrasion treatment of skin            T             1         0000       0.0000        0.00         0.00         0.00
15782    Abrasion treatment of skin            T             1         0000       0.0000        0.00         0.00         0.00
15783    Abrasion treatment of skin            T             1         0000       0.0000        0.00         0.00         0.00
15786    Abrasion, lesion, single              T             1         0000       0.0000        0.00         0.00         0.00
15787    Abrasion, lesions, add-on             T             1         0000       0.0000        0.00         0.00         0.00
15788    Chemical peel, face, epiderm          T             1         0000       0.0000        0.00         0.00         0.00
15789    Chemical peel, face, dermal           T             1         0000       0.0000        0.00         0.00         0.00
15792    Chemical peel, nonfacial              T             1         0000       0.0000        0.00         0.00         0.00
15793    Chemical peel, nonfacial              T             1         0000       0.0000        0.00         0.00         0.00
15819    Plastic surgery, neck                 T             1         0000       0.0000        0.00         0.00         0.00
15820    Revision of lower eyelid              T             T         0027      18.1956       805.70      1,851.40     2,121.61
15821    Revision of lower eyelid              T             T         0027      18.1956       805.70      1,851.40     2,121.61
15822    Revision of upper eyelid              T             T         0027      18.1956       805.70      1,851.40     2,121.61
15823    Revision of upper eyelid              T             T         0027      18.1956       805.70      1,851.40     2,121.61
15824    Removal of forehead wrinkles          T             1         0000       0.0000        0.00         0.00         0.00
15825    Removal of neck wrinkles              T             1         0000       0.0000        0.00         0.00         0.00
15826    Removal of brow wrinkles              T             1         0000       0.0000        0.00         0.00         0.00
15828    Removal of face wrinkles              T             1         0000       0.0000        0.00         0.00         0.00
15829    Removal of skin wrinkles              T             1         0000       0.0000        0.00         0.00         0.00
15831    Excise excessive skin tissue          T             T         0022      19.5716       866.63      1,991.41     2,282.05
15832    Excise excessive skin tissue          T             1         0000       0.0000        0.00         0.00         0.00
15833    Excise excessive skin tissue          T             1         0000       0.0000        0.00         0.00         0.00
15834    Excise excessive skin tissue          T             1         0000       0.0000        0.00         0.00         0.00
15835    Excise excessive skin tissue          T             1         0000       0.0000        0.00         0.00         0.00
15836    Excise excessive skin tissue          T             1         0000       0.0000        0.00         0.00         0.00
15837    Excise excessive skin tissue          T             1         0000       0.0000        0.00         0.00         0.00
15838    Excise excessive skin tissue          T             1         0000       0.0000        0.00         0.00         0.00
15839    Excise excessive skin tissue          T             1         0000       0.0000        0.00         0.00         0.00
15840    Graft for face nerve palsy            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15841    Graft for face nerve palsy            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15842    Flap for face nerve palsy             T             T         0686      13.4973       597.66      1,373.35     1,573.79
15845    Skin and muscle repair, face          T             T         0027      18.1956       805.70      1,851.40     2,121.61
15850    Removal of sutures                    T             T         0016       2.5080       111.05       255.19       292.43
15851    Removal of sutures                    T             T         0016       2.5080       111.05       255.19       292.43
15852    Dressing change not for burn          X             X         0340       0.6137        27.17       62.44        71.56
15860    Test for blood flow in graft          X             X         0359       0.8036        35.58       81.77        93.70
15876    Suction assisted lipectomy            T             1         0000       0.0000        0.00         0.00         0.00
15877    Suction assisted lipectomy            T             1         0000       0.0000        0.00         0.00         0.00
15878    Suction assisted lipectomy            T             1         0000       0.0000        0.00         0.00         0.00
15879    Suction assisted lipectomy            T             1         0000       0.0000        0.00         0.00         0.00
15920    Removal of tail bone ulcer            T             T         0019       4.1481       183.68       422.07       483.67
15922    Removal of tail bone ulcer            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15931    Remove sacrum pressure sore           T             T         0022      19.5716       866.63      1,991.41     2,282.05
15933    Remove sacrum pressure sore           T             T         0022      19.5716       866.63      1,991.41     2,282.05
15934    Remove sacrum pressure sore           T             T         0027      18.1956       805.70      1,851.40     2,121.61
15935    Remove sacrum pressure sore           T             T         0027      18.1956       805.70      1,851.40     2,121.61
15936    Remove sacrum pressure sore           T             T         0027      18.1956       805.70      1,851.40     2,121.61
15937    Remove sacrum pressure sore           T             T         0027      18.1956       805.70      1,851.40     2,121.61
15940    Remove hip pressure sore              T             T         0022      19.5716       866.63      1,991.41     2,282.05
15941    Remove hip pressure sore              T             T         0022      19.5716       866.63      1,991.41     2,282.05
15944    Remove hip pressure sore              T             T         0027      18.1956       805.70      1,851.40     2,121.61
15945    Remove hip pressure sore              T             T         0027      18.1956       805.70      1,851.40     2,121.61


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  10 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

15946    Remove hip pressure sore              T             T         0027      18.1956       805.70      1,851.40     2,121.61
15950    Remove thigh pressure sore            T             T         0022      19.5716       866.63      1,991.41     2,282.05
15951    Remove thigh pressure sore            T             T         0022      19.5716       866.63      1,991.41     2,282.05
15952    Remove thigh pressure sore            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15953    Remove thigh pressure sore            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15956    Remove thigh pressure sore            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15958    Remove thigh pressure sore            T             T         0027      18.1956       805.70      1,851.40     2,121.61
15999    Removal of pressure sore              T             1         0000       0.0000        0.00         0.00         0.00
16000    Initial treatment of burn(s)          T             T         0012       0.8477        37.54       86.25        98.84
16020    Treatment of burn(s)                  T             T         0013       1.0603        46.95       107.89       123.63
16025    Treatment of burn(s)                  T             T         0013       1.0603        46.95       107.89       123.63
16030    Treatment of burn(s)                  T             T         0015       1.6338        72.34       166.24       190.50
16035    Incision of burn scab, initi          C             C         0000       0.0000        0.00         0.00         0.00
16036    Escharotomy; add’l incision           C             C         0000       0.0000        0.00         0.00         0.00
17000    Destroy benign/premlg lesion          T             T         0010       0.5923        26.23       60.27        69.06
17003    Destroy lesions, 2-14                 T             T         0010       0.5923        26.23       60.27        69.06
17004    Destroy lesions, 15 or more           T             T         0011       2.2274        98.63       226.64       259.71
17106    Destruction of skin lesions           T             T         0011       2.2274        98.63       226.64       259.71
17107    Destruction of skin lesions           T             T         0011       2.2274        98.63       226.64       259.71
17108    Destruction of skin lesions           T             T         0011       2.2274        98.63       226.64       259.71
17110    Destruct lesion, 1-14                 T             T         0013       1.0603        46.95       107.89       123.63
17111    Destruct lesion, 15 or more           T             T         0013       1.0603        46.95       107.89       123.63
17250    Chemical cautery, tissue              T             T         0013       1.0603        46.95       107.89       123.63
17260    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17261    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17262    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17263    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17264    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17266    Destruction of skin lesions           T             T         0016       2.5080       111.05       255.19       292.43
17270    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17271    Destruction of skin lesions           T             T         0013       1.0603        46.95       107.89       123.63
17272    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17273    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17274    Destruction of skin lesions           T             T         0016       2.5080       111.05       255.19       292.43
17276    Destruction of skin lesions           T             T         0016       2.5080       111.05       255.19       292.43
17280    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17281    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17282    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17283    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17284    Destruction of skin lesions           T             T         0016       2.5080       111.05       255.19       292.43
17286    Destruction of skin lesions           T             T         0015       1.6338        72.34       166.24       190.50
17304    1 stage mohs, up to 5 spec            T             T         0694       3.8832       171.95       395.12       452.78
17305    2 stage mohs, up to 5 spec            T             T         0694       3.8832       171.95       395.12       452.78
17306    3 stage mohs, up to 5 spec            T             T         0694       3.8832       171.95       395.12       452.78
17307    Mohs addl stage up to 5 spec          T             T         0694       3.8832       171.95       395.12       452.78
17310    Mohs any stage > 5 spec each          T             T         0694       3.8832       171.95       395.12       452.78
17340    Cryotherapy of skin                   T             T         0012       0.8477        37.54       86.25        98.84
17360    Skin peel therapy                     T             1         0000       0.0000        0.00         0.00         0.00
17380    Hair removal by electrolysis          T             1         0000       0.0000        0.00         0.00         0.00
17999    Skin tissue procedure                 T             1         0000       0.0000        0.00         0.00         0.00
19000    Drainage of breast lesion             T             T         0004       1.7771        78.69       180.82       207.21
19001    Drain breast lesion add-on            T             T         0004       1.7771        78.69       180.82       207.21
19020    Incision of breast lesion             T             T         0008      16.2953       721.56      1,658.05     1,900.03
19030    Injection for breast x-ray            N             N         0000       0.0000        0.00         0.00         0.00
19100    Bx breast percut w/o image            T             T         0005       3.5834       158.67       364.61       417.82
19101    Biopsy of breast, open                T             T         0028      19.4351       860.59      1,977.52     2,266.13
19102    Bx breast percut w/image              T             T         0005       3.5834       158.67       364.61       417.82
19103    Bx breast percut w/device             T             T         0658       5.9888       265.18       609.36       698.29


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  11 of 223
State of Wyoming Oupatient Prospective Payment System                                                           Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                       Critical
                                                                                              General        Children's                 Change
                                               2006      WY 2006                                                           Access
 CPT/                                                                           APC Relative Hospital         Hospital                   from
                 Description (short)          Status       Status       APC                                                Hospital
HCPCS                                                                             Weight     Outpatient      Outpatient                 4-14-06
                                            Indicator    Indicator                                                        Outpatient
                                                                                                Fee             Fee                    Schedule
                                           (FYI Only)                                                                        Fee

19110    Nipple exploration                    T             T         0028      19.4351           860.59     1,977.52     2,266.13
19112    Excise breast duct fistula            T             T         0028      19.4351           860.59     1,977.52     2,266.13
19120    Removal of breast lesion              T             T         0028      19.4351           860.59     1,977.52     2,266.13
19125    Excision, breast lesion               T             T         0028      19.4351           860.59     1,977.52     2,266.13
19126    Excision, addl breast lesion          T             T         0028      19.4351           860.59     1,977.52     2,266.13
19140    Removal of breast tissue              T             T         0028      19.4351           860.59     1,977.52     2,266.13
19160    Partial mastectomy                    T             T         0028      19.4351           860.59     1,977.52     2,266.13
19162    P-mastectomy w/ln removal             T             T         0693      42.2886          1,872.54    4,302.87     4,930.85
19180    Removal of breast                     T             T         0029      31.4826          1,394.05    3,203.35     3,670.87
19182    Removal of breast                     T             T         0029      31.4826          1,394.05    3,203.35     3,670.87
19200    Removal of breast                     C             C         0000       0.0000            0.00        0.00         0.00
19220    Removal of breast                     C             C         0000       0.0000            0.00        0.00         0.00
19240    Removal of breast                     T             T         0030      39.9779          1,770.22    4,067.75     4,661.42
19260    Removal of chest wall lesion          T             T         0021      14.9984           664.13     1,526.09     1,748.81
19271    Revision of chest wall                C             C         0000       0.0000            0.00        0.00         0.00
19272    Extensive chest wall surgery          C             C         0000       0.0000            0.00        0.00         0.00
19290    Place needle wire, breast             N             N         0000       0.0000            0.00        0.00         0.00
19291    Place needle wire, breast             N             N         0000       0.0000            0.00        0.00         0.00
19295    Place breast clip, percut             S             S         0657       1.6092            71.26      163.74       187.63
19296    Place po breast cath for rad          S             S         1524      54.6118      *   2,418.21    5,556.75     6,367.74
19297    Place breast cath for rad             S             S         1523      46.2099      *   2,046.17    4,701.86     5,388.07
19298    Place breast rad tube/caths           S             S         1524      54.6118      *   2,418.21    5,556.75     6,367.74
19316    Suspension of breast                  T             T         0029      31.4826          1,394.05    3,203.35     3,670.87
19318    Reduction of large breast             T             T         0693      42.2886          1,872.54    4,302.87     4,930.85
19324    Enlarge breast                        T             1         0000       0.0000            0.00        0.00         0.00
19325    Enlarge breast with implant           T             T         0648      53.5307          2,370.34    5,446.75     6,241.68
19328    Removal of breast implant             T             T         0029      31.4826          1,394.05    3,203.35     3,670.87
19330    Removal of implant material           T             T         0029      31.4826          1,394.05    3,203.35     3,670.87
19340    Immediate breast prosthesis           T             T         0030      39.9779          1,770.22    4,067.75     4,661.42
19342    Delayed breast prosthesis             T             T         0648      53.5307          2,370.34    5,446.75     6,241.68
19350    Breast reconstruction                 T             T         0028      19.4351           860.59     1,977.52     2,266.13
19355    Correct inverted nipple(s)            T             1         0000       0.0000            0.00        0.00         0.00
19357    Breast reconstruction                 T             T         0648      53.5307          2,370.34    5,446.75     6,241.68
19361    Breast reconstruction                 C             C         0000       0.0000            0.00        0.00         0.00
19364    Breast reconstruction                 C             C         0000       0.0000            0.00        0.00         0.00
19366    Breast reconstruction                 T             T         0029      31.4826          1,394.05    3,203.35     3,670.87
19367    Breast reconstruction                 C             C         0000       0.0000            0.00        0.00         0.00
19368    Breast reconstruction                 C             C         0000       0.0000            0.00        0.00         0.00
19369    Breast reconstruction                 C             C         0000       0.0000            0.00        0.00         0.00
19370    Surgery of breast capsule             T             T         0029      31.4826          1,394.05    3,203.35     3,670.87
19371    Removal of breast capsule             T             T         0029      31.4826          1,394.05    3,203.35     3,670.87
19380    Revise breast reconstruction          T             T         0030      39.9779          1,770.22    4,067.75     4,661.42
19396    Design custom breast implant          T             T         0029      31.4826          1,394.05    3,203.35     3,670.87
19499    Breast surgery procedure              T             1         0000       0.0000            0.00        0.00         0.00
20000    Incision of abscess                   T             T         0006       1.5100            66.86      153.64       176.07
20005    Incision of deep abscess              T             T         0049      20.3891           902.83     2,074.59     2,377.37
20100    Explore wound, neck                   T             T         0023       4.7662           211.05      484.96       555.74
20101    Explore wound, chest                  T             T         0027      18.1956           805.70     1,851.40     2,121.61
20102    Explore wound, abdomen                T             T         0027      18.1956           805.70     1,851.40     2,121.61
20103    Explore wound, extremity              T             T         0023       4.7662           211.05      484.96       555.74
20150    Excise epiphyseal bar                 T             T         0051      36.6106          1,621.12    3,725.13     4,268.80
20200    Muscle biopsy                         T             T         0021      14.9984           664.13     1,526.09     1,748.81
20205    Deep muscle biopsy                    T             T         0021      14.9984           664.13     1,526.09     1,748.81
20206    Needle biopsy, muscle                 T             T         0005       3.5834           158.67      364.61       417.82
20220    Bone biopsy, trocar/needle            T             T         0019       4.1481           183.68      422.07       483.67
20225    Bone biopsy, trocar/needle            T             T         0020       6.9410           307.35      706.25       809.32
20240    Bone biopsy, excisional               T             T         0022      19.5716           866.63     1,991.41     2,282.05
20245    Bone biopsy, excisional               T             T         0022      19.5716           866.63     1,991.41     2,282.05


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                     12 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

20250    Open bone biopsy                      T             T         0049      20.3891       902.83      2,074.59     2,377.37
20251    Open bone biopsy                      T             T         0049      20.3891       902.83      2,074.59     2,377.37
20500    Injection of sinus tract              T             T         0251       2.0789        92.05       211.53       242.40
20501    Inject sinus tract for x-ray          N             N         0000       0.0000        0.00         0.00         0.00
20520    Removal of foreign body               T             T         0019       4.1481       183.68       422.07       483.67
20525    Removal of foreign body               T             T         0022      19.5716       866.63      1,991.41     2,282.05
20526    Ther injection, carp tunnel           T             T         0204       2.2667       100.37       230.64       264.30
20550    Inj tendon sheath/ligament            T             T         0204       2.2667       100.37       230.64       264.30
20551    Inj tendon origin/insertion           T             T         0204       2.2667       100.37       230.64       264.30
20552    Inj trigger point, 1/2 muscl          T             T         0204       2.2667       100.37       230.64       264.30
20553    Inject trigger points, =/> 3          T             T         0204       2.2667       100.37       230.64       264.30
20600    Drain/inject, joint/bursa             T             T         0204       2.2667       100.37       230.64       264.30
20605    Drain/inject, joint/bursa             T             T         0204       2.2667       100.37       230.64       264.30
20610    Drain/inject, joint/bursa             T             T         0204       2.2667       100.37       230.64       264.30
20612    Aspirate/inj ganglion cyst            T             T         0204       2.2667       100.37       230.64       264.30
20615    Treatment of bone cyst                T             T         0004       1.7771        78.69       180.82       207.21
20650    Insert and remove bone pin            T             T         0049      20.3891       902.83      2,074.59     2,377.37
20660    Apply, rem fixation device            C             C         0000       0.0000        0.00         0.00         0.00
20661    Application of head brace             C             C         0000       0.0000        0.00         0.00         0.00
20662    Application of pelvis brace           T             T         0049      20.3891       902.83      2,074.59     2,377.37
20663    Application of thigh brace            T             T         0049      20.3891       902.83      2,074.59     2,377.37
20664    Halo brace application                C             C         0000       0.0000        0.00         0.00         0.00
20665    Removal of fixation device            X             X         0340       0.6137        27.17       62.44        71.56
20670    Removal of support implant            T             T         0021      14.9984       664.13      1,526.09     1,748.81
20680    Removal of support implant            T             T         0022      19.5716       866.63      1,991.41     2,282.05
20690    Apply bone fixation device            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
20692    Apply bone fixation device            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
20693    Adjust bone fixation device           T             T         0049      20.3891       902.83      2,074.59     2,377.37
20694    Remove bone fixation device           T             T         0049      20.3891       902.83      2,074.59     2,377.37
20802    Replantation, arm, complete           C             C         0000       0.0000        0.00         0.00         0.00
20805    Replant forearm, complete             C             C         0000       0.0000        0.00         0.00         0.00
20808    Replantation hand, complete           C             C         0000       0.0000        0.00         0.00         0.00
20816    Replantation digit, complete          C             C         0000       0.0000        0.00         0.00         0.00
20822    Replantation digit, complete          T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
20824    Replantation thumb, complete          C             C         0000       0.0000        0.00         0.00         0.00
20827    Replantation thumb, complete          C             C         0000       0.0000        0.00         0.00         0.00
20838    Replantation foot, complete           C             C         0000       0.0000        0.00         0.00         0.00
20900    Removal of bone for graft             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
20902    Removal of bone for graft             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
20910    Remove cartilage for graft            T             T         0027      18.1956       805.70      1,851.40     2,121.61
20912    Remove cartilage for graft            T             T         0027      18.1956       805.70      1,851.40     2,121.61
20920    Removal of fascia for graft           T             T         0686      13.4973       597.66      1,373.35     1,573.79
20922    Removal of fascia for graft           T             T         0027      18.1956       805.70      1,851.40     2,121.61
20924    Removal of tendon for graft           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
20926    Removal of tissue for graft           T             T         0686      13.4973       597.66      1,373.35     1,573.79
20930    Spinal bone allograft                 C             C         0000       0.0000        0.00         0.00         0.00
20931    Spinal bone allograft                 C             C         0000       0.0000        0.00         0.00         0.00
20936    Spinal bone autograft                 C             C         0000       0.0000        0.00         0.00         0.00
20937    Spinal bone autograft                 C             C         0000       0.0000        0.00         0.00         0.00
20938    Spinal bone autograft                 C             C         0000       0.0000        0.00         0.00         0.00
20950    Fluid pressure, muscle                T             T         0006       1.5100        66.86       153.64       176.07
20955    Fibula bone graft, microvasc          C             C         0000       0.0000        0.00         0.00         0.00
20956    Iliac bone graft, microvasc           C             C         0000       0.0000        0.00         0.00         0.00
20957    Mt bone graft, microvasc              C             C         0000       0.0000        0.00         0.00         0.00
20962    Other bone graft, microvasc           C             C         0000       0.0000        0.00         0.00         0.00
20969    Bone/skin graft, microvasc            C             C         0000       0.0000        0.00         0.00         0.00
20970    Bone/skin graft, iliac crest          C             C         0000       0.0000        0.00         0.00         0.00
20972    Bone/skin graft, metatarsal           T             T         0056      40.5436      1,795.27     4,125.31     4,727.38


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  13 of 223
State of Wyoming Oupatient Prospective Payment System                                                           Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                       Critical
                                                                                              General        Children's                 Change
                                               2006      WY 2006                                                           Access
 CPT/                                                                           APC Relative Hospital         Hospital                   from
                 Description (short)          Status       Status       APC                                                Hospital
HCPCS                                                                             Weight     Outpatient      Outpatient                 4-14-06
                                            Indicator    Indicator                                                        Outpatient
                                                                                                Fee             Fee                    Schedule
                                           (FYI Only)                                                                        Fee

20973    Bone/skin graft, great toe            T             T         0056      40.5436          1,795.27    4,125.31     4,727.38
20974    Electrical bone stimulation           A             3         0000       0.0000             M01        M01          M01
20975    Electrical bone stimulation           X             X         0340       0.6137            27.17      62.44        71.56
20979    Us bone stimulation                   B             1         0000       0.0000            0.00        0.00         0.00
20982    Ablate, bone tumor(s) perq            T             T         1557      31.0867      *   1,376.52    3,163.07     3,624.71
20999    Musculoskeletal surgery               T             1         0000       0.0000            0.00        0.00         0.00
21010    Incision of jaw joint                 T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21015    Resection of facial tumor             T             T         0253      16.0740           711.76     1,635.53     1,874.23
21025    Excision of bone, lower jaw           T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21026    Excision of facial bone(s)            T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21029    Contour of face bone lesion           T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21030    Excise max/zygoma b9 tumor            T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21031    Remove exostosis, mandible            T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21032    Remove exostosis, maxilla             T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21034    Excise max/zygoma mlg tumor           T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21040    Excise mandible lesion                T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21044    Removal of jaw bone lesion            T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21045    Extensive jaw surgery                 C             C         0000       0.0000            0.00        0.00         0.00
21046    Remove mandible cyst complex          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21047    Excise lwr jaw cyst w/repair          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21048    Remove maxilla cyst complex           T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21049    Excis uppr jaw cyst w/repair          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21050    Removal of jaw joint                  T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21060    Remove jaw joint cartilage            T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21070    Remove coronoid process               T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21076    Prepare face/oral prosthesis          T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21077    Prepare face/oral prosthesis          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21079    Prepare face/oral prosthesis          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21080    Prepare face/oral prosthesis          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21081    Prepare face/oral prosthesis          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21082    Prepare face/oral prosthesis          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21083    Prepare face/oral prosthesis          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21084    Prepare face/oral prosthesis          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21085    Prepare face/oral prosthesis          T             T         0253      16.0740           711.76     1,635.53     1,874.23
21086    Prepare face/oral prosthesis          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21087    Prepare face/oral prosthesis          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21088    Prepare face/oral prosthesis          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21089    Prepare face/oral prosthesis          T             1         0000       0.0000            0.00        0.00         0.00
21100    Maxillofacial fixation                T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21110    Interdental fixation                  T             T         0252       8.1033           358.81      824.51       944.84
21116    Injection, jaw joint x-ray            N             N         0000       0.0000            0.00        0.00         0.00
21120    Reconstruction of chin                T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21121    Reconstruction of chin                T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21122    Reconstruction of chin                T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21123    Reconstruction of chin                T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21125    Augmentation, lower jaw bone          T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21127    Augmentation, lower jaw bone          T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21137    Reduction of forehead                 T             T         0254      23.3114          1,032.23    2,371.93     2,718.11
21138    Reduction of forehead                 T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21139    Reduction of forehead                 T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21141    Reconstruct midface, lefort           C             C         0000       0.0000            0.00        0.00         0.00
21142    Reconstruct midface, lefort           C             C         0000       0.0000            0.00        0.00         0.00
21143    Reconstruct midface, lefort           C             C         0000       0.0000            0.00        0.00         0.00
21145    Reconstruct midface, lefort           C             C         0000       0.0000            0.00        0.00         0.00
21146    Reconstruct midface, lefort           C             C         0000       0.0000            0.00        0.00         0.00
21147    Reconstruct midface, lefort           C             C         0000       0.0000            0.00        0.00         0.00
21150    Reconstruct midface, lefort           T             T         0256      37.0000          1,638.36    3,764.75     4,314.20
21151    Reconstruct midface, lefort           C             C         0000       0.0000            0.00        0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                     14 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

21154    Reconstruct midface, lefort           C             C         0000       0.0000        0.00         0.00         0.00
21155    Reconstruct midface, lefort           C             C         0000       0.0000        0.00         0.00         0.00
21159    Reconstruct midface, lefort           C             C         0000       0.0000        0.00         0.00         0.00
21160    Reconstruct midface, lefort           C             C         0000       0.0000        0.00         0.00         0.00
21172    Reconstruct orbit/forehead            C             C         0000       0.0000        0.00         0.00         0.00
21175    Reconstruct orbit/forehead            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21179    Reconstruct entire forehead           C             C         0000       0.0000        0.00         0.00         0.00
21180    Reconstruct entire forehead           C             C         0000       0.0000        0.00         0.00         0.00
21181    Contour cranial bone lesion           T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21182    Reconstruct cranial bone              C             C         0000       0.0000        0.00         0.00         0.00
21183    Reconstruct cranial bone              C             C         0000       0.0000        0.00         0.00         0.00
21184    Reconstruct cranial bone              C             C         0000       0.0000        0.00         0.00         0.00
21188    Reconstruction of midface             C             C         0000       0.0000        0.00         0.00         0.00
21193    Reconst lwr jaw w/o graft             C             C         0000       0.0000        0.00         0.00         0.00
21194    Reconst lwr jaw w/graft               C             C         0000       0.0000        0.00         0.00         0.00
21195    Reconst lwr jaw w/o fixation          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21196    Reconst lwr jaw w/fixation            C             C         0000       0.0000        0.00         0.00         0.00
21198    Reconstr lwr jaw segment              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21199    Reconstr lwr jaw w/advance            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21206    Reconstruct upper jaw bone            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21208    Augmentation of facial bones          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21209    Reduction of facial bones             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21210    Face bone graft                       T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21215    Lower jaw bone graft                  T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21230    Rib cartilage graft                   T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21235    Ear cartilage graft                   T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21240    Reconstruction of jaw joint           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21242    Reconstruction of jaw joint           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21243    Reconstruction of jaw joint           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21244    Reconstruction of lower jaw           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21245    Reconstruction of jaw                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21246    Reconstruction of jaw                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21247    Reconstruct lower jaw bone            C             C         0000       0.0000        0.00         0.00         0.00
21248    Reconstruction of jaw                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21249    Reconstruction of jaw                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21255    Reconstruct lower jaw bone            C             C         0000       0.0000        0.00         0.00         0.00
21256    Reconstruction of orbit               C             C         0000       0.0000        0.00         0.00         0.00
21260    Revise eye sockets                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21261    Revise eye sockets                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21263    Revise eye sockets                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21267    Revise eye sockets                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21268    Revise eye sockets                    C             C         0000       0.0000        0.00         0.00         0.00
21270    Augmentation, cheek bone              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21275    Revision, orbitofacial bones          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21280    Revision of eyelid                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21282    Revision of eyelid                    T             T         0253      16.0740       711.76      1,635.53     1,874.23
21295    Revision of jaw muscle/bone           T             T         0252       8.1033       358.81       824.51       944.84
21296    Revision of jaw muscle/bone           T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21299    Cranio/maxillofacial surgery          T             1         0000       0.0000        0.00         0.00         0.00
21300    Treatment of skull fracture           T             T         0253      16.0740       711.76      1,635.53     1,874.23
21310    Treatment of nose fracture            T             T         0251       2.0789        92.05       211.53       242.40
21315    Treatment of nose fracture            T             T         0251       2.0789        92.05       211.53       242.40
21320    Treatment of nose fracture            T             T         0252       8.1033       358.81       824.51       944.84
21325    Treatment of nose fracture            T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21330    Treatment of nose fracture            T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21335    Treatment of nose fracture            T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21336    Treat nasal septal fracture           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
21337    Treat nasal septal fracture           T             T         0253      16.0740       711.76      1,635.53     1,874.23


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  15 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

21338    Treat nasoethmoid fracture            T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21339    Treat nasoethmoid fracture            T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21340    Treatment of nose fracture            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21343    Treatment of sinus fracture           C             C         0000       0.0000        0.00         0.00         0.00
21344    Treatment of sinus fracture           C             C         0000       0.0000        0.00         0.00         0.00
21345    Treat nose/jaw fracture               T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21346    Treat nose/jaw fracture               C             C         0000       0.0000        0.00         0.00         0.00
21347    Treat nose/jaw fracture               C             C         0000       0.0000        0.00         0.00         0.00
21348    Treat nose/jaw fracture               C             C         0000       0.0000        0.00         0.00         0.00
21355    Treat cheek bone fracture             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21356    Treat cheek bone fracture             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21360    Treat cheek bone fracture             C             C         0000       0.0000        0.00         0.00         0.00
21365    Treat cheek bone fracture             C             C         0000       0.0000        0.00         0.00         0.00
21366    Treat cheek bone fracture             C             C         0000       0.0000        0.00         0.00         0.00
21385    Treat eye socket fracture             C             C         0000       0.0000        0.00         0.00         0.00
21386    Treat eye socket fracture             C             C         0000       0.0000        0.00         0.00         0.00
21387    Treat eye socket fracture             C             C         0000       0.0000        0.00         0.00         0.00
21390    Treat eye socket fracture             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21395    Treat eye socket fracture             C             C         0000       0.0000        0.00         0.00         0.00
21400    Treat eye socket fracture             T             T         0252       8.1033       358.81       824.51       944.84
21401    Treat eye socket fracture             T             T         0253      16.0740       711.76      1,635.53     1,874.23
21406    Treat eye socket fracture             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21407    Treat eye socket fracture             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21408    Treat eye socket fracture             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21421    Treat mouth roof fracture             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21422    Treat mouth roof fracture             C             C         0000       0.0000        0.00         0.00         0.00
21423    Treat mouth roof fracture             C             C         0000       0.0000        0.00         0.00         0.00
21431    Treat craniofacial fracture           C             C         0000       0.0000        0.00         0.00         0.00
21432    Treat craniofacial fracture           C             C         0000       0.0000        0.00         0.00         0.00
21433    Treat craniofacial fracture           C             C         0000       0.0000        0.00         0.00         0.00
21435    Treat craniofacial fracture           C             C         0000       0.0000        0.00         0.00         0.00
21436    Treat craniofacial fracture           C             C         0000       0.0000        0.00         0.00         0.00
21440    Treat dental ridge fracture           T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21445    Treat dental ridge fracture           T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21450    Treat lower jaw fracture              T             T         0251       2.0789        92.05       211.53       242.40
21451    Treat lower jaw fracture              T             T         0252       8.1033       358.81       824.51       944.84
21452    Treat lower jaw fracture              T             T         0253      16.0740       711.76      1,635.53     1,874.23
21453    Treat lower jaw fracture              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21454    Treat lower jaw fracture              T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
21461    Treat lower jaw fracture              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21462    Treat lower jaw fracture              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21465    Treat lower jaw fracture              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21470    Treat lower jaw fracture              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21480    Reset dislocated jaw                  T             T         0251       2.0789        92.05       211.53       242.40
21485    Reset dislocated jaw                  T             T         0253      16.0740       711.76      1,635.53     1,874.23
21490    Repair dislocated jaw                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
21495    Treat hyoid bone fracture             T             T         0253      16.0740       711.76      1,635.53     1,874.23
21497    Interdental wiring                    T             T         0253      16.0740       711.76      1,635.53     1,874.23
21499    Head surgery procedure                T             1         0000       0.0000        0.00         0.00         0.00
21501    Drain neck/chest lesion               T             T         0008      16.2953       721.56      1,658.05     1,900.03
21502    Drain chest lesion                    T             T         0049      20.3891       902.83      2,074.59     2,377.37
21510    Drainage of bone lesion               C             C         0000       0.0000        0.00         0.00         0.00
21550    Biopsy of neck/chest                  T             T         0021      14.9984       664.13      1,526.09     1,748.81
21555    Remove lesion, neck/chest             T             T         0022      19.5716       866.63      1,991.41     2,282.05
21556    Remove lesion, neck/chest             T             T         0022      19.5716       866.63      1,991.41     2,282.05
21557    Remove tumor, neck/chest              T             T         0022      19.5716       866.63      1,991.41     2,282.05
21600    Partial removal of rib                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
21610    Partial removal of rib                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  16 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

21615    Removal of rib                        C             C         0000       0.0000        0.00         0.00         0.00
21616    Removal of rib and nerves             C             C         0000       0.0000        0.00         0.00         0.00
21620    Partial removal of sternum            C             C         0000       0.0000        0.00         0.00         0.00
21627    Sternal debridement                   C             C         0000       0.0000        0.00         0.00         0.00
21630    Extensive sternum surgery             C             C         0000       0.0000        0.00         0.00         0.00
21632    Extensive sternum surgery             C             C         0000       0.0000        0.00         0.00         0.00
21685    Hyoid myotomy & suspension            T             T         0252       8.1033       358.81       824.51       944.84
21700    Revision of neck muscle               T             T         0049      20.3891       902.83      2,074.59     2,377.37
21705    Revision of neck muscle/rib           C             C         0000       0.0000        0.00         0.00         0.00
21720    Revision of neck muscle               T             T         0049      20.3891       902.83      2,074.59     2,377.37
21725    Revision of neck muscle               T             T         0006       1.5100        66.86       153.64       176.07
21740    Reconstruction of sternum             C             C         0000       0.0000        0.00         0.00         0.00
21742    Repair stern/nuss w/o scope           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
21743    Repair sternum/nuss w/scope           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
21750    Repair of sternum separation          C             C         0000       0.0000        0.00         0.00         0.00
21800    Treatment of rib fracture             T             T         0043       1.7200        76.16       175.01       200.55
21805    Treatment of rib fracture             T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
21810    Treatment of rib fracture(s)          C             C         0000       0.0000        0.00         0.00         0.00
21820    Treat sternum fracture                T             T         0043       1.7200        76.16       175.01       200.55
21825    Treat sternum fracture                C             C         0000       0.0000        0.00         0.00         0.00
21899    Neck/chest surgery procedure          T             1         0000       0.0000        0.00         0.00         0.00
21920    Biopsy soft tissue of back            T             T         0020       6.9410       307.35       706.25       809.32
21925    Biopsy soft tissue of back            T             T         0022      19.5716       866.63      1,991.41     2,282.05
21930    Remove lesion, back or flank          T             T         0022      19.5716       866.63      1,991.41     2,282.05
21935    Remove tumor, back                    T             T         0022      19.5716       866.63      1,991.41     2,282.05
22010    I&d, p-spine, c/t/cerv-thor           C             C         0000       0.0000        0.00         0.00         0.00
22015    I&d, p-spine, l/s/ls                  C             C         0000       0.0000        0.00         0.00         0.00
22100    Remove part of neck vertebra          T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
22101    Remove part, thorax vertebra          T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
22102    Remove part, lumbar vertebra          T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
22103    Remove extra spine segment            T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
22110    Remove part of neck vertebra          C             C         0000       0.0000        0.00         0.00         0.00
22112    Remove part, thorax vertebra          C             C         0000       0.0000        0.00         0.00         0.00
22114    Remove part, lumbar vertebra          C             C         0000       0.0000        0.00         0.00         0.00
22116    Remove extra spine segment            C             C         0000       0.0000        0.00         0.00         0.00
22210    Revision of neck spine                C             C         0000       0.0000        0.00         0.00         0.00
22212    Revision of thorax spine              C             C         0000       0.0000        0.00         0.00         0.00
22214    Revision of lumbar spine              C             C         0000       0.0000        0.00         0.00         0.00
22216    Revise, extra spine segment           C             C         0000       0.0000        0.00         0.00         0.00
22220    Revision of neck spine                C             C         0000       0.0000        0.00         0.00         0.00
22222    Revision of thorax spine              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
22224    Revision of lumbar spine              C             C         0000       0.0000        0.00         0.00         0.00
22226    Revise, extra spine segment           C             C         0000       0.0000        0.00         0.00         0.00
22305    Treat spine process fracture          T             T         0043       1.7200        76.16       175.01       200.55
22310    Treat spine fracture                  T             T         0043       1.7200        76.16       175.01       200.55
22315    Treat spine fracture                  T             T         0043       1.7200        76.16       175.01       200.55
22318    Treat odontoid fx w/o graft           C             C         0000       0.0000        0.00         0.00         0.00
22319    Treat odontoid fx w/graft             C             C         0000       0.0000        0.00         0.00         0.00
22325    Treat spine fracture                  C             C         0000       0.0000        0.00         0.00         0.00
22326    Treat neck spine fracture             C             C         0000       0.0000        0.00         0.00         0.00
22327    Treat thorax spine fracture           C             C         0000       0.0000        0.00         0.00         0.00
22328    Treat each add spine fx               C             C         0000       0.0000        0.00         0.00         0.00
22505    Manipulation of spine                 T             T         0045      14.3413       635.03      1,459.23     1,672.20
22520    Percut vertebroplasty thor            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
22521    Percut vertebroplasty lumb            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
22522    Percut vertebroplasty add’l           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
22523    Percut kyphoplasty, thor              T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
22524    Percut kyphoplasty, lumbar            T             T         0052      43.5555      1,928.64     4,431.77     5,078.57


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  17 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

22525    Percut kyphoplasty, add-on            T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
22532    Lat thorax spine fusion               C             C         0000       0.0000        0.00         0.00         0.00
22533    Lat lumbar spine fusion               C             C         0000       0.0000        0.00         0.00         0.00
22534    Lat thor/lumb, add’l seg              C             C         0000       0.0000        0.00         0.00         0.00
22548    Neck spine fusion                     C             C         0000       0.0000        0.00         0.00         0.00
22554    Neck spine fusion                     C             C         0000       0.0000        0.00         0.00         0.00
22556    Thorax spine fusion                   C             C         0000       0.0000        0.00         0.00         0.00
22558    Lumbar spine fusion                   C             C         0000       0.0000        0.00         0.00         0.00
22585    Additional spinal fusion              C             C         0000       0.0000        0.00         0.00         0.00
22590    Spine & skull spinal fusion           C             C         0000       0.0000        0.00         0.00         0.00
22595    Neck spinal fusion                    C             C         0000       0.0000        0.00         0.00         0.00
22600    Neck spine fusion                     C             C         0000       0.0000        0.00         0.00         0.00
22610    Thorax spine fusion                   C             C         0000       0.0000        0.00         0.00         0.00
22612    Lumbar spine fusion                   T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
22614    Spine fusion, extra segment           T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
22630    Lumbar spine fusion                   C             C         0000       0.0000        0.00         0.00         0.00
22632    Spine fusion, extra segment           C             C         0000       0.0000        0.00         0.00         0.00
22800    Fusion of spine                       C             C         0000       0.0000        0.00         0.00         0.00
22802    Fusion of spine                       C             C         0000       0.0000        0.00         0.00         0.00
22804    Fusion of spine                       C             C         0000       0.0000        0.00         0.00         0.00
22808    Fusion of spine                       C             C         0000       0.0000        0.00         0.00         0.00
22810    Fusion of spine                       C             C         0000       0.0000        0.00         0.00         0.00
22812    Fusion of spine                       C             C         0000       0.0000        0.00         0.00         0.00
22818    Kyphectomy, 1-2 segments              C             C         0000       0.0000        0.00         0.00         0.00
22819    Kyphectomy, 3 or more                 C             C         0000       0.0000        0.00         0.00         0.00
22830    Exploration of spinal fusion          C             C         0000       0.0000        0.00         0.00         0.00
22840    Insert spine fixation device          C             C         0000       0.0000        0.00         0.00         0.00
22841    Insert spine fixation device          C             C         0000       0.0000        0.00         0.00         0.00
22842    Insert spine fixation device          C             C         0000       0.0000        0.00         0.00         0.00
22843    Insert spine fixation device          C             C         0000       0.0000        0.00         0.00         0.00
22844    Insert spine fixation device          C             C         0000       0.0000        0.00         0.00         0.00
22845    Insert spine fixation device          C             C         0000       0.0000        0.00         0.00         0.00
22846    Insert spine fixation device          C             C         0000       0.0000        0.00         0.00         0.00
22847    Insert spine fixation device          C             C         0000       0.0000        0.00         0.00         0.00
22848    Insert pelv fixation device           C             C         0000       0.0000        0.00         0.00         0.00
22849    Reinsert spinal fixation              C             C         0000       0.0000        0.00         0.00         0.00
22850    Remove spine fixation device          C             C         0000       0.0000        0.00         0.00         0.00
22851    Apply spine prosth device             C             C         0000       0.0000        0.00         0.00         0.00
22852    Remove spine fixation device          C             C         0000       0.0000        0.00         0.00         0.00
22855    Remove spine fixation device          C             C         0000       0.0000        0.00         0.00         0.00
22899    Spine surgery procedure               T             1         0000       0.0000        0.00         0.00         0.00
22900    Remove abdominal wall lesion          T             T         0022      19.5716       866.63      1,991.41     2,282.05
22999    Abdomen surgery procedure             T             1         0000       0.0000        0.00         0.00         0.00
23000    Removal of calcium deposits           T             T         0021      14.9984       664.13      1,526.09     1,748.81
23020    Release shoulder joint                T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23030    Drain shoulder lesion                 T             T         0008      16.2953       721.56      1,658.05     1,900.03
23031    Drain shoulder bursa                  T             T         0008      16.2953       721.56      1,658.05     1,900.03
23035    Drain shoulder bone lesion            T             T         0049      20.3891       902.83      2,074.59     2,377.37
23040    Exploratory shoulder surgery          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23044    Exploratory shoulder surgery          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23065    Biopsy shoulder tissues               T             T         0021      14.9984       664.13      1,526.09     1,748.81
23066    Biopsy shoulder tissues               T             T         0022      19.5716       866.63      1,991.41     2,282.05
23075    Removal of shoulder lesion            T             T         0021      14.9984       664.13      1,526.09     1,748.81
23076    Removal of shoulder lesion            T             T         0022      19.5716       866.63      1,991.41     2,282.05
23077    Remove tumor of shoulder              T             T         0022      19.5716       866.63      1,991.41     2,282.05
23100    Biopsy of shoulder joint              T             T         0049      20.3891       902.83      2,074.59     2,377.37
23101    Shoulder joint surgery                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23105    Remove shoulder joint lining          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  18 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

23106    Incision of collarbone joint          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23107    Explore treat shoulder joint          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23120    Partial removal, collar bone          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23125    Removal of collar bone                T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23130    Remove shoulder bone, part            T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23140    Removal of bone lesion                T             T         0049      20.3891       902.83      2,074.59     2,377.37
23145    Removal of bone lesion                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23146    Removal of bone lesion                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23150    Removal of humerus lesion             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23155    Removal of humerus lesion             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23156    Removal of humerus lesion             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23170    Remove collar bone lesion             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23172    Remove shoulder blade lesion          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23174    Remove humerus lesion                 T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23180    Remove collar bone lesion             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23182    Remove shoulder blade lesion          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23184    Remove humerus lesion                 T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23190    Partial removal of scapula            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23195    Removal of head of humerus            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23200    Removal of collar bone                C             C         0000       0.0000        0.00         0.00         0.00
23210    Removal of shoulder blade             C             C         0000       0.0000        0.00         0.00         0.00
23220    Partial removal of humerus            C             C         0000       0.0000        0.00         0.00         0.00
23221    Partial removal of humerus            C             C         0000       0.0000        0.00         0.00         0.00
23222    Partial removal of humerus            C             C         0000       0.0000        0.00         0.00         0.00
23330    Remove shoulder foreign body          T             T         0020       6.9410       307.35       706.25       809.32
23331    Remove shoulder foreign body          T             T         0022      19.5716       866.63      1,991.41     2,282.05
23332    Remove shoulder foreign body          C             C         0000       0.0000        0.00         0.00         0.00
23350    Injection for shoulder x-ray          N             N         0000       0.0000        0.00         0.00         0.00
23395    Muscle transfer,shoulder/arm          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23397    Muscle transfers                      T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23400    Fixation of shoulder blade            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23405    Incision of tendon & muscle           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23406    Incise tendon(s) & muscle(s)          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
23410    Repair rotator cuff, acute            T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23412    Repair rotator cuff, chronic          T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23415    Release of shoulder ligament          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23420    Repair of shoulder                    T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23430    Repair biceps tendon                  T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23440    Remove/transplant tendon              T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23450    Repair shoulder capsule               T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23455    Repair shoulder capsule               T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23460    Repair shoulder capsule               T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23462    Repair shoulder capsule               T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23465    Repair shoulder capsule               T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23466    Repair shoulder capsule               T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
23470    Reconstruct shoulder joint            T             T         0425      104.7352     4,637.67    10,656.81    12,212.12
23472    Reconstruct shoulder joint            C             C         0000       0.0000        0.00         0.00         0.00
23480    Revision of collar bone               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23485    Revision of collar bone               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23490    Reinforce clavicle                    T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23491    Reinforce shoulder bones              T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23500    Treat clavicle fracture               T             T         0043       1.7200        76.16       175.01       200.55
23505    Treat clavicle fracture               T             T         0043       1.7200        76.16       175.01       200.55
23515    Treat clavicle fracture               T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
23520    Treat clavicle dislocation            T             T         0043       1.7200        76.16       175.01       200.55
23525    Treat clavicle dislocation            T             T         0043       1.7200        76.16       175.01       200.55
23530    Treat clavicle dislocation            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
23532    Treat clavicle dislocation            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  19 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

23540    Treat clavicle dislocation            T             T         0043       1.7200        76.16       175.01       200.55
23545    Treat clavicle dislocation            T             T         0043       1.7200        76.16       175.01       200.55
23550    Treat clavicle dislocation            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
23552    Treat clavicle dislocation            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
23570    Treat shoulder blade fx               T             T         0043       1.7200        76.16       175.01       200.55
23575    Treat shoulder blade fx               T             T         0043       1.7200        76.16       175.01       200.55
23585    Treat scapula fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
23600    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
23605    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
23615    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
23616    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
23620    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
23625    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
23630    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
23650    Treat shoulder dislocation            T             T         0043       1.7200        76.16       175.01       200.55
23655    Treat shoulder dislocation            T             T         0045      14.3413       635.03      1,459.23     1,672.20
23660    Treat shoulder dislocation            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
23665    Treat dislocation/fracture            T             T         0043       1.7200        76.16       175.01       200.55
23670    Treat dislocation/fracture            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
23675    Treat dislocation/fracture            T             T         0043       1.7200        76.16       175.01       200.55
23680    Treat dislocation/fracture            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
23700    Fixation of shoulder                  T             T         0045      14.3413       635.03      1,459.23     1,672.20
23800    Fusion of shoulder joint              T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23802    Fusion of shoulder joint              T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
23900    Amputation of arm & girdle            C             C         0000       0.0000        0.00         0.00         0.00
23920    Amputation at shoulder joint          C             C         0000       0.0000        0.00         0.00         0.00
23921    Amputation follow-up surgery          T             T         0025       5.3051       234.91       539.79       618.57
23929    Shoulder surgery procedure            T             1         0000       0.0000        0.00         0.00         0.00
23930    Drainage of arm lesion                T             T         0008      16.2953       721.56      1,658.05     1,900.03
23931    Drainage of arm bursa                 T             T         0008      16.2953       721.56      1,658.05     1,900.03
23935    Drain arm/elbow bone lesion           T             T         0049      20.3891       902.83      2,074.59     2,377.37
24000    Exploratory elbow surgery             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24006    Release elbow joint                   T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24065    Biopsy arm/elbow soft tissue          T             T         0021      14.9984       664.13      1,526.09     1,748.81
24066    Biopsy arm/elbow soft tissue          T             T         0021      14.9984       664.13      1,526.09     1,748.81
24075    Remove arm/elbow lesion               T             T         0021      14.9984       664.13      1,526.09     1,748.81
24076    Remove arm/elbow lesion               T             T         0022      19.5716       866.63      1,991.41     2,282.05
24077    Remove tumor of arm/elbow             T             T         0022      19.5716       866.63      1,991.41     2,282.05
24100    Biopsy elbow joint lining             T             T         0049      20.3891       902.83      2,074.59     2,377.37
24101    Explore/treat elbow joint             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24102    Remove elbow joint lining             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24105    Removal of elbow bursa                T             T         0049      20.3891       902.83      2,074.59     2,377.37
24110    Remove humerus lesion                 T             T         0049      20.3891       902.83      2,074.59     2,377.37
24115    Remove/graft bone lesion              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24116    Remove/graft bone lesion              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24120    Remove elbow lesion                   T             T         0049      20.3891       902.83      2,074.59     2,377.37
24125    Remove/graft bone lesion              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24126    Remove/graft bone lesion              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24130    Removal of head of radius             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24134    Removal of arm bone lesion            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24136    Remove radius bone lesion             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24138    Remove elbow bone lesion              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24140    Partial removal of arm bone           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24145    Partial removal of radius             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24147    Partial removal of elbow              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24149    Radical resection of elbow            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24150    Extensive humerus surgery             T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
24151    Extensive humerus surgery             T             T         0052      43.5555      1,928.64     4,431.77     5,078.57


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  20 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

24152    Extensive radius surgery              T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
24153    Extensive radius surgery              T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
24155    Removal of elbow joint                T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24160    Remove elbow joint implant            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24164    Remove radius head implant            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24200    Removal of arm foreign body           T             T         0019       4.1481       183.68       422.07       483.67
24201    Removal of arm foreign body           T             T         0021      14.9984       664.13      1,526.09     1,748.81
24220    Injection for elbow x-ray             N             N         0000       0.0000        0.00         0.00         0.00
24300    Manipulate elbow w/anesth             T             T         0045      14.3413       635.03      1,459.23     1,672.20
24301    Muscle/tendon transfer                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24305    Arm tendon lengthening                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24310    Revision of arm tendon                T             T         0049      20.3891       902.83      2,074.59     2,377.37
24320    Repair of arm tendon                  T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24330    Revision of arm muscles               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24331    Revision of arm muscles               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24332    Tenolysis, triceps                    T             T         0049      20.3891       902.83      2,074.59     2,377.37
24340    Repair of biceps tendon               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24341    Repair arm tendon/muscle              T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24342    Repair of ruptured tendon             T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24343    Repr elbow lat ligmnt w/tiss          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24344    Reconstruct elbow lat ligmnt          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24345    Repr elbw med ligmnt w/tissu          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24346    Reconstruct elbow med ligmnt          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24350    Repair of tennis elbow                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24351    Repair of tennis elbow                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24352    Repair of tennis elbow                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24354    Repair of tennis elbow                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24356    Revision of tennis elbow              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24360    Reconstruct elbow joint               T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
24361    Reconstruct elbow joint               T             T         0425      104.7352     4,637.67    10,656.81    12,212.12
24362    Reconstruct elbow joint               T             T         0048      43.3955      1,921.55     4,415.49     5,059.92
24363    Replace elbow joint                   T             T         0425      104.7352     4,637.67    10,656.81    12,212.12
24365    Reconstruct head of radius            T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
24366    Reconstruct head of radius            T             T         0425      104.7352     4,637.67    10,656.81    12,212.12
24400    Revision of humerus                   T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24410    Revision of humerus                   T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24420    Revision of humerus                   T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24430    Repair of humerus                     T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24435    Repair humerus with graft             T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24470    Revision of elbow joint               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24495    Decompression of forearm              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
24498    Reinforce humerus                     T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24500    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
24505    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
24515    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24516    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24530    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
24535    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
24538    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24545    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24546    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24560    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
24565    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
24566    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24575    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24576    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
24577    Treat humerus fracture                T             T         0043       1.7200        76.16       175.01       200.55
24579    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  21 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

24582    Treat humerus fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24586    Treat elbow fracture                  T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24587    Treat elbow fracture                  T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24600    Treat elbow dislocation               T             T         0043       1.7200        76.16       175.01       200.55
24605    Treat elbow dislocation               T             T         0045      14.3413       635.03      1,459.23     1,672.20
24615    Treat elbow dislocation               T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24620    Treat elbow fracture                  T             T         0043       1.7200        76.16       175.01       200.55
24635    Treat elbow fracture                  T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24640    Treat elbow dislocation               T             T         0043       1.7200        76.16       175.01       200.55
24650    Treat radius fracture                 T             T         0043       1.7200        76.16       175.01       200.55
24655    Treat radius fracture                 T             T         0043       1.7200        76.16       175.01       200.55
24665    Treat radius fracture                 T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24666    Treat radius fracture                 T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24670    Treat ulnar fracture                  T             T         0043       1.7200        76.16       175.01       200.55
24675    Treat ulnar fracture                  T             T         0043       1.7200        76.16       175.01       200.55
24685    Treat ulnar fracture                  T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
24800    Fusion of elbow joint                 T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24802    Fusion/graft of elbow joint           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
24900    Amputation of upper arm               C             C         0000       0.0000        0.00         0.00         0.00
24920    Amputation of upper arm               C             C         0000       0.0000        0.00         0.00         0.00
24925    Amputation follow-up surgery          T             T         0049      20.3891       902.83      2,074.59     2,377.37
24930    Amputation follow-up surgery          C             C         0000       0.0000        0.00         0.00         0.00
24931    Amputate upper arm & implant          C             C         0000       0.0000        0.00         0.00         0.00
24935    Revision of amputation                T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
24940    Revision of upper arm                 C             C         0000       0.0000        0.00         0.00         0.00
24999    Upper arm/elbow surgery               T             1         0000       0.0000        0.00         0.00         0.00
25000    Incision of tendon sheath             T             T         0049      20.3891       902.83      2,074.59     2,377.37
25001    Incise flexor carpi radialis          T             T         0049      20.3891       902.83      2,074.59     2,377.37
25020    Decompress forearm 1 space            T             T         0049      20.3891       902.83      2,074.59     2,377.37
25023    Decompress forearm 1 space            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25024    Decompress forearm 2 spaces           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25025    Decompress forearm 2 spaces           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25028    Drainage of forearm lesion            T             T         0049      20.3891       902.83      2,074.59     2,377.37
25031    Drainage of forearm bursa             T             T         0049      20.3891       902.83      2,074.59     2,377.37
25035    Treat forearm bone lesion             T             T         0049      20.3891       902.83      2,074.59     2,377.37
25040    Explore/treat wrist joint             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25065    Biopsy forearm soft tissues           T             T         0021      14.9984       664.13      1,526.09     1,748.81
25066    Biopsy forearm soft tissues           T             T         0022      19.5716       866.63      1,991.41     2,282.05
25075    Removal forearm lesion subcu          T             T         0021      14.9984       664.13      1,526.09     1,748.81
25076    Removal forearm lesion deep           T             T         0022      19.5716       866.63      1,991.41     2,282.05
25077    Remove tumor, forearm/wrist           T             T         0022      19.5716       866.63      1,991.41     2,282.05
25085    Incision of wrist capsule             T             T         0049      20.3891       902.83      2,074.59     2,377.37
25100    Biopsy of wrist joint                 T             T         0049      20.3891       902.83      2,074.59     2,377.37
25101    Explore/treat wrist joint             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25105    Remove wrist joint lining             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25107    Remove wrist joint cartilage          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25110    Remove wrist tendon lesion            T             T         0049      20.3891       902.83      2,074.59     2,377.37
25111    Remove wrist tendon lesion            T             T         0053      15.6396       692.52      1,591.33     1,823.58
25112    Reremove wrist tendon lesion          T             T         0053      15.6396       692.52      1,591.33     1,823.58
25115    Remove wrist/forearm lesion           T             T         0049      20.3891       902.83      2,074.59     2,377.37
25116    Remove wrist/forearm lesion           T             T         0049      20.3891       902.83      2,074.59     2,377.37
25118    Excise wrist tendon sheath            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25119    Partial removal of ulna               T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25120    Removal of forearm lesion             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25125    Remove/graft forearm lesion           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25126    Remove/graft forearm lesion           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25130    Removal of wrist lesion               T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25135    Remove & graft wrist lesion           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  22 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

25136    Remove & graft wrist lesion           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25145    Remove forearm bone lesion            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25150    Partial removal of ulna               T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25151    Partial removal of radius             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25170    Extensive forearm surgery             T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
25210    Removal of wrist bone                 T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
25215    Removal of wrist bones                T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
25230    Partial removal of radius             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25240    Partial removal of ulna               T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25246    Injection for wrist x-ray             N             N         0000       0.0000        0.00         0.00         0.00
25248    Remove forearm foreign body           T             T         0049      20.3891       902.83      2,074.59     2,377.37
25250    Removal of wrist prosthesis           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25251    Removal of wrist prosthesis           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25259    Manipulate wrist w/anesthes           T             T         0043       1.7200        76.16       175.01       200.55
25260    Repair forearm tendon/muscle          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25263    Repair forearm tendon/muscle          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25265    Repair forearm tendon/muscle          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25270    Repair forearm tendon/muscle          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25272    Repair forearm tendon/muscle          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25274    Repair forearm tendon/muscle          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25275    Repair forearm tendon sheath          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25280    Revise wrist/forearm tendon           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25290    Incise wrist/forearm tendon           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25295    Release wrist/forearm tendon          T             T         0049      20.3891       902.83      2,074.59     2,377.37
25300    Fusion of tendons at wrist            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25301    Fusion of tendons at wrist            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25310    Transplant forearm tendon             T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25312    Transplant forearm tendon             T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25315    Revise palsy hand tendon(s)           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25316    Revise palsy hand tendon(s)           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25320    Repair/revise wrist joint             T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25332    Revise wrist joint                    T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
25335    Realignment of hand                   T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25337    Reconstruct ulna/radioulnar           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25350    Revision of radius                    T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25355    Revision of radius                    T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25360    Revision of ulna                      T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25365    Revise radius & ulna                  T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25370    Revise radius or ulna                 T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25375    Revise radius & ulna                  T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25390    Shorten radius or ulna                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25391    Lengthen radius or ulna               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25392    Shorten radius & ulna                 T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25393    Lengthen radius & ulna                T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25394    Repair carpal bone, shorten           T             T         0053      15.6396       692.52      1,591.33     1,823.58
25400    Repair radius or ulna                 T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25405    Repair/graft radius or ulna           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25415    Repair radius & ulna                  T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
25420    Repair/graft radius & ulna            T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25425    Repair/graft radius or ulna           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25426    Repair/graft radius & ulna            T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25430    Vasc graft into carpal bone           T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
25431    Repair nonunion carpal bone           T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
25440    Repair/graft wrist bone               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25441    Reconstruct wrist joint               T             T         0425      104.7352     4,637.67    10,656.81    12,212.12
25442    Reconstruct wrist joint               T             T         0425      104.7352     4,637.67    10,656.81    12,212.12
25443    Reconstruct wrist joint               T             T         0048      43.3955      1,921.55     4,415.49     5,059.92
25444    Reconstruct wrist joint               T             T         0048      43.3955      1,921.55     4,415.49     5,059.92


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  23 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

25445    Reconstruct wrist joint               T             T         0048      43.3955      1,921.55     4,415.49     5,059.92
25446    Wrist replacement                     T             T         0425      104.7352     4,637.67    10,656.81    12,212.12
25447    Repair wrist joint(s)                 T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
25449    Remove wrist joint implant            T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
25450    Revision of wrist joint               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25455    Revision of wrist joint               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25490    Reinforce radius                      T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25491    Reinforce ulna                        T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25492    Reinforce radius and ulna             T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25500    Treat fracture of radius              T             T         0043       1.7200        76.16       175.01       200.55
25505    Treat fracture of radius              T             T         0043       1.7200        76.16       175.01       200.55
25515    Treat fracture of radius              T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25520    Treat fracture of radius              T             T         0043       1.7200        76.16       175.01       200.55
25525    Treat fracture of radius              T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25526    Treat fracture of radius              T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25530    Treat fracture of ulna                T             T         0043       1.7200        76.16       175.01       200.55
25535    Treat fracture of ulna                T             T         0043       1.7200        76.16       175.01       200.55
25545    Treat fracture of ulna                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25560    Treat fracture radius & ulna          T             T         0043       1.7200        76.16       175.01       200.55
25565    Treat fracture radius & ulna          T             T         0043       1.7200        76.16       175.01       200.55
25574    Treat fracture radius & ulna          T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25575    Treat fracture radius/ulna            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25600    Treat fracture radius/ulna            T             T         0043       1.7200        76.16       175.01       200.55
25605    Treat fracture radius/ulna            T             T         0043       1.7200        76.16       175.01       200.55
25611    Treat fracture radius/ulna            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25620    Treat fracture radius/ulna            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25622    Treat wrist bone fracture             T             T         0043       1.7200        76.16       175.01       200.55
25624    Treat wrist bone fracture             T             T         0043       1.7200        76.16       175.01       200.55
25628    Treat wrist bone fracture             T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25630    Treat wrist bone fracture             T             T         0043       1.7200        76.16       175.01       200.55
25635    Treat wrist bone fracture             T             T         0043       1.7200        76.16       175.01       200.55
25645    Treat wrist bone fracture             T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25650    Treat wrist bone fracture             T             T         0043       1.7200        76.16       175.01       200.55
25651    Pin ulnar styloid fracture            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25652    Treat fracture ulnar styloid          T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25660    Treat wrist dislocation               T             T         0043       1.7200        76.16       175.01       200.55
25670    Treat wrist dislocation               T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25671    Pin radioulnar dislocation            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25675    Treat wrist dislocation               T             T         0043       1.7200        76.16       175.01       200.55
25676    Treat wrist dislocation               T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25680    Treat wrist fracture                  T             T         0043       1.7200        76.16       175.01       200.55
25685    Treat wrist fracture                  T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25690    Treat wrist dislocation               T             T         0043       1.7200        76.16       175.01       200.55
25695    Treat wrist dislocation               T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
25800    Fusion of wrist joint                 T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25805    Fusion/graft of wrist joint           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25810    Fusion/graft of wrist joint           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25820    Fusion of hand bones                  T             T         0053      15.6396       692.52      1,591.33     1,823.58
25825    Fuse hand bones with graft            T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
25830    Fusion, radioulnar jnt/ulna           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
25900    Amputation of forearm                 C             C         0000       0.0000        0.00         0.00         0.00
25905    Amputation of forearm                 C             C         0000       0.0000        0.00         0.00         0.00
25907    Amputation follow-up surgery          T             T         0049      20.3891       902.83      2,074.59     2,377.37
25909    Amputation follow-up surgery          C             C         0000       0.0000        0.00         0.00         0.00
25915    Amputation of forearm                 C             C         0000       0.0000        0.00         0.00         0.00
25920    Amputate hand at wrist                C             C         0000       0.0000        0.00         0.00         0.00
25922    Amputate hand at wrist                T             T         0049      20.3891       902.83      2,074.59     2,377.37
25924    Amputation follow-up surgery          C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  24 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

25927    Amputation of hand                    C             C         0000       0.0000        0.00         0.00         0.00
25929    Amputation follow-up surgery          T             T         0686      13.4973       597.66      1,373.35     1,573.79
25931    Amputation follow-up surgery          C             C         0000       0.0000        0.00         0.00         0.00
25999    Forearm or wrist surgery              T             1         0000       0.0000        0.00         0.00         0.00
26010    Drainage of finger abscess            T             T         0006       1.5100        66.86       153.64       176.07
26011    Drainage of finger abscess            T             T         0007      11.6717       516.82      1,187.60     1,360.92
26020    Drain hand tendon sheath              T             T         0053      15.6396       692.52      1,591.33     1,823.58
26025    Drainage of palm bursa                T             T         0053      15.6396       692.52      1,591.33     1,823.58
26030    Drainage of palm bursa(s)             T             T         0053      15.6396       692.52      1,591.33     1,823.58
26034    Treat hand bone lesion                T             T         0053      15.6396       692.52      1,591.33     1,823.58
26035    Decompress fingers/hand               T             T         0053      15.6396       692.52      1,591.33     1,823.58
26037    Decompress fingers/hand               T             T         0053      15.6396       692.52      1,591.33     1,823.58
26040    Release palm contracture              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26045    Release palm contracture              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26055    Incise finger tendon sheath           T             T         0053      15.6396       692.52      1,591.33     1,823.58
26060    Incision of finger tendon             T             T         0053      15.6396       692.52      1,591.33     1,823.58
26070    Explore/treat hand joint              T             T         0053      15.6396       692.52      1,591.33     1,823.58
26075    Explore/treat finger joint            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26080    Explore/treat finger joint            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26100    Biopsy hand joint lining              T             T         0053      15.6396       692.52      1,591.33     1,823.58
26105    Biopsy finger joint lining            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26110    Biopsy finger joint lining            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26115    Removal hand lesion subcut            T             T         0022      19.5716       866.63      1,991.41     2,282.05
26116    Removal hand lesion, deep             T             T         0022      19.5716       866.63      1,991.41     2,282.05
26117    Remove tumor, hand/finger             T             T         0022      19.5716       866.63      1,991.41     2,282.05
26121    Release palm contracture              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26123    Release palm contracture              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26125    Release palm contracture              T             T         0053      15.6396       692.52      1,591.33     1,823.58
26130    Remove wrist joint lining             T             T         0053      15.6396       692.52      1,591.33     1,823.58
26135    Revise finger joint, each             T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26140    Revise finger joint, each             T             T         0053      15.6396       692.52      1,591.33     1,823.58
26145    Tendon excision, palm/finger          T             T         0053      15.6396       692.52      1,591.33     1,823.58
26160    Remove tendon sheath lesion           T             T         0053      15.6396       692.52      1,591.33     1,823.58
26170    Removal of palm tendon, each          T             T         0053      15.6396       692.52      1,591.33     1,823.58
26180    Removal of finger tendon              T             T         0053      15.6396       692.52      1,591.33     1,823.58
26185    Remove finger bone                    T             T         0053      15.6396       692.52      1,591.33     1,823.58
26200    Remove hand bone lesion               T             T         0053      15.6396       692.52      1,591.33     1,823.58
26205    Remove/graft bone lesion              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26210    Removal of finger lesion              T             T         0053      15.6396       692.52      1,591.33     1,823.58
26215    Remove/graft finger lesion            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26230    Partial removal of hand bone          T             T         0053      15.6396       692.52      1,591.33     1,823.58
26235    Partial removal, finger bone          T             T         0053      15.6396       692.52      1,591.33     1,823.58
26236    Partial removal, finger bone          T             T         0053      15.6396       692.52      1,591.33     1,823.58
26250    Extensive hand surgery                T             T         0053      15.6396       692.52      1,591.33     1,823.58
26255    Extensive hand surgery                T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26260    Extensive finger surgery              T             T         0053      15.6396       692.52      1,591.33     1,823.58
26261    Extensive finger surgery              T             T         0053      15.6396       692.52      1,591.33     1,823.58
26262    Partial removal of finger             T             T         0053      15.6396       692.52      1,591.33     1,823.58
26320    Removal of implant from hand          T             T         0021      14.9984       664.13      1,526.09     1,748.81
26340    Manipulate finger w/anesth            T             T         0043       1.7200        76.16       175.01       200.55
26350    Repair finger/hand tendon             T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26352    Repair/graft hand tendon              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26356    Repair finger/hand tendon             T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26357    Repair finger/hand tendon             T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26358    Repair/graft hand tendon              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26370    Repair finger/hand tendon             T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26372    Repair/graft hand tendon              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26373    Repair finger/hand tendon             T             T         0054      25.1321      1,112.85     2,557.19     2,930.40


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  25 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

26390    Revise hand/finger tendon             T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26392    Repair/graft hand tendon              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26410    Repair hand tendon                    T             T         0053      15.6396       692.52      1,591.33     1,823.58
26412    Repair/graft hand tendon              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26415    Excision, hand/finger tendon          T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26416    Graft hand or finger tendon           T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26418    Repair finger tendon                  T             T         0053      15.6396       692.52      1,591.33     1,823.58
26420    Repair/graft finger tendon            T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26426    Repair finger/hand tendon             T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26428    Repair/graft finger tendon            T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26432    Repair finger tendon                  T             T         0053      15.6396       692.52      1,591.33     1,823.58
26433    Repair finger tendon                  T             T         0053      15.6396       692.52      1,591.33     1,823.58
26434    Repair/graft finger tendon            T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26437    Realignment of tendons                T             T         0053      15.6396       692.52      1,591.33     1,823.58
26440    Release palm/finger tendon            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26442    Release palm & finger tendon          T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26445    Release hand/finger tendon            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26449    Release forearm/hand tendon           T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26450    Incision of palm tendon               T             T         0053      15.6396       692.52      1,591.33     1,823.58
26455    Incision of finger tendon             T             T         0053      15.6396       692.52      1,591.33     1,823.58
26460    Incise hand/finger tendon             T             T         0053      15.6396       692.52      1,591.33     1,823.58
26471    Fusion of finger tendons              T             T         0053      15.6396       692.52      1,591.33     1,823.58
26474    Fusion of finger tendons              T             T         0053      15.6396       692.52      1,591.33     1,823.58
26476    Tendon lengthening                    T             T         0053      15.6396       692.52      1,591.33     1,823.58
26477    Tendon shortening                     T             T         0053      15.6396       692.52      1,591.33     1,823.58
26478    Lengthening of hand tendon            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26479    Shortening of hand tendon             T             T         0053      15.6396       692.52      1,591.33     1,823.58
26480    Transplant hand tendon                T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26483    Transplant/graft hand tendon          T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26485    Transplant palm tendon                T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26489    Transplant/graft palm tendon          T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26490    Revise thumb tendon                   T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26492    Tendon transfer with graft            T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26494    Hand tendon/muscle transfer           T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26496    Revise thumb tendon                   T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26497    Finger tendon transfer                T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26498    Finger tendon transfer                T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26499    Revision of finger                    T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26500    Hand tendon reconstruction            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26502    Hand tendon reconstruction            T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26504    Hand tendon reconstruction            T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26508    Release thumb contracture             T             T         0053      15.6396       692.52      1,591.33     1,823.58
26510    Thumb tendon transfer                 T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26516    Fusion of knuckle joint               T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26517    Fusion of knuckle joints              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26518    Fusion of knuckle joints              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26520    Release knuckle contracture           T             T         0053      15.6396       692.52      1,591.33     1,823.58
26525    Release finger contracture            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26530    Revise knuckle joint                  T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
26531    Revise knuckle with implant           T             T         0048      43.3955      1,921.55     4,415.49     5,059.92
26535    Revise finger joint                   T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
26536    Revise/implant finger joint           T             T         0048      43.3955      1,921.55     4,415.49     5,059.92
26540    Repair hand joint                     T             T         0053      15.6396       692.52      1,591.33     1,823.58
26541    Repair hand joint with graft          T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26542    Repair hand joint with graft          T             T         0053      15.6396       692.52      1,591.33     1,823.58
26545    Reconstruct finger joint              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26546    Repair nonunion hand                  T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26548    Reconstruct finger joint              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  26 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

26550    Construct thumb replacement           T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26551    Great toe-hand transfer               C             C         0000       0.0000        0.00         0.00         0.00
26553    Single transfer, toe-hand             C             C         0000       0.0000        0.00         0.00         0.00
26554    Double transfer, toe-hand             C             C         0000       0.0000        0.00         0.00         0.00
26555    Positional change of finger           T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26556    Toe joint transfer                    C             C         0000       0.0000        0.00         0.00         0.00
26560    Repair of web finger                  T             T         0053      15.6396       692.52      1,591.33     1,823.58
26561    Repair of web finger                  T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26562    Repair of web finger                  T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26565    Correct metacarpal flaw               T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26567    Correct finger deformity              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26568    Lengthen metacarpal/finger            T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26580    Repair hand deformity                 T             T         0053      15.6396       692.52      1,591.33     1,823.58
26587    Reconstruct extra finger              T             T         0053      15.6396       692.52      1,591.33     1,823.58
26590    Repair finger deformity               T             T         0053      15.6396       692.52      1,591.33     1,823.58
26591    Repair muscles of hand                T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26593    Release muscles of hand               T             T         0053      15.6396       692.52      1,591.33     1,823.58
26596    Excision constricting tissue          T             T         0053      15.6396       692.52      1,591.33     1,823.58
26600    Treat metacarpal fracture             T             T         0043       1.7200        76.16       175.01       200.55
26605    Treat metacarpal fracture             T             T         0043       1.7200        76.16       175.01       200.55
26607    Treat metacarpal fracture             T             T         0043       1.7200        76.16       175.01       200.55
26608    Treat metacarpal fracture             T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26615    Treat metacarpal fracture             T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26641    Treat thumb dislocation               T             T         0043       1.7200        76.16       175.01       200.55
26645    Treat thumb fracture                  T             T         0043       1.7200        76.16       175.01       200.55
26650    Treat thumb fracture                  T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26665    Treat thumb fracture                  T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26670    Treat hand dislocation                T             T         0043       1.7200        76.16       175.01       200.55
26675    Treat hand dislocation                T             T         0043       1.7200        76.16       175.01       200.55
26676    Pin hand dislocation                  T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26685    Treat hand dislocation                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26686    Treat hand dislocation                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26700    Treat knuckle dislocation             T             T         0043       1.7200        76.16       175.01       200.55
26705    Treat knuckle dislocation             T             T         0043       1.7200        76.16       175.01       200.55
26706    Pin knuckle dislocation               T             T         0043       1.7200        76.16       175.01       200.55
26715    Treat knuckle dislocation             T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26720    Treat finger fracture, each           T             T         0043       1.7200        76.16       175.01       200.55
26725    Treat finger fracture, each           T             T         0043       1.7200        76.16       175.01       200.55
26727    Treat finger fracture, each           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26735    Treat finger fracture, each           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26740    Treat finger fracture, each           T             T         0043       1.7200        76.16       175.01       200.55
26742    Treat finger fracture, each           T             T         0043       1.7200        76.16       175.01       200.55
26746    Treat finger fracture, each           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26750    Treat finger fracture, each           T             T         0043       1.7200        76.16       175.01       200.55
26755    Treat finger fracture, each           T             T         0043       1.7200        76.16       175.01       200.55
26756    Pin finger fracture, each             T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26765    Treat finger fracture, each           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26770    Treat finger dislocation              T             T         0043       1.7200        76.16       175.01       200.55
26775    Treat finger dislocation              T             T         0045      14.3413       635.03      1,459.23     1,672.20
26776    Pin finger dislocation                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26785    Treat finger dislocation              T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
26820    Thumb fusion with graft               T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26841    Fusion of thumb                       T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26842    Thumb fusion with graft               T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26843    Fusion of hand joint                  T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26844    Fusion/graft of hand joint            T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26850    Fusion of knuckle                     T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26852    Fusion of knuckle with graft          T             T         0054      25.1321      1,112.85     2,557.19     2,930.40


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  27 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

26860    Fusion of finger joint                T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26861    Fusion of finger jnt, add-on          T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26862    Fusion/graft of finger joint          T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26863    Fuse/graft added joint                T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26910    Amputate metacarpal bone              T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
26951    Amputation of finger/thumb            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26952    Amputation of finger/thumb            T             T         0053      15.6396       692.52      1,591.33     1,823.58
26989    Hand/finger surgery                   T             1         0000       0.0000        0.00         0.00         0.00
26990    Drainage of pelvis lesion             T             T         0049      20.3891       902.83      2,074.59     2,377.37
26991    Drainage of pelvis bursa              T             T         0049      20.3891       902.83      2,074.59     2,377.37
26992    Drainage of bone lesion               C             C         0000       0.0000        0.00         0.00         0.00
27000    Incision of hip tendon                T             T         0049      20.3891       902.83      2,074.59     2,377.37
27001    Incision of hip tendon                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27003    Incision of hip tendon                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27005    Incision of hip tendon                C             C         0000       0.0000        0.00         0.00         0.00
27006    Incision of hip tendons               C             C         0000       0.0000        0.00         0.00         0.00
27025    Incision of hip/thigh fascia          C             C         0000       0.0000        0.00         0.00         0.00
27030    Drainage of hip joint                 C             C         0000       0.0000        0.00         0.00         0.00
27033    Exploration of hip joint              T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27035    Denervation of hip joint              T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
27036    Excision of hip joint/muscle          C             C         0000       0.0000        0.00         0.00         0.00
27040    Biopsy of soft tissues                T             T         0020       6.9410       307.35       706.25       809.32
27041    Biopsy of soft tissues                T             T         0020       6.9410       307.35       706.25       809.32
27047    Remove hip/pelvis lesion              T             T         0022      19.5716       866.63      1,991.41     2,282.05
27048    Remove hip/pelvis lesion              T             T         0022      19.5716       866.63      1,991.41     2,282.05
27049    Remove tumor, hip/pelvis              T             T         0022      19.5716       866.63      1,991.41     2,282.05
27050    Biopsy of sacroiliac joint            T             T         0049      20.3891       902.83      2,074.59     2,377.37
27052    Biopsy of hip joint                   T             T         0049      20.3891       902.83      2,074.59     2,377.37
27054    Removal of hip joint lining           C             C         0000       0.0000        0.00         0.00         0.00
27060    Removal of ischial bursa              T             T         0049      20.3891       902.83      2,074.59     2,377.37
27062    Remove femur lesion/bursa             T             T         0049      20.3891       902.83      2,074.59     2,377.37
27065    Removal of hip bone lesion            T             T         0049      20.3891       902.83      2,074.59     2,377.37
27066    Removal of hip bone lesion            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27067    Remove/graft hip bone lesion          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27070    Partial removal of hip bone           C             C         0000       0.0000        0.00         0.00         0.00
27071    Partial removal of hip bone           C             C         0000       0.0000        0.00         0.00         0.00
27075    Extensive hip surgery                 C             C         0000       0.0000        0.00         0.00         0.00
27076    Extensive hip surgery                 C             C         0000       0.0000        0.00         0.00         0.00
27077    Extensive hip surgery                 C             C         0000       0.0000        0.00         0.00         0.00
27078    Extensive hip surgery                 C             C         0000       0.0000        0.00         0.00         0.00
27079    Extensive hip surgery                 C             C         0000       0.0000        0.00         0.00         0.00
27080    Removal of tail bone                  T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27086    Remove hip foreign body               T             T         0020       6.9410       307.35       706.25       809.32
27087    Remove hip foreign body               T             T         0049      20.3891       902.83      2,074.59     2,377.37
27090    Removal of hip prosthesis             C             C         0000       0.0000        0.00         0.00         0.00
27091    Removal of hip prosthesis             C             C         0000       0.0000        0.00         0.00         0.00
27093    Injection for hip x-ray               N             N         0000       0.0000        0.00         0.00         0.00
27095    Injection for hip x-ray               N             N         0000       0.0000        0.00         0.00         0.00
27096    Inject sacroiliac joint               B             1         0000       0.0000        0.00         0.00         0.00
27097    Revision of hip tendon                T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27098    Transfer tendon to pelvis             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27100    Transfer of abdominal muscle          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27105    Transfer of spinal muscle             T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27110    Transfer of iliopsoas muscle          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27111    Transfer of iliopsoas muscle          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27120    Reconstruction of hip socket          C             C         0000       0.0000        0.00         0.00         0.00
27122    Reconstruction of hip socket          C             C         0000       0.0000        0.00         0.00         0.00
27125    Partial hip replacement               C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  28 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

27130    Total hip arthroplasty                C             C         0000       0.0000        0.00         0.00         0.00
27132    Total hip arthroplasty                C             C         0000       0.0000        0.00         0.00         0.00
27134    Revise hip joint replacement          C             C         0000       0.0000        0.00         0.00         0.00
27137    Revise hip joint replacement          C             C         0000       0.0000        0.00         0.00         0.00
27138    Revise hip joint replacement          C             C         0000       0.0000        0.00         0.00         0.00
27140    Transplant femur ridge                C             C         0000       0.0000        0.00         0.00         0.00
27146    Incision of hip bone                  C             C         0000       0.0000        0.00         0.00         0.00
27147    Revision of hip bone                  C             C         0000       0.0000        0.00         0.00         0.00
27151    Incision of hip bones                 C             C         0000       0.0000        0.00         0.00         0.00
27156    Revision of hip bones                 C             C         0000       0.0000        0.00         0.00         0.00
27158    Revision of pelvis                    C             C         0000       0.0000        0.00         0.00         0.00
27161    Incision of neck of femur             C             C         0000       0.0000        0.00         0.00         0.00
27165    Incision/fixation of femur            C             C         0000       0.0000        0.00         0.00         0.00
27170    Repair/graft femur head/neck          C             C         0000       0.0000        0.00         0.00         0.00
27175    Treat slipped epiphysis               C             C         0000       0.0000        0.00         0.00         0.00
27176    Treat slipped epiphysis               C             C         0000       0.0000        0.00         0.00         0.00
27177    Treat slipped epiphysis               C             C         0000       0.0000        0.00         0.00         0.00
27178    Treat slipped epiphysis               C             C         0000       0.0000        0.00         0.00         0.00
27179    Revise head/neck of femur             C             C         0000       0.0000        0.00         0.00         0.00
27181    Treat slipped epiphysis               C             C         0000       0.0000        0.00         0.00         0.00
27185    Revision of femur epiphysis           C             C         0000       0.0000        0.00         0.00         0.00
27187    Reinforce hip bones                   C             C         0000       0.0000        0.00         0.00         0.00
27193    Treat pelvic ring fracture            T             T         0043       1.7200        76.16       175.01       200.55
27194    Treat pelvic ring fracture            T             T         0045      14.3413       635.03      1,459.23     1,672.20
27200    Treat tail bone fracture              T             T         0043       1.7200        76.16       175.01       200.55
27202    Treat tail bone fracture              T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27215    Treat pelvic fracture(s)              C             C         0000       0.0000        0.00         0.00         0.00
27216    Treat pelvic ring fracture            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27217    Treat pelvic ring fracture            C             C         0000       0.0000        0.00         0.00         0.00
27218    Treat pelvic ring fracture            C             C         0000       0.0000        0.00         0.00         0.00
27220    Treat hip socket fracture             T             T         0043       1.7200        76.16       175.01       200.55
27222    Treat hip socket fracture             C             C         0000       0.0000        0.00         0.00         0.00
27226    Treat hip wall fracture               C             C         0000       0.0000        0.00         0.00         0.00
27227    Treat hip fracture(s)                 C             C         0000       0.0000        0.00         0.00         0.00
27228    Treat hip fracture(s)                 C             C         0000       0.0000        0.00         0.00         0.00
27230    Treat thigh fracture                  T             T         0043       1.7200        76.16       175.01       200.55
27232    Treat thigh fracture                  C             C         0000       0.0000        0.00         0.00         0.00
27235    Treat thigh fracture                  T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27236    Treat thigh fracture                  C             C         0000       0.0000        0.00         0.00         0.00
27238    Treat thigh fracture                  T             T         0043       1.7200        76.16       175.01       200.55
27240    Treat thigh fracture                  C             C         0000       0.0000        0.00         0.00         0.00
27244    Treat thigh fracture                  C             C         0000       0.0000        0.00         0.00         0.00
27245    Treat thigh fracture                  C             C         0000       0.0000        0.00         0.00         0.00
27246    Treat thigh fracture                  T             T         0043       1.7200        76.16       175.01       200.55
27248    Treat thigh fracture                  C             C         0000       0.0000        0.00         0.00         0.00
27250    Treat hip dislocation                 T             T         0043       1.7200        76.16       175.01       200.55
27252    Treat hip dislocation                 T             T         0045      14.3413       635.03      1,459.23     1,672.20
27253    Treat hip dislocation                 C             C         0000       0.0000        0.00         0.00         0.00
27254    Treat hip dislocation                 C             C         0000       0.0000        0.00         0.00         0.00
27256    Treat hip dislocation                 T             T         0043       1.7200        76.16       175.01       200.55
27257    Treat hip dislocation                 T             T         0045      14.3413       635.03      1,459.23     1,672.20
27258    Treat hip dislocation                 C             C         0000       0.0000        0.00         0.00         0.00
27259    Treat hip dislocation                 C             C         0000       0.0000        0.00         0.00         0.00
27265    Treat hip dislocation                 T             T         0043       1.7200        76.16       175.01       200.55
27266    Treat hip dislocation                 T             T         0045      14.3413       635.03      1,459.23     1,672.20
27275    Manipulation of hip joint             T             T         0045      14.3413       635.03      1,459.23     1,672.20
27280    Fusion of sacroiliac joint            C             C         0000       0.0000        0.00         0.00         0.00
27282    Fusion of pubic bones                 C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  29 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

27284    Fusion of hip joint                   C             C         0000       0.0000        0.00         0.00         0.00
27286    Fusion of hip joint                   C             C         0000       0.0000        0.00         0.00         0.00
27290    Amputation of leg at hip              C             C         0000       0.0000        0.00         0.00         0.00
27295    Amputation of leg at hip              C             C         0000       0.0000        0.00         0.00         0.00
27299    Pelvis/hip joint surgery              T             1         0000       0.0000        0.00         0.00         0.00
27301    Drain thigh/knee lesion               T             T         0008      16.2953       721.56      1,658.05     1,900.03
27303    Drainage of bone lesion               C             C         0000       0.0000        0.00         0.00         0.00
27305    Incise thigh tendon & fascia          T             T         0049      20.3891       902.83      2,074.59     2,377.37
27306    Incision of thigh tendon              T             T         0049      20.3891       902.83      2,074.59     2,377.37
27307    Incision of thigh tendons             T             T         0049      20.3891       902.83      2,074.59     2,377.37
27310    Exploration of knee joint             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27315    Partial removal, thigh nerve          T             T         0220      17.3203       766.94      1,762.34     2,019.55
27320    Partial removal, thigh nerve          T             T         0220      17.3203       766.94      1,762.34     2,019.55
27323    Biopsy, thigh soft tissues            T             T         0021      14.9984       664.13      1,526.09     1,748.81
27324    Biopsy, thigh soft tissues            T             T         0022      19.5716       866.63      1,991.41     2,282.05
27327    Removal of thigh lesion               T             T         0022      19.5716       866.63      1,991.41     2,282.05
27328    Removal of thigh lesion               T             T         0022      19.5716       866.63      1,991.41     2,282.05
27329    Remove tumor, thigh/knee              T             T         0022      19.5716       866.63      1,991.41     2,282.05
27330    Biopsy, knee joint lining             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27331    Explore/treat knee joint              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27332    Removal of knee cartilage             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27333    Removal of knee cartilage             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27334    Remove knee joint lining              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27335    Remove knee joint lining              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27340    Removal of kneecap bursa              T             T         0049      20.3891       902.83      2,074.59     2,377.37
27345    Removal of knee cyst                  T             T         0049      20.3891       902.83      2,074.59     2,377.37
27347    Remove knee cyst                      T             T         0049      20.3891       902.83      2,074.59     2,377.37
27350    Removal of kneecap                    T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27355    Remove femur lesion                   T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27356    Remove femur lesion/graft             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27357    Remove femur lesion/graft             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27358    Remove femur lesion/fixation          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27360    Partial removal, leg bone(s)          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27365    Extensive leg surgery                 C             C         0000       0.0000        0.00         0.00         0.00
27370    Injection for knee x-ray              N             N         0000       0.0000        0.00         0.00         0.00
27372    Removal of foreign body               T             T         0022      19.5716       866.63      1,991.41     2,282.05
27380    Repair of kneecap tendon              T             T         0049      20.3891       902.83      2,074.59     2,377.37
27381    Repair/graft kneecap tendon           T             T         0049      20.3891       902.83      2,074.59     2,377.37
27385    Repair of thigh muscle                T             T         0049      20.3891       902.83      2,074.59     2,377.37
27386    Repair/graft of thigh muscle          T             T         0049      20.3891       902.83      2,074.59     2,377.37
27390    Incision of thigh tendon              T             T         0049      20.3891       902.83      2,074.59     2,377.37
27391    Incision of thigh tendons             T             T         0049      20.3891       902.83      2,074.59     2,377.37
27392    Incision of thigh tendons             T             T         0049      20.3891       902.83      2,074.59     2,377.37
27393    Lengthening of thigh tendon           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27394    Lengthening of thigh tendons          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27395    Lengthening of thigh tendons          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27396    Transplant of thigh tendon            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27397    Transplants of thigh tendons          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27400    Revise thigh muscles/tendons          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27403    Repair of knee cartilage              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27405    Repair of knee ligament               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27407    Repair of knee ligament               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27409    Repair of knee ligaments              T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27412    Autochondrocyte implant knee          T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
27415    Osteochondral knee allograft          T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
27418    Repair degenerated kneecap            T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27420    Revision of unstable kneecap          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27422    Revision of unstable kneecap          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  30 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

27424    Revision/removal of kneecap           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27425    Lat retinacular release open          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27427    Reconstruction, knee                  T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
27428    Reconstruction, knee                  T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
27429    Reconstruction, knee                  T             T         0052      43.5555      1,928.64     4,431.77     5,078.57
27430    Revision of thigh muscles             T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27435    Incision of knee joint                T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27437    Revise kneecap                        T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
27438    Revise kneecap with implant           T             T         0048      43.3955      1,921.55     4,415.49     5,059.92
27440    Revision of knee joint                T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
27441    Revision of knee joint                T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
27442    Revision of knee joint                T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
27443    Revision of knee joint                T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
27445    Revision of knee joint                C             C         0000       0.0000        0.00         0.00         0.00
27446    Revision of knee joint                T             T         0681      135.4643     5,998.36    13,783.49    15,795.14
27447    Total knee arthroplasty               C             C         0000       0.0000        0.00         0.00         0.00
27448    Incision of thigh                     C             C         0000       0.0000        0.00         0.00         0.00
27450    Incision of thigh                     C             C         0000       0.0000        0.00         0.00         0.00
27454    Realignment of thigh bone             C             C         0000       0.0000        0.00         0.00         0.00
27455    Realignment of knee                   C             C         0000       0.0000        0.00         0.00         0.00
27457    Realignment of knee                   C             C         0000       0.0000        0.00         0.00         0.00
27465    Shortening of thigh bone              C             C         0000       0.0000        0.00         0.00         0.00
27466    Lengthening of thigh bone             C             C         0000       0.0000        0.00         0.00         0.00
27468    Shorten/lengthen thighs               C             C         0000       0.0000        0.00         0.00         0.00
27470    Repair of thigh                       C             C         0000       0.0000        0.00         0.00         0.00
27472    Repair/graft of thigh                 C             C         0000       0.0000        0.00         0.00         0.00
27475    Surgery to stop leg growth            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27477    Surgery to stop leg growth            C             C         0000       0.0000        0.00         0.00         0.00
27479    Surgery to stop leg growth            C             C         0000       0.0000        0.00         0.00         0.00
27485    Surgery to stop leg growth            C             C         0000       0.0000        0.00         0.00         0.00
27486    Revise/replace knee joint             C             C         0000       0.0000        0.00         0.00         0.00
27487    Revise/replace knee joint             C             C         0000       0.0000        0.00         0.00         0.00
27488    Removal of knee prosthesis            C             C         0000       0.0000        0.00         0.00         0.00
27495    Reinforce thigh                       C             C         0000       0.0000        0.00         0.00         0.00
27496    Decompression of thigh/knee           T             T         0049      20.3891       902.83      2,074.59     2,377.37
27497    Decompression of thigh/knee           T             T         0049      20.3891       902.83      2,074.59     2,377.37
27498    Decompression of thigh/knee           T             T         0049      20.3891       902.83      2,074.59     2,377.37
27499    Decompression of thigh/knee           T             T         0049      20.3891       902.83      2,074.59     2,377.37
27500    Treatment of thigh fracture           T             T         0043       1.7200        76.16       175.01       200.55
27501    Treatment of thigh fracture           T             T         0043       1.7200        76.16       175.01       200.55
27502    Treatment of thigh fracture           T             T         0043       1.7200        76.16       175.01       200.55
27503    Treatment of thigh fracture           T             T         0043       1.7200        76.16       175.01       200.55
27506    Treatment of thigh fracture           C             C         0000       0.0000        0.00         0.00         0.00
27507    Treatment of thigh fracture           C             C         0000       0.0000        0.00         0.00         0.00
27508    Treatment of thigh fracture           T             T         0043       1.7200        76.16       175.01       200.55
27509    Treatment of thigh fracture           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27510    Treatment of thigh fracture           T             T         0043       1.7200        76.16       175.01       200.55
27511    Treatment of thigh fracture           C             C         0000       0.0000        0.00         0.00         0.00
27513    Treatment of thigh fracture           C             C         0000       0.0000        0.00         0.00         0.00
27514    Treatment of thigh fracture           C             C         0000       0.0000        0.00         0.00         0.00
27516    Treat thigh fx growth plate           T             T         0043       1.7200        76.16       175.01       200.55
27517    Treat thigh fx growth plate           T             T         0043       1.7200        76.16       175.01       200.55
27519    Treat thigh fx growth plate           C             C         0000       0.0000        0.00         0.00         0.00
27520    Treat kneecap fracture                T             T         0043       1.7200        76.16       175.01       200.55
27524    Treat kneecap fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27530    Treat knee fracture                   T             T         0043       1.7200        76.16       175.01       200.55
27532    Treat knee fracture                   T             T         0043       1.7200        76.16       175.01       200.55
27535    Treat knee fracture                   C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  31 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

27536    Treat knee fracture                   C             C         0000       0.0000        0.00         0.00         0.00
27538    Treat knee fracture(s)                T             T         0043       1.7200        76.16       175.01       200.55
27540    Treat knee fracture                   C             C         0000       0.0000        0.00         0.00         0.00
27550    Treat knee dislocation                T             T         0043       1.7200        76.16       175.01       200.55
27552    Treat knee dislocation                T             T         0045      14.3413       635.03      1,459.23     1,672.20
27556    Treat knee dislocation                C             C         0000       0.0000        0.00         0.00         0.00
27557    Treat knee dislocation                C             C         0000       0.0000        0.00         0.00         0.00
27558    Treat knee dislocation                C             C         0000       0.0000        0.00         0.00         0.00
27560    Treat kneecap dislocation             T             T         0043       1.7200        76.16       175.01       200.55
27562    Treat kneecap dislocation             T             T         0045      14.3413       635.03      1,459.23     1,672.20
27566    Treat kneecap dislocation             T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27570    Fixation of knee joint                T             T         0045      14.3413       635.03      1,459.23     1,672.20
27580    Fusion of knee                        C             C         0000       0.0000        0.00         0.00         0.00
27590    Amputate leg at thigh                 C             C         0000       0.0000        0.00         0.00         0.00
27591    Amputate leg at thigh                 C             C         0000       0.0000        0.00         0.00         0.00
27592    Amputate leg at thigh                 C             C         0000       0.0000        0.00         0.00         0.00
27594    Amputation follow-up surgery          T             T         0049      20.3891       902.83      2,074.59     2,377.37
27596    Amputation follow-up surgery          C             C         0000       0.0000        0.00         0.00         0.00
27598    Amputate lower leg at knee            C             C         0000       0.0000        0.00         0.00         0.00
27599    Leg surgery procedure                 T             1         0000       0.0000        0.00         0.00         0.00
27600    Decompression of lower leg            T             T         0049      20.3891       902.83      2,074.59     2,377.37
27601    Decompression of lower leg            T             T         0049      20.3891       902.83      2,074.59     2,377.37
27602    Decompression of lower leg            T             T         0049      20.3891       902.83      2,074.59     2,377.37
27603    Drain lower leg lesion                T             T         0008      16.2953       721.56      1,658.05     1,900.03
27604    Drain lower leg bursa                 T             T         0049      20.3891       902.83      2,074.59     2,377.37
27605    Incision of achilles tendon           T             T         0055      19.9374       882.83      2,028.63     2,324.70
27606    Incision of achilles tendon           T             T         0049      20.3891       902.83      2,074.59     2,377.37
27607    Treat lower leg bone lesion           T             T         0049      20.3891       902.83      2,074.59     2,377.37
27610    Explore/treat ankle joint             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27612    Exploration of ankle joint            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27613    Biopsy lower leg soft tissue          T             T         0020       6.9410       307.35       706.25       809.32
27614    Biopsy lower leg soft tissue          T             T         0022      19.5716       866.63      1,991.41     2,282.05
27615    Remove tumor, lower leg               T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27618    Remove lower leg lesion               T             T         0021      14.9984       664.13      1,526.09     1,748.81
27619    Remove lower leg lesion               T             T         0022      19.5716       866.63      1,991.41     2,282.05
27620    Explore/treat ankle joint             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27625    Remove ankle joint lining             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27626    Remove ankle joint lining             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27630    Removal of tendon lesion              T             T         0049      20.3891       902.83      2,074.59     2,377.37
27635    Remove lower leg bone lesion          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27637    Remove/graft leg bone lesion          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27638    Remove/graft leg bone lesion          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27640    Partial removal of tibia              T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27641    Partial removal of fibula             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27645    Extensive lower leg surgery           C             C         0000       0.0000        0.00         0.00         0.00
27646    Extensive lower leg surgery           C             C         0000       0.0000        0.00         0.00         0.00
27647    Extensive ankle/heel surgery          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27648    Injection for ankle x-ray             N             N         0000       0.0000        0.00         0.00         0.00
27650    Repair achilles tendon                T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27652    Repair/graft achilles tendon          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27654    Repair of achilles tendon             T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27656    Repair leg fascia defect              T             T         0049      20.3891       902.83      2,074.59     2,377.37
27658    Repair of leg tendon, each            T             T         0049      20.3891       902.83      2,074.59     2,377.37
27659    Repair of leg tendon, each            T             T         0049      20.3891       902.83      2,074.59     2,377.37
27664    Repair of leg tendon, each            T             T         0049      20.3891       902.83      2,074.59     2,377.37
27665    Repair of leg tendon, each            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27675    Repair lower leg tendons              T             T         0049      20.3891       902.83      2,074.59     2,377.37
27676    Repair lower leg tendons              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  32 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

27680    Release of lower leg tendon           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27681    Release of lower leg tendons          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27685    Revision of lower leg tendon          T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27686    Revise lower leg tendons              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27687    Revision of calf tendon               T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27690    Revise lower leg tendon               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27691    Revise lower leg tendon               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27692    Revise additional leg tendon          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27695    Repair of ankle ligament              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27696    Repair of ankle ligaments             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27698    Repair of ankle ligament              T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27700    Revision of ankle joint               T             T         0047      31.2345      1,383.06     3,178.11     3,641.94
27702    Reconstruct ankle joint               C             C         0000       0.0000        0.00         0.00         0.00
27703    Reconstruction, ankle joint           C             C         0000       0.0000        0.00         0.00         0.00
27704    Removal of ankle implant              T             T         0049      20.3891       902.83      2,074.59     2,377.37
27705    Incision of tibia                     T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27707    Incision of fibula                    T             T         0049      20.3891       902.83      2,074.59     2,377.37
27709    Incision of tibia & fibula            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27712    Realignment of lower leg              C             C         0000       0.0000        0.00         0.00         0.00
27715    Revision of lower leg                 C             C         0000       0.0000        0.00         0.00         0.00
27720    Repair of tibia                       C             C         0000       0.0000        0.00         0.00         0.00
27722    Repair/graft of tibia                 C             C         0000       0.0000        0.00         0.00         0.00
27724    Repair/graft of tibia                 C             C         0000       0.0000        0.00         0.00         0.00
27725    Repair of lower leg                   C             C         0000       0.0000        0.00         0.00         0.00
27727    Repair of lower leg                   C             C         0000       0.0000        0.00         0.00         0.00
27730    Repair of tibia epiphysis             T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27732    Repair of fibula epiphysis            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27734    Repair lower leg epiphyses            T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27740    Repair of leg epiphyses               T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27742    Repair of leg epiphyses               T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27745    Reinforce tibia                       T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27750    Treatment of tibia fracture           T             T         0043       1.7200        76.16       175.01       200.55
27752    Treatment of tibia fracture           T             T         0043       1.7200        76.16       175.01       200.55
27756    Treatment of tibia fracture           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27758    Treatment of tibia fracture           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27759    Treatment of tibia fracture           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27760    Treatment of ankle fracture           T             T         0043       1.7200        76.16       175.01       200.55
27762    Treatment of ankle fracture           T             T         0043       1.7200        76.16       175.01       200.55
27766    Treatment of ankle fracture           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27780    Treatment of fibula fracture          T             T         0043       1.7200        76.16       175.01       200.55
27781    Treatment of fibula fracture          T             T         0043       1.7200        76.16       175.01       200.55
27784    Treatment of fibula fracture          T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27786    Treatment of ankle fracture           T             T         0043       1.7200        76.16       175.01       200.55
27788    Treatment of ankle fracture           T             T         0043       1.7200        76.16       175.01       200.55
27792    Treatment of ankle fracture           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27808    Treatment of ankle fracture           T             T         0043       1.7200        76.16       175.01       200.55
27810    Treatment of ankle fracture           T             T         0043       1.7200        76.16       175.01       200.55
27814    Treatment of ankle fracture           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27816    Treatment of ankle fracture           T             T         0043       1.7200        76.16       175.01       200.55
27818    Treatment of ankle fracture           T             T         0043       1.7200        76.16       175.01       200.55
27822    Treatment of ankle fracture           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27823    Treatment of ankle fracture           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27824    Treat lower leg fracture              T             T         0043       1.7200        76.16       175.01       200.55
27825    Treat lower leg fracture              T             T         0043       1.7200        76.16       175.01       200.55
27826    Treat lower leg fracture              T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27827    Treat lower leg fracture              T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27828    Treat lower leg fracture              T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27829    Treat lower leg joint                 T             T         0046      37.8852      1,677.56     3,854.82     4,417.41


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  33 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

27830    Treat lower leg dislocation           T             T         0043       1.7200        76.16       175.01       200.55
27831    Treat lower leg dislocation           T             T         0043       1.7200        76.16       175.01       200.55
27832    Treat lower leg dislocation           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27840    Treat ankle dislocation               T             T         0043       1.7200        76.16       175.01       200.55
27842    Treat ankle dislocation               T             T         0045      14.3413       635.03      1,459.23     1,672.20
27846    Treat ankle dislocation               T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27848    Treat ankle dislocation               T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
27860    Fixation of ankle joint               T             T         0045      14.3413       635.03      1,459.23     1,672.20
27870    Fusion of ankle joint, open           T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27871    Fusion of tibiofibular joint          T             T         0051      36.6106      1,621.12     3,725.13     4,268.80
27880    Amputation of lower leg               C             C         0000       0.0000        0.00         0.00         0.00
27881    Amputation of lower leg               C             C         0000       0.0000        0.00         0.00         0.00
27882    Amputation of lower leg               C             C         0000       0.0000        0.00         0.00         0.00
27884    Amputation follow-up surgery          T             T         0049      20.3891       902.83      2,074.59     2,377.37
27886    Amputation follow-up surgery          C             C         0000       0.0000        0.00         0.00         0.00
27888    Amputation of foot at ankle           C             C         0000       0.0000        0.00         0.00         0.00
27889    Amputation of foot at ankle           T             T         0050      23.9367      1,059.92     2,435.56     2,791.02
27892    Decompression of leg                  T             T         0049      20.3891       902.83      2,074.59     2,377.37
27893    Decompression of leg                  T             T         0049      20.3891       902.83      2,074.59     2,377.37
27894    Decompression of leg                  T             T         0049      20.3891       902.83      2,074.59     2,377.37
27899    Leg/ankle surgery procedure           T             1         0000       0.0000        0.00         0.00         0.00
28001    Drainage of bursa of foot             T             T         0007      11.6717       516.82      1,187.60     1,360.92
28002    Treatment of foot infection           T             T         0049      20.3891       902.83      2,074.59     2,377.37
28003    Treatment of foot infection           T             T         0049      20.3891       902.83      2,074.59     2,377.37
28005    Treat foot bone lesion                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28008    Incision of foot fascia               T             T         0055      19.9374       882.83      2,028.63     2,324.70
28010    Incision of toe tendon                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28011    Incision of toe tendons               T             T         0055      19.9374       882.83      2,028.63     2,324.70
28020    Exploration of foot joint             T             T         0055      19.9374       882.83      2,028.63     2,324.70
28022    Exploration of foot joint             T             T         0055      19.9374       882.83      2,028.63     2,324.70
28024    Exploration of toe joint              T             T         0055      19.9374       882.83      2,028.63     2,324.70
28030    Removal of foot nerve                 T             T         0220      17.3203       766.94      1,762.34     2,019.55
28035    Decompression of tibia nerve          T             T         0220      17.3203       766.94      1,762.34     2,019.55
28043    Excision of foot lesion               T             T         0021      14.9984       664.13      1,526.09     1,748.81
28045    Excision of foot lesion               T             T         0055      19.9374       882.83      2,028.63     2,324.70
28046    Resection of tumor, foot              T             T         0055      19.9374       882.83      2,028.63     2,324.70
28050    Biopsy of foot joint lining           T             T         0055      19.9374       882.83      2,028.63     2,324.70
28052    Biopsy of foot joint lining           T             T         0055      19.9374       882.83      2,028.63     2,324.70
28054    Biopsy of toe joint lining            T             T         0055      19.9374       882.83      2,028.63     2,324.70
28060    Partial removal, foot fascia          T             T         0055      19.9374       882.83      2,028.63     2,324.70
28062    Removal of foot fascia                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28070    Removal of foot joint lining          T             T         0055      19.9374       882.83      2,028.63     2,324.70
28072    Removal of foot joint lining          T             T         0055      19.9374       882.83      2,028.63     2,324.70
28080    Removal of foot lesion                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28086    Excise foot tendon sheath             T             T         0055      19.9374       882.83      2,028.63     2,324.70
28088    Excise foot tendon sheath             T             T         0055      19.9374       882.83      2,028.63     2,324.70
28090    Removal of foot lesion                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28092    Removal of toe lesions                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28100    Removal of ankle/heel lesion          T             T         0055      19.9374       882.83      2,028.63     2,324.70
28102    Remove/graft foot lesion              T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28103    Remove/graft foot lesion              T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28104    Removal of foot lesion                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28106    Remove/graft foot lesion              T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28107    Remove/graft foot lesion              T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28108    Removal of toe lesions                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28110    Part removal of metatarsal            T             T         0055      19.9374       882.83      2,028.63     2,324.70
28111    Part removal of metatarsal            T             T         0055      19.9374       882.83      2,028.63     2,324.70
28112    Part removal of metatarsal            T             T         0055      19.9374       882.83      2,028.63     2,324.70


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  34 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

28113    Part removal of metatarsal            T             T         0055      19.9374       882.83      2,028.63     2,324.70
28114    Removal of metatarsal heads           T             T         0055      19.9374       882.83      2,028.63     2,324.70
28116    Revision of foot                      T             T         0055      19.9374       882.83      2,028.63     2,324.70
28118    Removal of heel bone                  T             T         0055      19.9374       882.83      2,028.63     2,324.70
28119    Removal of heel spur                  T             T         0055      19.9374       882.83      2,028.63     2,324.70
28120    Part removal of ankle/heel            T             T         0055      19.9374       882.83      2,028.63     2,324.70
28122    Partial removal of foot bone          T             T         0055      19.9374       882.83      2,028.63     2,324.70
28124    Partial removal of toe                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28126    Partial removal of toe                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28130    Removal of ankle bone                 T             T         0055      19.9374       882.83      2,028.63     2,324.70
28140    Removal of metatarsal                 T             T         0055      19.9374       882.83      2,028.63     2,324.70
28150    Removal of toe                        T             T         0055      19.9374       882.83      2,028.63     2,324.70
28153    Partial removal of toe                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28160    Partial removal of toe                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28171    Extensive foot surgery                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28173    Extensive foot surgery                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28175    Extensive foot surgery                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28190    Removal of foot foreign body          T             T         0019       4.1481       183.68       422.07       483.67
28192    Removal of foot foreign body          T             T         0021      14.9984       664.13      1,526.09     1,748.81
28193    Removal of foot foreign body          T             T         0020       6.9410       307.35       706.25       809.32
28200    Repair of foot tendon                 T             T         0055      19.9374       882.83      2,028.63     2,324.70
28202    Repair/graft of foot tendon           T             T         0055      19.9374       882.83      2,028.63     2,324.70
28208    Repair of foot tendon                 T             T         0055      19.9374       882.83      2,028.63     2,324.70
28210    Repair/graft of foot tendon           T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28220    Release of foot tendon                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28222    Release of foot tendons               T             T         0055      19.9374       882.83      2,028.63     2,324.70
28225    Release of foot tendon                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28226    Release of foot tendons               T             T         0055      19.9374       882.83      2,028.63     2,324.70
28230    Incision of foot tendon(s)            T             T         0055      19.9374       882.83      2,028.63     2,324.70
28232    Incision of toe tendon                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28234    Incision of foot tendon               T             T         0055      19.9374       882.83      2,028.63     2,324.70
28238    Revision of foot tendon               T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28240    Release of big toe                    T             T         0055      19.9374       882.83      2,028.63     2,324.70
28250    Revision of foot fascia               T             T         0055      19.9374       882.83      2,028.63     2,324.70
28260    Release of midfoot joint              T             T         0055      19.9374       882.83      2,028.63     2,324.70
28261    Revision of foot tendon               T             T         0055      19.9374       882.83      2,028.63     2,324.70
28262    Revision of foot and ankle            T             T         0055      19.9374       882.83      2,028.63     2,324.70
28264    Release of midfoot joint              T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28270    Release of foot contracture           T             T         0055      19.9374       882.83      2,028.63     2,324.70
28272    Release of toe joint, each            T             T         0055      19.9374       882.83      2,028.63     2,324.70
28280    Fusion of toes                        T             T         0055      19.9374       882.83      2,028.63     2,324.70
28285    Repair of hammertoe                   T             T         0055      19.9374       882.83      2,028.63     2,324.70
28286    Repair of hammertoe                   T             T         0055      19.9374       882.83      2,028.63     2,324.70
28288    Partial removal of foot bone          T             T         0055      19.9374       882.83      2,028.63     2,324.70
28289    Repair hallux rigidus                 T             T         0055      19.9374       882.83      2,028.63     2,324.70
28290    Correction of bunion                  T             T         0057      27.3981      1,213.19     2,787.76     3,194.62
28292    Correction of bunion                  T             T         0057      27.3981      1,213.19     2,787.76     3,194.62
28293    Correction of bunion                  T             T         0057      27.3981      1,213.19     2,787.76     3,194.62
28294    Correction of bunion                  T             T         0057      27.3981      1,213.19     2,787.76     3,194.62
28296    Correction of bunion                  T             T         0057      27.3981      1,213.19     2,787.76     3,194.62
28297    Correction of bunion                  T             T         0057      27.3981      1,213.19     2,787.76     3,194.62
28298    Correction of bunion                  T             T         0057      27.3981      1,213.19     2,787.76     3,194.62
28299    Correction of bunion                  T             T         0057      27.3981      1,213.19     2,787.76     3,194.62
28300    Incision of heel bone                 T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28302    Incision of ankle bone                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28304    Incision of midfoot bones             T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28305    Incise/graft midfoot bones            T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28306    Incision of metatarsal                T             T         0055      19.9374       882.83      2,028.63     2,324.70


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  35 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

28307    Incision of metatarsal                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28308    Incision of metatarsal                T             T         0055      19.9374       882.83      2,028.63     2,324.70
28309    Incision of metatarsals               T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28310    Revision of big toe                   T             T         0055      19.9374       882.83      2,028.63     2,324.70
28312    Revision of toe                       T             T         0055      19.9374       882.83      2,028.63     2,324.70
28313    Repair deformity of toe               T             T         0055      19.9374       882.83      2,028.63     2,324.70
28315    Removal of sesamoid bone              T             T         0055      19.9374       882.83      2,028.63     2,324.70
28320    Repair of foot bones                  T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28322    Repair of metatarsals                 T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28340    Resect enlarged toe tissue            T             T         0055      19.9374       882.83      2,028.63     2,324.70
28341    Resect enlarged toe                   T             T         0055      19.9374       882.83      2,028.63     2,324.70
28344    Repair extra toe(s)                   T             T         0055      19.9374       882.83      2,028.63     2,324.70
28345    Repair webbed toe(s)                  T             T         0055      19.9374       882.83      2,028.63     2,324.70
28360    Reconstruct cleft foot                T             T         0056      40.5436      1,795.27     4,125.31     4,727.38
28400    Treatment of heel fracture            T             T         0043       1.7200        76.16       175.01       200.55
28405    Treatment of heel fracture            T             T         0043       1.7200        76.16       175.01       200.55
28406    Treatment of heel fracture            T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28415    Treat heel fracture                   T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28420    Treat/graft heel fracture             T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28430    Treatment of ankle fracture           T             T         0043       1.7200        76.16       175.01       200.55
28435    Treatment of ankle fracture           T             T         0043       1.7200        76.16       175.01       200.55
28436    Treatment of ankle fracture           T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28445    Treat ankle fracture                  T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28450    Treat midfoot fracture, each          T             T         0043       1.7200        76.16       175.01       200.55
28455    Treat midfoot fracture, each          T             T         0043       1.7200        76.16       175.01       200.55
28456    Treat midfoot fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28465    Treat midfoot fracture, each          T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28470    Treat metatarsal fracture             T             T         0043       1.7200        76.16       175.01       200.55
28475    Treat metatarsal fracture             T             T         0043       1.7200        76.16       175.01       200.55
28476    Treat metatarsal fracture             T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28485    Treat metatarsal fracture             T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28490    Treat big toe fracture                T             T         0043       1.7200        76.16       175.01       200.55
28495    Treat big toe fracture                T             T         0043       1.7200        76.16       175.01       200.55
28496    Treat big toe fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28505    Treat big toe fracture                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28510    Treatment of toe fracture             T             T         0043       1.7200        76.16       175.01       200.55
28515    Treatment of toe fracture             T             T         0043       1.7200        76.16       175.01       200.55
28525    Treat toe fracture                    T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28530    Treat sesamoid bone fracture          T             T         0043       1.7200        76.16       175.01       200.55
28531    Treat sesamoid bone fracture          T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28540    Treat foot dislocation                T             T         0043       1.7200        76.16       175.01       200.55
28545    Treat foot dislocation                T             T         0045      14.3413       635.03      1,459.23     1,672.20
28546    Treat foot dislocation                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28555    Repair foot dislocation               T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28570    Treat foot dislocation                T             T         0043       1.7200        76.16       175.01       200.55
28575    Treat foot dislocation                T             T         0043       1.7200        76.16       175.01       200.55
28576    Treat foot dislocation                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28585    Repair foot dislocation               T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28600    Treat foot dislocation                T             T         0043       1.7200        76.16       175.01       200.55
28605    Treat foot dislocation                T             T         0043       1.7200        76.16       175.01       200.55
28606    Treat foot dislocation                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28615    Repair foot dislocation               T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28630    Treat toe dislocation                 T             T         0043       1.7200        76.16       175.01       200.55
28635    Treat toe dislocation                 T             T         0045      14.3413       635.03      1,459.23     1,672.20
28636    Treat toe dislocation                 T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28645    Repair toe dislocation                T             T         0046      37.8852      1,677.56     3,854.82     4,417.41
28660    Treat toe dislocation                 T             T         0043       1.7200        76.16       175.01       200.55
28665    Treat toe dislocation                 T             T         0045      14.3413       635.03      1,459.23     1,672.20


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  36 of 223
State of Wyoming Oupatient Prospective Payment System                                                           Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                       Critical
                                                                                              General        Children's                 Change
                                               2006      WY 2006                                                           Access
 CPT/                                                                           APC Relative Hospital         Hospital                   from
                 Description (short)          Status       Status       APC                                                Hospital
HCPCS                                                                             Weight     Outpatient      Outpatient                 4-14-06
                                            Indicator    Indicator                                                        Outpatient
                                                                                                Fee             Fee                    Schedule
                                           (FYI Only)                                                                        Fee

28666    Treat toe dislocation                 T             T         0046      37.8852          1,677.56    3,854.82     4,417.41
28675    Repair of toe dislocation             T             T         0046      37.8852          1,677.56    3,854.82     4,417.41
28705    Fusion of foot bones                  T             T         0056      40.5436          1,795.27    4,125.31     4,727.38
28715    Fusion of foot bones                  T             T         0056      40.5436          1,795.27    4,125.31     4,727.38
28725    Fusion of foot bones                  T             T         0056      40.5436          1,795.27    4,125.31     4,727.38
28730    Fusion of foot bones                  T             T         0056      40.5436          1,795.27    4,125.31     4,727.38
28735    Fusion of foot bones                  T             T         0056      40.5436          1,795.27    4,125.31     4,727.38
28737    Revision of foot bones                T             T         0056      40.5436          1,795.27    4,125.31     4,727.38
28740    Fusion of foot bones                  T             T         0056      40.5436          1,795.27    4,125.31     4,727.38
28750    Fusion of big toe joint               T             T         0056      40.5436          1,795.27    4,125.31     4,727.38
28755    Fusion of big toe joint               T             T         0055      19.9374           882.83     2,028.63     2,324.70
28760    Fusion of big toe joint               T             T         0056      40.5436          1,795.27    4,125.31     4,727.38
28800    Amputation of midfoot                 C             C         0000       0.0000            0.00        0.00         0.00
28805    Amputation thru metatarsal            C             C         0000       0.0000            0.00        0.00         0.00
28810    Amputation toe & metatarsal           T             T         0055      19.9374           882.83     2,028.63     2,324.70
28820    Amputation of toe                     T             T         0055      19.9374           882.83     2,028.63     2,324.70
28825    Partial amputation of toe             T             T         0055      19.9374           882.83     2,028.63     2,324.70
28890    High energy eswt, plantar f           T             T         1547      14.2831      *    632.46     1,453.31     1,665.41
28899    Foot/toes surgery procedure           T             1         0000       0.0000            0.00        0.00         0.00
29000    Application of body cast              S             S         0058       1.0803            47.84      109.92       125.96
29010    Application of body cast              S             S         0426       2.2146            98.06      225.34       258.22
29015    Application of body cast              S             S         0426       2.2146            98.06      225.34       258.22
29020    Application of body cast              S             S         0058       1.0803            47.84      109.92       125.96
29025    Application of body cast              S             S         0058       1.0803            47.84      109.92       125.96
29035    Application of body cast              S             S         0426       2.2146            98.06      225.34       258.22
29040    Application of body cast              S             S         0058       1.0803            47.84      109.92       125.96
29044    Application of body cast              S             S         0426       2.2146            98.06      225.34       258.22
29046    Application of body cast              S             S         0426       2.2146            98.06      225.34       258.22
29049    Application of figure eight           S             S         0058       1.0803            47.84      109.92       125.96
29055    Application of shoulder cast          S             S         0426       2.2146            98.06      225.34       258.22
29058    Application of shoulder cast          S             S         0058       1.0803            47.84      109.92       125.96
29065    Application of long arm cast          S             S         0426       2.2146            98.06      225.34       258.22
29075    Application of forearm cast           S             S         0426       2.2146            98.06      225.34       258.22
29085    Apply hand/wrist cast                 S             S         0058       1.0803            47.84      109.92       125.96
29086    Apply finger cast                     S             S         0058       1.0803            47.84      109.92       125.96
29105    Apply long arm splint                 S             S         0058       1.0803            47.84      109.92       125.96
29125    Apply forearm splint                  S             S         0058       1.0803            47.84      109.92       125.96
29126    Apply forearm splint                  S             S         0058       1.0803            47.84      109.92       125.96
29130    Application of finger splint          S             S         0058       1.0803            47.84      109.92       125.96
29131    Application of finger splint          S             S         0058       1.0803            47.84      109.92       125.96
29200    Strapping of chest                    S             S         0058       1.0803            47.84      109.92       125.96
29220    Strapping of low back                 S             S         0058       1.0803            47.84      109.92       125.96
29240    Strapping of shoulder                 S             S         0058       1.0803            47.84      109.92       125.96
29260    Strapping of elbow or wrist           S             S         0058       1.0803            47.84      109.92       125.96
29280    Strapping of hand or finger           S             S         0058       1.0803            47.84      109.92       125.96
29305    Application of hip cast               S             S         0426       2.2146            98.06      225.34       258.22
29325    Application of hip casts              S             S         0426       2.2146            98.06      225.34       258.22
29345    Application of long leg cast          S             S         0426       2.2146            98.06      225.34       258.22
29355    Application of long leg cast          S             S         0426       2.2146            98.06      225.34       258.22
29358    Apply long leg cast brace             S             S         0426       2.2146            98.06      225.34       258.22
29365    Application of long leg cast          S             S         0426       2.2146            98.06      225.34       258.22
29405    Apply short leg cast                  S             S         0426       2.2146            98.06      225.34       258.22
29425    Apply short leg cast                  S             S         0426       2.2146            98.06      225.34       258.22
29435    Apply short leg cast                  S             S         0426       2.2146            98.06      225.34       258.22
29440    Addition of walker to cast            S             S         0058       1.0803            47.84      109.92       125.96
29445    Apply rigid leg cast                  S             S         0426       2.2146            98.06      225.34       258.22
29450    Application of leg cast               S             S         0058       1.0803            47.84      109.92       125.96
29505    Application, long leg splint          S             S         0058       1.0803            47.84      109.92       125.96


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                     37 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

29515    Application lower leg splint          S             S         0058       1.0803        47.84       109.92       125.96
29520    Strapping of hip                      S             S         0058       1.0803        47.84       109.92       125.96
29530    Strapping of knee                     S             S         0058       1.0803        47.84       109.92       125.96
29540    Strapping of ankle and/or ft          S             S         0058       1.0803        47.84       109.92       125.96
29550    Strapping of toes                     S             S         0058       1.0803        47.84       109.92       125.96
29580    Application of paste boot             S             S         0058       1.0803        47.84       109.92       125.96
29590    Application of foot splint            S             S         0058       1.0803        47.84       109.92       125.96
29700    Removal/revision of cast              S             S         0058       1.0803        47.84       109.92       125.96
29705    Removal/revision of cast              S             S         0058       1.0803        47.84       109.92       125.96
29710    Removal/revision of cast              S             S         0426       2.2146        98.06       225.34       258.22
29715    Removal/revision of cast              S             S         0058       1.0803        47.84       109.92       125.96
29720    Repair of body cast                   S             S         0058       1.0803        47.84       109.92       125.96
29730    Windowing of cast                     S             S         0058       1.0803        47.84       109.92       125.96
29740    Wedging of cast                       S             S         0058       1.0803        47.84       109.92       125.96
29750    Wedging of clubfoot cast              S             S         0058       1.0803        47.84       109.92       125.96
29799    Casting/strapping procedure           S             1         0000       0.0000        0.00         0.00         0.00
29800    Jaw arthroscopy/surgery               T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29804    Jaw arthroscopy/surgery               T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29805    Shoulder arthroscopy, dx              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29806    Shoulder arthroscopy/surgery          T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29807    Shoulder arthroscopy/surgery          T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29819    Shoulder arthroscopy/surgery          T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29820    Shoulder arthroscopy/surgery          T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29821    Shoulder arthroscopy/surgery          T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29822    Shoulder arthroscopy/surgery          T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29823    Shoulder arthroscopy/surgery          T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29824    Shoulder arthroscopy/surgery          T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29825    Shoulder arthroscopy/surgery          T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29826    Shoulder arthroscopy/surgery          T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29827    Arthroscop rotator cuff repr          T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29830    Elbow arthroscopy                     T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29834    Elbow arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29835    Elbow arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29836    Elbow arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29837    Elbow arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29838    Elbow arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29840    Wrist arthroscopy                     T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29843    Wrist arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29844    Wrist arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29845    Wrist arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29846    Wrist arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29847    Wrist arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29848    Wrist endoscopy/surgery               T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29850    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29851    Knee arthroscopy/surgery              T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29855    Tibial arthroscopy/surgery            T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29856    Tibial arthroscopy/surgery            T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29860    Hip arthroscopy, dx                   T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29861    Hip arthroscopy/surgery               T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29862    Hip arthroscopy/surgery               T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29863    Hip arthroscopy/surgery               T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29866    Autgrft implnt, knee w/scope          T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29867    Allgrft implnt, knee w/scope          T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29868    Meniscal trnspl, knee w/scpe          T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29870    Knee arthroscopy, dx                  T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29871    Knee arthroscopy/drainage             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29873    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29874    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  38 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

29875    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29876    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29877    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29879    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29880    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29881    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29882    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29883    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29884    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29885    Knee arthroscopy/surgery              T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29886    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29887    Knee arthroscopy/surgery              T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29888    Knee arthroscopy/surgery              T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29889    Knee arthroscopy/surgery              T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29891    Ankle arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29892    Ankle arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29893    Scope, plantar fasciotomy             T             T         0055      19.9374       882.83      2,028.63     2,324.70
29894    Ankle arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29895    Ankle arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29897    Ankle arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29898    Ankle arthroscopy/surgery             T             T         0041      28.0686      1,242.88     2,855.98     3,272.80
29899    Ankle arthroscopy/surgery             T             T         0042      44.2075      1,957.51     4,498.11     5,154.59
29900    Mcp joint arthroscopy, dx             T             T         0053      15.6396       692.52      1,591.33     1,823.58
29901    Mcp joint arthroscopy, surg           T             T         0053      15.6396       692.52      1,591.33     1,823.58
29902    Mcp joint arthroscopy, surg           T             T         0053      15.6396       692.52      1,591.33     1,823.58
29999    Arthroscopy of joint                  T             1         0000       0.0000        0.00         0.00         0.00
30000    Drainage of nose lesion               T             T         0251       2.0789        92.05       211.53       242.40
30020    Drainage of nose lesion               T             T         0251       2.0789        92.05       211.53       242.40
30100    Intranasal biopsy                     T             T         0252       8.1033       358.81       824.51       944.84
30110    Removal of nose polyp(s)              T             T         0253      16.0740       711.76      1,635.53     1,874.23
30115    Removal of nose polyp(s)              T             T         0253      16.0740       711.76      1,635.53     1,874.23
30117    Removal of intranasal lesion          T             T         0253      16.0740       711.76      1,635.53     1,874.23
30118    Removal of intranasal lesion          T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
30120    Revision of nose                      T             T         0253      16.0740       711.76      1,635.53     1,874.23
30124    Removal of nose lesion                T             T         0252       8.1033       358.81       824.51       944.84
30125    Removal of nose lesion                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
30130    Removal of turbinate bones            T             T         0253      16.0740       711.76      1,635.53     1,874.23
30140    Removal of turbinate bones            T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
30150    Partial removal of nose               T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
30160    Removal of nose                       T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
30200    Injection treatment of nose           T             T         0252       8.1033       358.81       824.51       944.84
30210    Nasal sinus therapy                   T             T         0252       8.1033       358.81       824.51       944.84
30220    Insert nasal septal button            T             T         0252       8.1033       358.81       824.51       944.84
30300    Remove nasal foreign body             X             X         0340       0.6137        27.17       62.44        71.56
30310    Remove nasal foreign body             T             T         0253      16.0740       711.76      1,635.53     1,874.23
30320    Remove nasal foreign body             T             T         0253      16.0740       711.76      1,635.53     1,874.23
30400    Reconstruction of nose                T             1         0000       0.0000        0.00         0.00         0.00
30410    Reconstruction of nose                T             1         0000       0.0000        0.00         0.00         0.00
30420    Reconstruction of nose                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
30430    Revision of nose                      T             1         0000       0.0000        0.00         0.00         0.00
30435    Revision of nose                      T             1         0000       0.0000        0.00         0.00         0.00
30450    Revision of nose                      T             1         0000       0.0000        0.00         0.00         0.00
30460    Revision of nose                      T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
30462    Revision of nose                      T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
30465    Repair nasal stenosis                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
30520    Repair of nasal septum                T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
30540    Repair nasal defect                   T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
30545    Repair nasal defect                   T             T         0256      37.0000      1,638.36     3,764.75     4,314.20


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  39 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

30560    Release of nasal adhesions            T             T         0251       2.0789        92.05       211.53       242.40
30580    Repair upper jaw fistula              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
30600    Repair mouth/nose fistula             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
30620    Intranasal reconstruction             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
30630    Repair nasal septum defect            T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
30801    Cauterization, inner nose             T             T         0252       8.1033       358.81       824.51       944.84
30802    Cauterization, inner nose             T             T         0252       8.1033       358.81       824.51       944.84
30901    Control of nosebleed                  T             T         0250       1.2241        54.20       124.55       142.73
30903    Control of nosebleed                  T             T         0250       1.2241        54.20       124.55       142.73
30905    Control of nosebleed                  T             T         0250       1.2241        54.20       124.55       142.73
30906    Repeat control of nosebleed           T             T         0250       1.2241        54.20       124.55       142.73
30915    Ligation, nasal sinus artery          T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
30920    Ligation, upper jaw artery            T             T         0092      26.5104      1,173.88     2,697.43     3,091.11
30930    Therapy, fracture of nose             T             T         0253      16.0740       711.76      1,635.53     1,874.23
30999    Nasal surgery procedure               T             1         0000       0.0000        0.00         0.00         0.00
31000    Irrigation, maxillary sinus           T             T         0251       2.0789        92.05       211.53       242.40
31002    Irrigation, sphenoid sinus            T             T         0252       8.1033       358.81       824.51       944.84
31020    Exploration, maxillary sinus          T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
31030    Exploration, maxillary sinus          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31032    Explore sinus, remove polyps          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31040    Exploration behind upper jaw          T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
31050    Exploration, sphenoid sinus           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31051    Sphenoid sinus surgery                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31070    Exploration of frontal sinus          T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
31075    Exploration of frontal sinus          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31080    Removal of frontal sinus              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31081    Removal of frontal sinus              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31084    Removal of frontal sinus              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31085    Removal of frontal sinus              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31086    Removal of frontal sinus              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31087    Removal of frontal sinus              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31090    Exploration of sinuses                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31200    Removal of ethmoid sinus              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31201    Removal of ethmoid sinus              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31205    Removal of ethmoid sinus              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31225    Removal of upper jaw                  C             C         0000       0.0000        0.00         0.00         0.00
31230    Removal of upper jaw                  C             C         0000       0.0000        0.00         0.00         0.00
31231    Nasal endoscopy, dx                   T             T         0072       1.4448        63.98       147.01       168.46
31233    Nasal/sinus endoscopy, dx             T             T         0072       1.4448        63.98       147.01       168.46
31235    Nasal/sinus endoscopy, dx             T             T         0074      15.4603       684.58      1,573.09     1,802.67
31237    Nasal/sinus endoscopy, surg           T             T         0075      21.2258       939.88      2,159.73     2,474.93
31238    Nasal/sinus endoscopy, surg           T             T         0074      15.4603       684.58      1,573.09     1,802.67
31239    Nasal/sinus endoscopy, surg           T             T         0075      21.2258       939.88      2,159.73     2,474.93
31240    Nasal/sinus endoscopy, surg           T             T         0074      15.4603       684.58      1,573.09     1,802.67
31254    Revision of ethmoid sinus             T             T         0075      21.2258       939.88      2,159.73     2,474.93
31255    Removal of ethmoid sinus              T             T         0075      21.2258       939.88      2,159.73     2,474.93
31256    Exploration maxillary sinus           T             T         0075      21.2258       939.88      2,159.73     2,474.93
31267    Endoscopy, maxillary sinus            T             T         0075      21.2258       939.88      2,159.73     2,474.93
31276    Sinus endoscopy, surgical             T             T         0075      21.2258       939.88      2,159.73     2,474.93
31287    Nasal/sinus endoscopy, surg           T             T         0075      21.2258       939.88      2,159.73     2,474.93
31288    Nasal/sinus endoscopy, surg           T             T         0075      21.2258       939.88      2,159.73     2,474.93
31290    Nasal/sinus endoscopy, surg           C             C         0000       0.0000        0.00         0.00         0.00
31291    Nasal/sinus endoscopy, surg           C             C         0000       0.0000        0.00         0.00         0.00
31292    Nasal/sinus endoscopy, surg           T             T         0075      21.2258       939.88      2,159.73     2,474.93
31293    Nasal/sinus endoscopy, surg           T             T         0075      21.2258       939.88      2,159.73     2,474.93
31294    Nasal/sinus endoscopy, surg           T             T         0075      21.2258       939.88      2,159.73     2,474.93
31299    Sinus surgery procedure               T             1         0000       0.0000        0.00         0.00         0.00
31300    Removal of larynx lesion              T             T         0254      23.3114      1,032.23     2,371.93     2,718.11


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  40 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

31320    Diagnostic incision, larynx           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31360    Removal of larynx                     C             C         0000       0.0000        0.00         0.00         0.00
31365    Removal of larynx                     C             C         0000       0.0000        0.00         0.00         0.00
31367    Partial removal of larynx             C             C         0000       0.0000        0.00         0.00         0.00
31368    Partial removal of larynx             C             C         0000       0.0000        0.00         0.00         0.00
31370    Partial removal of larynx             C             C         0000       0.0000        0.00         0.00         0.00
31375    Partial removal of larynx             C             C         0000       0.0000        0.00         0.00         0.00
31380    Partial removal of larynx             C             C         0000       0.0000        0.00         0.00         0.00
31382    Partial removal of larynx             C             C         0000       0.0000        0.00         0.00         0.00
31390    Removal of larynx & pharynx           C             C         0000       0.0000        0.00         0.00         0.00
31395    Reconstruct larynx & pharynx          C             C         0000       0.0000        0.00         0.00         0.00
31400    Revision of larynx                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31420    Removal of epiglottis                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31500    Insert emergency airway               S             S         0094       2.4582       108.85       250.12       286.63
31502    Change of windpipe airway             T             T         0121       2.2374        99.07       227.66       260.88
31505    Diagnostic laryngoscopy               T             T         0071       0.8034        35.57       81.75        93.68
31510    Laryngoscopy with biopsy              T             T         0074      15.4603       684.58      1,573.09     1,802.67
31511    Remove foreign body, larynx           T             T         0072       1.4448        63.98       147.01       168.46
31512    Removal of larynx lesion              T             T         0074      15.4603       684.58      1,573.09     1,802.67
31513    Injection into vocal cord             T             T         0072       1.4448        63.98       147.01       168.46
31515    Laryngoscopy for aspiration           T             T         0074      15.4603       684.58      1,573.09     1,802.67
31520    Diagnostic laryngoscopy               T             T         0072       1.4448        63.98       147.01       168.46
31525    Diagnostic laryngoscopy               T             T         0074      15.4603       684.58      1,573.09     1,802.67
31526    Diagnostic laryngoscopy               T             T         0075      21.2258       939.88      2,159.73     2,474.93
31527    Laryngoscopy for treatment            T             T         0075      21.2258       939.88      2,159.73     2,474.93
31528    Laryngoscopy and dilation             T             T         0074      15.4603       684.58      1,573.09     1,802.67
31529    Laryngoscopy and dilation             T             T         0074      15.4603       684.58      1,573.09     1,802.67
31530    Operative laryngoscopy                T             T         0075      21.2258       939.88      2,159.73     2,474.93
31531    Operative laryngoscopy                T             T         0075      21.2258       939.88      2,159.73     2,474.93
31535    Operative laryngoscopy                T             T         0075      21.2258       939.88      2,159.73     2,474.93
31536    Operative laryngoscopy                T             T         0075      21.2258       939.88      2,159.73     2,474.93
31540    Operative laryngoscopy                T             T         0075      21.2258       939.88      2,159.73     2,474.93
31541    Operative laryngoscopy                T             T         0075      21.2258       939.88      2,159.73     2,474.93
31545    Remove vc lesion w/scope              T             T         0075      21.2258       939.88      2,159.73     2,474.93
31546    Remove vc lesion scope/graft          T             T         0075      21.2258       939.88      2,159.73     2,474.93
31560    Operative laryngoscopy                T             T         0075      21.2258       939.88      2,159.73     2,474.93
31561    Operative laryngoscopy                T             T         0075      21.2258       939.88      2,159.73     2,474.93
31570    Laryngoscopy with injection           T             T         0074      15.4603       684.58      1,573.09     1,802.67
31571    Laryngoscopy with injection           T             T         0075      21.2258       939.88      2,159.73     2,474.93
31575    Diagnostic laryngoscopy               T             T         0072       1.4448        63.98       147.01       168.46
31576    Laryngoscopy with biopsy              T             T         0075      21.2258       939.88      2,159.73     2,474.93
31577    Remove foreign body, larynx           T             T         0073       4.2171       186.73       429.09       491.71
31578    Removal of larynx lesion              T             T         0075      21.2258       939.88      2,159.73     2,474.93
31579    Diagnostic laryngoscopy               T             T         0073       4.2171       186.73       429.09       491.71
31580    Revision of larynx                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31582    Revision of larynx                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31584    Treat larynx fracture                 C             C         0000       0.0000        0.00         0.00         0.00
31587    Revision of larynx                    C             C         0000       0.0000        0.00         0.00         0.00
31588    Revision of larynx                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31590    Reinnervate larynx                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31595    Larynx nerve surgery                  T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31599    Larynx surgery procedure              T             1         0000       0.0000        0.00         0.00         0.00
31600    Incision of windpipe                  T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
31601    Incision of windpipe                  T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
31603    Incision of windpipe                  T             T         0252       8.1033       358.81       824.51       944.84
31605    Incision of windpipe                  T             T         0252       8.1033       358.81       824.51       944.84
31610    Incision of windpipe                  T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
31611    Surgery/speech prosthesis             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  41 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

31612    Puncture/clear windpipe               T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
31613    Repair windpipe opening               T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
31614    Repair windpipe opening               T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31615    Visualization of windpipe             T             T         0076       9.4030       416.36       956.76      1,096.39
31620    Endobronchial us add-on               S             S         0670      28.7546      1,273.25     2,925.78     3,352.79
31622    Dx bronchoscope/wash                  T             T         0076       9.4030       416.36       956.76      1,096.39
31623    Dx bronchoscope/brush                 T             T         0076       9.4030       416.36       956.76      1,096.39
31624    Dx bronchoscope/lavage                T             T         0076       9.4030       416.36       956.76      1,096.39
31625    Bronchoscopy w/biopsy(s)              T             T         0076       9.4030       416.36       956.76      1,096.39
31628    Bronchoscopy/lung bx, each            T             T         0076       9.4030       416.36       956.76      1,096.39
31629    Bronchoscopy/needle bx, each          T             T         0076       9.4030       416.36       956.76      1,096.39
31630    Bronchoscopy dilate/fx repr           T             T         0415      22.0722       977.36      2,245.85     2,573.62
31631    Bronchoscopy, dilate w/stent          T             T         0415      22.0722       977.36      2,245.85     2,573.62
31632    Bronchoscopy/lung bx, add’l           T             T         0076       9.4030       416.36       956.76      1,096.39
31633    Bronchoscopy/needle bx add’l          T             T         0076       9.4030       416.36       956.76      1,096.39
31635    Bronchoscopy w/fb removal             T             T         0076       9.4030       416.36       956.76      1,096.39
31636    Bronchoscopy, bronch stents           T             T         0415      22.0722       977.36      2,245.85     2,573.62
31637    Bronchoscopy, stent add-on            T             T         0076       9.4030       416.36       956.76      1,096.39
31638    Bronchoscopy, revise stent            T             T         0415      22.0722       977.36      2,245.85     2,573.62
31640    Bronchoscopy w/tumor excise           T             T         0415      22.0722       977.36      2,245.85     2,573.62
31641    Bronchoscopy, treat blockage          T             T         0415      22.0722       977.36      2,245.85     2,573.62
31643    Diag bronchoscope/catheter            T             T         0076       9.4030       416.36       956.76      1,096.39
31645    Bronchoscopy, clear airways           T             T         0076       9.4030       416.36       956.76      1,096.39
31646    Bronchoscopy, reclear airway          T             T         0076       9.4030       416.36       956.76      1,096.39
31656    Bronchoscopy, inj for x-ray           T             T         0076       9.4030       416.36       956.76      1,096.39
31700    Insertion of airway catheter          T             T         0072       1.4448        63.98       147.01       168.46
31708    Instill airway contrast dye           N             N         0000       0.0000        0.00         0.00         0.00
31710    Insertion of airway catheter          N             N         0000       0.0000        0.00         0.00         0.00
31715    Injection for bronchus x-ray          N             N         0000       0.0000        0.00         0.00         0.00
31717    Bronchial brush biopsy                T             T         0073       4.2171       186.73       429.09       491.71
31720    Clearance of airways                  T             T         0071       0.8034        35.57       81.75        93.68
31725    Clearance of airways                  C             C         0000       0.0000        0.00         0.00         0.00
31730    Intro, windpipe wire/tube             T             T         0073       4.2171       186.73       429.09       491.71
31750    Repair of windpipe                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31755    Repair of windpipe                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
31760    Repair of windpipe                    C             C         0000       0.0000        0.00         0.00         0.00
31766    Reconstruction of windpipe            C             C         0000       0.0000        0.00         0.00         0.00
31770    Repair/graft of bronchus              C             C         0000       0.0000        0.00         0.00         0.00
31775    Reconstruct bronchus                  C             C         0000       0.0000        0.00         0.00         0.00
31780    Reconstruct windpipe                  C             C         0000       0.0000        0.00         0.00         0.00
31781    Reconstruct windpipe                  C             C         0000       0.0000        0.00         0.00         0.00
31785    Remove windpipe lesion                T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
31786    Remove windpipe lesion                C             C         0000       0.0000        0.00         0.00         0.00
31800    Repair of windpipe injury             C             C         0000       0.0000        0.00         0.00         0.00
31805    Repair of windpipe injury             C             C         0000       0.0000        0.00         0.00         0.00
31820    Closure of windpipe lesion            T             T         0253      16.0740       711.76      1,635.53     1,874.23
31825    Repair of windpipe defect             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
31830    Revise windpipe scar                  T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
31899    Airways surgical procedure            T             1         0000       0.0000        0.00         0.00         0.00
32000    Drainage of chest                     T             T         0070       3.2141       142.32       327.03       374.76
32002    Treatment of collapsed lung           T             T         0070       3.2141       142.32       327.03       374.76
32005    Treat lung lining chemically          T             T         0070       3.2141       142.32       327.03       374.76
32019    Insert pleural catheter               T             T         0427      10.0109       443.28      1,018.61     1,167.27
32020    Insertion of chest tube               T             T         0070       3.2141       142.32       327.03       374.76
32035    Exploration of chest                  C             C         0000       0.0000        0.00         0.00         0.00
32036    Exploration of chest                  C             C         0000       0.0000        0.00         0.00         0.00
32095    Biopsy through chest wall             C             C         0000       0.0000        0.00         0.00         0.00
32100    Exploration/biopsy of chest           C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  42 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

32110    Explore/repair chest                  C             C         0000       0.0000        0.00         0.00         0.00
32120    Re-exploration of chest               C             C         0000       0.0000        0.00         0.00         0.00
32124    Explore chest free adhesions          C             C         0000       0.0000        0.00         0.00         0.00
32140    Removal of lung lesion(s)             C             C         0000       0.0000        0.00         0.00         0.00
32141    Remove/treat lung lesions             C             C         0000       0.0000        0.00         0.00         0.00
32150    Removal of lung lesion(s)             C             C         0000       0.0000        0.00         0.00         0.00
32151    Remove lung foreign body              C             C         0000       0.0000        0.00         0.00         0.00
32160    Open chest heart massage              C             C         0000       0.0000        0.00         0.00         0.00
32200    Drain, open, lung lesion              C             C         0000       0.0000        0.00         0.00         0.00
32201    Drain, percut, lung lesion            T             T         0070       3.2141       142.32       327.03       374.76
32215    Treat chest lining                    C             C         0000       0.0000        0.00         0.00         0.00
32220    Release of lung                       C             C         0000       0.0000        0.00         0.00         0.00
32225    Partial release of lung               C             C         0000       0.0000        0.00         0.00         0.00
32310    Removal of chest lining               C             C         0000       0.0000        0.00         0.00         0.00
32320    Free/remove chest lining              C             C         0000       0.0000        0.00         0.00         0.00
32400    Needle biopsy chest lining            T             T         0685       6.0034       265.83       610.85       700.00
32402    Open biopsy chest lining              C             C         0000       0.0000        0.00         0.00         0.00
32405    Biopsy, lung or mediastinum           T             T         0685       6.0034       265.83       610.85       700.00
32420    Puncture/clear lung                   T             T         0070       3.2141       142.32       327.03       374.76
32440    Removal of lung                       C             C         0000       0.0000        0.00         0.00         0.00
32442    Sleeve pneumonectomy                  C             C         0000       0.0000        0.00         0.00         0.00
32445    Removal of lung                       C             C         0000       0.0000        0.00         0.00         0.00
32480    Partial removal of lung               C             C         0000       0.0000        0.00         0.00         0.00
32482    Bilobectomy                           C             C         0000       0.0000        0.00         0.00         0.00
32484    Segmentectomy                         C             C         0000       0.0000        0.00         0.00         0.00
32486    Sleeve lobectomy                      C             C         0000       0.0000        0.00         0.00         0.00
32488    Completion pneumonectomy              C             C         0000       0.0000        0.00         0.00         0.00
32491    Lung volume reduction                 C             C         0000       0.0000        0.00         0.00         0.00
32500    Partial removal of lung               C             C         0000       0.0000        0.00         0.00         0.00
32501    Repair bronchus add-on                C             C         0000       0.0000        0.00         0.00         0.00
32503    Resect apical lung tumor              C             C         0000       0.0000        0.00         0.00         0.00
32504    Resect apical lung tum/chest          C             C         0000       0.0000        0.00         0.00         0.00
32540    Removal of lung lesion                C             C         0000       0.0000        0.00         0.00         0.00
32601    Thoracoscopy, diagnostic              T             T         0069      30.9541      1,370.65     3,149.58     3,609.25
32602    Thoracoscopy, diagnostic              T             T         0069      30.9541      1,370.65     3,149.58     3,609.25
32603    Thoracoscopy, diagnostic              T             T         0069      30.9541      1,370.65     3,149.58     3,609.25
32604    Thoracoscopy, diagnostic              T             T         0069      30.9541      1,370.65     3,149.58     3,609.25
32605    Thoracoscopy, diagnostic              T             T         0069      30.9541      1,370.65     3,149.58     3,609.25
32606    Thoracoscopy, diagnostic              T             T         0069      30.9541      1,370.65     3,149.58     3,609.25
32650    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32651    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32652    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32653    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32654    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32655    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32656    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32657    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32658    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32659    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32660    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32661    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32662    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32663    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32664    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32665    Thoracoscopy, surgical                C             C         0000       0.0000        0.00         0.00         0.00
32800    Repair lung hernia                    C             C         0000       0.0000        0.00         0.00         0.00
32810    Close chest after drainage            C             C         0000       0.0000        0.00         0.00         0.00
32815    Close bronchial fistula               C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  43 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

32820    Reconstruct injured chest             C             C         0000       0.0000        0.00         0.00         0.00
32850    Donor pneumonectomy                   C             C         0000       0.0000        0.00         0.00         0.00
32851    Lung transplant, single               C             C         0000       0.0000        0.00         0.00         0.00
32852    Lung transplant with bypass           C             C         0000       0.0000        0.00         0.00         0.00
32853    Lung transplant, double               C             C         0000       0.0000        0.00         0.00         0.00
32854    Lung transplant with bypass           C             C         0000       0.0000        0.00         0.00         0.00
32855    Prepare donor lung, single            C             C         0000       0.0000        0.00         0.00         0.00
32856    Prepare donor lung, double            C             C         0000       0.0000        0.00         0.00         0.00
32900    Removal of rib(s)                     C             C         0000       0.0000        0.00         0.00         0.00
32905    Revise & repair chest wall            C             C         0000       0.0000        0.00         0.00         0.00
32906    Revise & repair chest wall            C             C         0000       0.0000        0.00         0.00         0.00
32940    Revision of lung                      C             C         0000       0.0000        0.00         0.00         0.00
32960    Therapeutic pneumothorax              T             T         0070       3.2141       142.32       327.03       374.76
32997    Total lung lavage                     C             C         0000       0.0000        0.00         0.00         0.00
32999    Chest surgery procedure               T             1         0000       0.0000        0.00         0.00         0.00
33010    Drainage of heart sac                 T             T         0070       3.2141       142.32       327.03       374.76
33011    Repeat drainage of heart sac          T             T         0070       3.2141       142.32       327.03       374.76
33015    Incision of heart sac                 C             C         0000       0.0000        0.00         0.00         0.00
33020    Incision of heart sac                 C             C         0000       0.0000        0.00         0.00         0.00
33025    Incision of heart sac                 C             C         0000       0.0000        0.00         0.00         0.00
33030    Partial removal of heart sac          C             C         0000       0.0000        0.00         0.00         0.00
33031    Partial removal of heart sac          C             C         0000       0.0000        0.00         0.00         0.00
33050    Removal of heart sac lesion           C             C         0000       0.0000        0.00         0.00         0.00
33120    Removal of heart lesion               C             C         0000       0.0000        0.00         0.00         0.00
33130    Removal of heart lesion               C             C         0000       0.0000        0.00         0.00         0.00
33140    Heart revascularize (tmr)             C             C         0000       0.0000        0.00         0.00         0.00
33141    Heart tmr w/other procedure           C             C         0000       0.0000        0.00         0.00         0.00
33200    Insertion of heart pacemaker          C             C         0000       0.0000        0.00         0.00         0.00
33201    Insertion of heart pacemaker          C             C         0000       0.0000        0.00         0.00         0.00
33206    Insertion of heart pacemaker          T             T         0089      117.0463     5,182.81    11,909.46    13,647.60
33207    Insertion of heart pacemaker          T             T         0089      117.0463     5,182.81    11,909.46    13,647.60
33208    Insertion of heart pacemaker          T             T         0655      136.8448     6,059.49    13,923.96    15,956.10
33210    Insertion of heart electrode          T             T         0106      55.9362      2,476.85     5,691.51     6,522.16
33211    Insertion of heart electrode          T             T         0106      55.9362      2,476.85     5,691.51     6,522.16
33212    Insertion of pulse generator          T             T         0090      90.2017      3,994.13     9,178.02    10,517.52
33213    Insertion of pulse generator          T             T         0654      112.0279     4,960.60    11,398.84    13,062.45
33214    Upgrade of pacemaker system           T             T         0655      136.8448     6,059.49    13,923.96    15,956.10
33215    Reposition pacing-defib lead          T             T         0105      21.9865       973.56      2,237.13     2,563.63
33216    Insert lead pace-defib, one           T             T         0106      55.9362      2,476.85     5,691.51     6,522.16
33217    Insert lead pace-defib, dual          T             T         0106      55.9362      2,476.85     5,691.51     6,522.16
33218    Repair lead pace-defib, one           T             T         0106      55.9362      2,476.85     5,691.51     6,522.16
33220    Repair lead pace-defib, dual          T             T         0106      55.9362      2,476.85     5,691.51     6,522.16
33222    Revise pocket, pacemaker              T             T         0027      18.1956       805.70      1,851.40     2,121.61
33223    Revise pocket, pacing-defib           T             T         0027      18.1956       805.70      1,851.40     2,121.61
33224    Insert pacing lead & connect          T             T         0418      169.3514     7,498.88    17,231.50    19,746.37
33225    L ventric pacing lead add-on          T             T         0418      169.3514     7,498.88    17,231.50    19,746.37
33226    Reposition l ventric lead             T             T         0105      21.9865       973.56      2,237.13     2,563.63
33233    Removal of pacemaker system           T             T         0105      21.9865       973.56      2,237.13     2,563.63
33234    Removal of pacemaker system           T             T         0105      21.9865       973.56      2,237.13     2,563.63
33235    Removal pacemaker electrode           T             T         0105      21.9865       973.56      2,237.13     2,563.63
33236    Remove electrode/thoracotomy          C             C         0000       0.0000        0.00         0.00         0.00
33237    Remove electrode/thoracotomy          C             C         0000       0.0000        0.00         0.00         0.00
33238    Remove electrode/thoracotomy          C             C         0000       0.0000        0.00         0.00         0.00
33240    Insert pulse generator                B             1         0000       0.0000        0.00         0.00         0.00
33241    Remove pulse generator                T             T         0105      21.9865       973.56      2,237.13     2,563.63
33243    Remove eltrd/thoracotomy              C             C         0000       0.0000        0.00         0.00         0.00
33244    Remove eltrd, transven                T             T         0105      21.9865       973.56      2,237.13     2,563.63
33245    Insert epic eltrd pace-defib          C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  44 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

33246    Insert epic eltrd/generator           C             C         0000       0.0000        0.00         0.00         0.00
33249    Eltrd/insert pace-defib               B             1         0000       0.0000        0.00         0.00         0.00
33250    Ablate heart dysrhythm focus          C             C         0000       0.0000        0.00         0.00         0.00
33251    Ablate heart dysrhythm focus          C             C         0000       0.0000        0.00         0.00         0.00
33253    Reconstruct atria                     C             C         0000       0.0000        0.00         0.00         0.00
33261    Ablate heart dysrhythm focus          C             C         0000       0.0000        0.00         0.00         0.00
33282    Implant pat-active ht record          S             S         0680      74.9052      3,316.80     7,621.60     8,733.95
33284    Remove pat-active ht record           T             T         0109      11.1714       494.67      1,136.69     1,302.59
33300    Repair of heart wound                 C             C         0000       0.0000        0.00         0.00         0.00
33305    Repair of heart wound                 C             C         0000       0.0000        0.00         0.00         0.00
33310    Exploratory heart surgery             C             C         0000       0.0000        0.00         0.00         0.00
33315    Exploratory heart surgery             C             C         0000       0.0000        0.00         0.00         0.00
33320    Repair major blood vessel(s)          C             C         0000       0.0000        0.00         0.00         0.00
33321    Repair major vessel                   C             C         0000       0.0000        0.00         0.00         0.00
33322    Repair major blood vessel(s)          C             C         0000       0.0000        0.00         0.00         0.00
33330    Insert major vessel graft             C             C         0000       0.0000        0.00         0.00         0.00
33332    Insert major vessel graft             C             C         0000       0.0000        0.00         0.00         0.00
33335    Insert major vessel graft             C             C         0000       0.0000        0.00         0.00         0.00
33400    Repair of aortic valve                C             C         0000       0.0000        0.00         0.00         0.00
33401    Valvuloplasty, open                   C             C         0000       0.0000        0.00         0.00         0.00
33403    Valvuloplasty, w/cp bypass            C             C         0000       0.0000        0.00         0.00         0.00
33404    Prepare heart-aorta conduit           C             C         0000       0.0000        0.00         0.00         0.00
33405    Replacement of aortic valve           C             C         0000       0.0000        0.00         0.00         0.00
33406    Replacement of aortic valve           C             C         0000       0.0000        0.00         0.00         0.00
33410    Replacement of aortic valve           C             C         0000       0.0000        0.00         0.00         0.00
33411    Replacement of aortic valve           C             C         0000       0.0000        0.00         0.00         0.00
33412    Replacement of aortic valve           C             C         0000       0.0000        0.00         0.00         0.00
33413    Replacement of aortic valve           C             C         0000       0.0000        0.00         0.00         0.00
33414    Repair of aortic valve                C             C         0000       0.0000        0.00         0.00         0.00
33415    Revision, subvalvular tissue          C             C         0000       0.0000        0.00         0.00         0.00
33416    Revise ventricle muscle               C             C         0000       0.0000        0.00         0.00         0.00
33417    Repair of aortic valve                C             C         0000       0.0000        0.00         0.00         0.00
33420    Revision of mitral valve              C             C         0000       0.0000        0.00         0.00         0.00
33422    Revision of mitral valve              C             C         0000       0.0000        0.00         0.00         0.00
33425    Repair of mitral valve                C             C         0000       0.0000        0.00         0.00         0.00
33426    Repair of mitral valve                C             C         0000       0.0000        0.00         0.00         0.00
33427    Repair of mitral valve                C             C         0000       0.0000        0.00         0.00         0.00
33430    Replacement of mitral valve           C             C         0000       0.0000        0.00         0.00         0.00
33460    Revision of tricuspid valve           C             C         0000       0.0000        0.00         0.00         0.00
33463    Valvuloplasty, tricuspid              C             C         0000       0.0000        0.00         0.00         0.00
33464    Valvuloplasty, tricuspid              C             C         0000       0.0000        0.00         0.00         0.00
33465    Replace tricuspid valve               C             C         0000       0.0000        0.00         0.00         0.00
33468    Revision of tricuspid valve           C             C         0000       0.0000        0.00         0.00         0.00
33470    Revision of pulmonary valve           C             C         0000       0.0000        0.00         0.00         0.00
33471    Valvotomy, pulmonary valve            C             C         0000       0.0000        0.00         0.00         0.00
33472    Revision of pulmonary valve           C             C         0000       0.0000        0.00         0.00         0.00
33474    Revision of pulmonary valve           C             C         0000       0.0000        0.00         0.00         0.00
33475    Replacement, pulmonary valve          C             C         0000       0.0000        0.00         0.00         0.00
33476    Revision of heart chamber             C             C         0000       0.0000        0.00         0.00         0.00
33478    Revision of heart chamber             C             C         0000       0.0000        0.00         0.00         0.00
33496    Repair, prosth valve clot             C             C         0000       0.0000        0.00         0.00         0.00
33500    Repair heart vessel fistula           C             C         0000       0.0000        0.00         0.00         0.00
33501    Repair heart vessel fistula           C             C         0000       0.0000        0.00         0.00         0.00
33502    Coronary artery correction            C             C         0000       0.0000        0.00         0.00         0.00
33503    Coronary artery graft                 C             C         0000       0.0000        0.00         0.00         0.00
33504    Coronary artery graft                 C             C         0000       0.0000        0.00         0.00         0.00
33505    Repair artery w/tunnel                C             C         0000       0.0000        0.00         0.00         0.00
33506    Repair artery, translocation          C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  45 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

33507    Repair art, intramural                C             C         0000       0.0000        0.00         0.00         0.00
33508    Endoscopic vein harvest               N             N         0000       0.0000        0.00         0.00         0.00
33510    CABG, vein, single                    C             C         0000       0.0000        0.00         0.00         0.00
33511    CABG, vein, two                       C             C         0000       0.0000        0.00         0.00         0.00
33512    CABG, vein, three                     C             C         0000       0.0000        0.00         0.00         0.00
33513    CABG, vein, four                      C             C         0000       0.0000        0.00         0.00         0.00
33514    CABG, vein, five                      C             C         0000       0.0000        0.00         0.00         0.00
33516    Cabg, vein, six or more               C             C         0000       0.0000        0.00         0.00         0.00
33517    CABG, artery-vein, single             C             C         0000       0.0000        0.00         0.00         0.00
33518    CABG, artery-vein, two                C             C         0000       0.0000        0.00         0.00         0.00
33519    CABG, artery-vein, three              C             C         0000       0.0000        0.00         0.00         0.00
33521    CABG, artery-vein, four               C             C         0000       0.0000        0.00         0.00         0.00
33522    CABG, artery-vein, five               C             C         0000       0.0000        0.00         0.00         0.00
33523    Cabg, art-vein, six or more           C             C         0000       0.0000        0.00         0.00         0.00
33530    Coronary artery, bypass/reop          C             C         0000       0.0000        0.00         0.00         0.00
33533    CABG, arterial, single                C             C         0000       0.0000        0.00         0.00         0.00
33534    CABG, arterial, two                   C             C         0000       0.0000        0.00         0.00         0.00
33535    CABG, arterial, three                 C             C         0000       0.0000        0.00         0.00         0.00
33536    Cabg, arterial, four or more          C             C         0000       0.0000        0.00         0.00         0.00
33542    Removal of heart lesion               C             C         0000       0.0000        0.00         0.00         0.00
33545    Repair of heart damage                C             C         0000       0.0000        0.00         0.00         0.00
33548    Restore/remodel, ventricle            C             C         0000       0.0000        0.00         0.00         0.00
33572    Open coronary endarterectomy          C             C         0000       0.0000        0.00         0.00         0.00
33600    Closure of valve                      C             C         0000       0.0000        0.00         0.00         0.00
33602    Closure of valve                      C             C         0000       0.0000        0.00         0.00         0.00
33606    Anastomosis/artery-aorta              C             C         0000       0.0000        0.00         0.00         0.00
33608    Repair anomaly w/conduit              C             C         0000       0.0000        0.00         0.00         0.00
33610    Repair by enlargement                 C             C         0000       0.0000        0.00         0.00         0.00
33611    Repair double ventricle               C             C         0000       0.0000        0.00         0.00         0.00
33612    Repair double ventricle               C             C         0000       0.0000        0.00         0.00         0.00
33615    Repair, modified fontan               C             C         0000       0.0000        0.00         0.00         0.00
33617    Repair single ventricle               C             C         0000       0.0000        0.00         0.00         0.00
33619    Repair single ventricle               C             C         0000       0.0000        0.00         0.00         0.00
33641    Repair heart septum defect            C             C         0000       0.0000        0.00         0.00         0.00
33645    Revision of heart veins               C             C         0000       0.0000        0.00         0.00         0.00
33647    Repair heart septum defects           C             C         0000       0.0000        0.00         0.00         0.00
33660    Repair of heart defects               C             C         0000       0.0000        0.00         0.00         0.00
33665    Repair of heart defects               C             C         0000       0.0000        0.00         0.00         0.00
33670    Repair of heart chambers              C             C         0000       0.0000        0.00         0.00         0.00
33681    Repair heart septum defect            C             C         0000       0.0000        0.00         0.00         0.00
33684    Repair heart septum defect            C             C         0000       0.0000        0.00         0.00         0.00
33688    Repair heart septum defect            C             C         0000       0.0000        0.00         0.00         0.00
33690    Reinforce pulmonary artery            C             C         0000       0.0000        0.00         0.00         0.00
33692    Repair of heart defects               C             C         0000       0.0000        0.00         0.00         0.00
33694    Repair of heart defects               C             C         0000       0.0000        0.00         0.00         0.00
33697    Repair of heart defects               C             C         0000       0.0000        0.00         0.00         0.00
33702    Repair of heart defects               C             C         0000       0.0000        0.00         0.00         0.00
33710    Repair of heart defects               C             C         0000       0.0000        0.00         0.00         0.00
33720    Repair of heart defect                C             C         0000       0.0000        0.00         0.00         0.00
33722    Repair of heart defect                C             C         0000       0.0000        0.00         0.00         0.00
33730    Repair heart-vein defect(s)           C             C         0000       0.0000        0.00         0.00         0.00
33732    Repair heart-vein defect              C             C         0000       0.0000        0.00         0.00         0.00
33735    Revision of heart chamber             C             C         0000       0.0000        0.00         0.00         0.00
33736    Revision of heart chamber             C             C         0000       0.0000        0.00         0.00         0.00
33737    Revision of heart chamber             C             C         0000       0.0000        0.00         0.00         0.00
33750    Major vessel shunt                    C             C         0000       0.0000        0.00         0.00         0.00
33755    Major vessel shunt                    C             C         0000       0.0000        0.00         0.00         0.00
33762    Major vessel shunt                    C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  46 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

33764    Major vessel shunt & graft            C             C         0000       0.0000        0.00         0.00         0.00
33766    Major vessel shunt                    C             C         0000       0.0000        0.00         0.00         0.00
33767    Major vessel shunt                    C             C         0000       0.0000        0.00         0.00         0.00
33768    Cavopulmonary shunting                C             C         0000       0.0000        0.00         0.00         0.00
33770    Repair great vessels defect           C             C         0000       0.0000        0.00         0.00         0.00
33771    Repair great vessels defect           C             C         0000       0.0000        0.00         0.00         0.00
33774    Repair great vessels defect           C             C         0000       0.0000        0.00         0.00         0.00
33775    Repair great vessels defect           C             C         0000       0.0000        0.00         0.00         0.00
33776    Repair great vessels defect           C             C         0000       0.0000        0.00         0.00         0.00
33777    Repair great vessels defect           C             C         0000       0.0000        0.00         0.00         0.00
33778    Repair great vessels defect           C             C         0000       0.0000        0.00         0.00         0.00
33779    Repair great vessels defect           C             C         0000       0.0000        0.00         0.00         0.00
33780    Repair great vessels defect           C             C         0000       0.0000        0.00         0.00         0.00
33781    Repair great vessels defect           C             C         0000       0.0000        0.00         0.00         0.00
33786    Repair arterial trunk                 C             C         0000       0.0000        0.00         0.00         0.00
33788    Revision of pulmonary artery          C             C         0000       0.0000        0.00         0.00         0.00
33800    Aortic suspension                     C             C         0000       0.0000        0.00         0.00         0.00
33802    Repair vessel defect                  C             C         0000       0.0000        0.00         0.00         0.00
33803    Repair vessel defect                  C             C         0000       0.0000        0.00         0.00         0.00
33813    Repair septal defect                  C             C         0000       0.0000        0.00         0.00         0.00
33814    Repair septal defect                  C             C         0000       0.0000        0.00         0.00         0.00
33820    Revise major vessel                   C             C         0000       0.0000        0.00         0.00         0.00
33822    Revise major vessel                   C             C         0000       0.0000        0.00         0.00         0.00
33824    Revise major vessel                   C             C         0000       0.0000        0.00         0.00         0.00
33840    Remove aorta constriction             C             C         0000       0.0000        0.00         0.00         0.00
33845    Remove aorta constriction             C             C         0000       0.0000        0.00         0.00         0.00
33851    Remove aorta constriction             C             C         0000       0.0000        0.00         0.00         0.00
33852    Repair septal defect                  C             C         0000       0.0000        0.00         0.00         0.00
33853    Repair septal defect                  C             C         0000       0.0000        0.00         0.00         0.00
33860    Ascending aortic graft                C             C         0000       0.0000        0.00         0.00         0.00
33861    Ascending aortic graft                C             C         0000       0.0000        0.00         0.00         0.00
33863    Ascending aortic graft                C             C         0000       0.0000        0.00         0.00         0.00
33870    Transverse aortic arch graft          C             C         0000       0.0000        0.00         0.00         0.00
33875    Thoracic aortic graft                 C             C         0000       0.0000        0.00         0.00         0.00
33877    Thoracoabdominal graft                C             C         0000       0.0000        0.00         0.00         0.00
33880    Endovasc taa repr incl subcl          C             C         0000       0.0000        0.00         0.00         0.00
33881    Endovasc taa repr w/o subcl           C             C         0000       0.0000        0.00         0.00         0.00
33883    Insert endovasc prosth, taa           C             C         0000       0.0000        0.00         0.00         0.00
33884    Endovasc prosth, taa, add-on          C             C         0000       0.0000        0.00         0.00         0.00
33886    Endovasc prosth, delayed              C             C         0000       0.0000        0.00         0.00         0.00
33889    Artery transpose/endovas taa          C             C         0000       0.0000        0.00         0.00         0.00
33891    Car-car bp grft/endovas taa           C             C         0000       0.0000        0.00         0.00         0.00
33910    Remove lung artery emboli             C             C         0000       0.0000        0.00         0.00         0.00
33915    Remove lung artery emboli             C             C         0000       0.0000        0.00         0.00         0.00
33916    Surgery of great vessel               C             C         0000       0.0000        0.00         0.00         0.00
33917    Repair pulmonary artery               C             C         0000       0.0000        0.00         0.00         0.00
33920    Repair pulmonary atresia              C             C         0000       0.0000        0.00         0.00         0.00
33922    Transect pulmonary artery             C             C         0000       0.0000        0.00         0.00         0.00
33924    Remove pulmonary shunt                C             C         0000       0.0000        0.00         0.00         0.00
33925    Rpr pul art unifocal w/o cpb          C             C         0000       0.0000        0.00         0.00         0.00
33926    Repr pul art, unifocal w/cpb          C             C         0000       0.0000        0.00         0.00         0.00
33930    Removal of donor heart/lung           C             C         0000       0.0000        0.00         0.00         0.00
33933    Prepare donor heart/lung              C             C         0000       0.0000        0.00         0.00         0.00
33935    Transplantation, heart/lung           C             C         0000       0.0000        0.00         0.00         0.00
33940    Removal of donor heart                C             C         0000       0.0000        0.00         0.00         0.00
33944    Prepare donor heart                   C             C         0000       0.0000        0.00         0.00         0.00
33945    Transplantation of heart              C             C         0000       0.0000        0.00         0.00         0.00
33960    External circulation assist           C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  47 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

33961    External circulation assist           C             C         0000       0.0000        0.00         0.00         0.00
33967    Insert ia percut device               C             C         0000       0.0000        0.00         0.00         0.00
33968    Remove aortic assist device           C             C         0000       0.0000        0.00         0.00         0.00
33970    Aortic circulation assist             C             C         0000       0.0000        0.00         0.00         0.00
33971    Aortic circulation assist             C             C         0000       0.0000        0.00         0.00         0.00
33973    Insert balloon device                 C             C         0000       0.0000        0.00         0.00         0.00
33974    Remove intra-aortic balloon           C             C         0000       0.0000        0.00         0.00         0.00
33975    Implant ventricular device            C             C         0000       0.0000        0.00         0.00         0.00
33976    Implant ventricular device            C             C         0000       0.0000        0.00         0.00         0.00
33977    Remove ventricular device             C             C         0000       0.0000        0.00         0.00         0.00
33978    Remove ventricular device             C             C         0000       0.0000        0.00         0.00         0.00
33979    Insert intracorporeal device          C             C         0000       0.0000        0.00         0.00         0.00
33980    Remove intracorporeal device          C             C         0000       0.0000        0.00         0.00         0.00
33999    Cardiac surgery procedure             T             1         0000       0.0000        0.00         0.00         0.00
34001    Removal of artery clot                C             C         0000       0.0000        0.00         0.00         0.00
34051    Removal of artery clot                C             C         0000       0.0000        0.00         0.00         0.00
34101    Removal of artery clot                T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
34111    Removal of arm artery clot            T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
34151    Removal of artery clot                C             C         0000       0.0000        0.00         0.00         0.00
34201    Removal of artery clot                T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
34203    Removal of leg artery clot            T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
34401    Removal of vein clot                  C             C         0000       0.0000        0.00         0.00         0.00
34421    Removal of vein clot                  T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
34451    Removal of vein clot                  C             C         0000       0.0000        0.00         0.00         0.00
34471    Removal of vein clot                  T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
34490    Removal of vein clot                  T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
34501    Repair valve, femoral vein            T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
34502    Reconstruct vena cava                 C             C         0000       0.0000        0.00         0.00         0.00
34510    Transposition of vein valve           T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
34520    Cross-over vein graft                 T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
34530    Leg vein fusion                       T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
34800    Endovas aaa repr w/sm tube            C             C         0000       0.0000        0.00         0.00         0.00
34802    Endovas aaa repr w/2-p part           C             C         0000       0.0000        0.00         0.00         0.00
34803    Endovas aaa repr w/3-p part           C             C         0000       0.0000        0.00         0.00         0.00
34804    Endovas aaa repr w/1-p part           C             C         0000       0.0000        0.00         0.00         0.00
34805    Endovas aaa repr w/long tube          C             C         0000       0.0000        0.00         0.00         0.00
34808    Endovas iliac a device addon          C             C         0000       0.0000        0.00         0.00         0.00
34812    Xpose for endoprosth, femorl          C             C         0000       0.0000        0.00         0.00         0.00
34813    Femoral endovas graft add-on          C             C         0000       0.0000        0.00         0.00         0.00
34820    Xpose for endoprosth, iliac           C             C         0000       0.0000        0.00         0.00         0.00
34825    Endovasc extend prosth, init          C             C         0000       0.0000        0.00         0.00         0.00
34826    Endovasc exten prosth, add’l          C             C         0000       0.0000        0.00         0.00         0.00
34830    Open aortic tube prosth repr          C             C         0000       0.0000        0.00         0.00         0.00
34831    Open aortoiliac prosth repr           C             C         0000       0.0000        0.00         0.00         0.00
34832    Open aortofemor prosth repr           C             C         0000       0.0000        0.00         0.00         0.00
34833    Xpose for endoprosth, iliac           C             C         0000       0.0000        0.00         0.00         0.00
34834    Xpose, endoprosth, brachial           C             C         0000       0.0000        0.00         0.00         0.00
34900    Endovasc iliac repr w/graft           C             C         0000       0.0000        0.00         0.00         0.00
35001    Repair defect of artery               C             C         0000       0.0000        0.00         0.00         0.00
35002    Repair artery rupture, neck           C             C         0000       0.0000        0.00         0.00         0.00
35005    Repair defect of artery               C             C         0000       0.0000        0.00         0.00         0.00
35011    Repair defect of artery               T             T         0653      36.9427      1,635.82     3,758.92     4,307.52
35013    Repair artery rupture, arm            C             C         0000       0.0000        0.00         0.00         0.00
35021    Repair defect of artery               C             C         0000       0.0000        0.00         0.00         0.00
35022    Repair artery rupture, chest          C             C         0000       0.0000        0.00         0.00         0.00
35045    Repair defect of arm artery           C             C         0000       0.0000        0.00         0.00         0.00
35081    Repair defect of artery               C             C         0000       0.0000        0.00         0.00         0.00
35082    Repair artery rupture, aorta          C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  48 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

35091    Repair defect of artery               C             C         0000       0.0000        0.00         0.00         0.00
35092    Repair artery rupture, aorta          C             C         0000       0.0000        0.00         0.00         0.00
35102    Repair defect of artery               C             C         0000       0.0000        0.00         0.00         0.00
35103    Repair artery rupture, groin          C             C         0000       0.0000        0.00         0.00         0.00
35111    Repair defect of artery               C             C         0000       0.0000        0.00         0.00         0.00
35112    Repair artery rupture,spleen          C             C         0000       0.0000        0.00         0.00         0.00
35121    Repair defect of artery               C             C         0000       0.0000        0.00         0.00         0.00
35122    Repair artery rupture, belly          C             C         0000       0.0000        0.00         0.00         0.00
35131    Repair defect of artery               C             C         0000       0.0000        0.00         0.00         0.00
35132    Repair artery rupture, groin          C             C         0000       0.0000        0.00         0.00         0.00
35141    Repair defect of artery               C             C         0000       0.0000        0.00         0.00         0.00
35142    Repair artery rupture, thigh          C             C         0000       0.0000        0.00         0.00         0.00
35151    Repair defect of artery               C             C         0000       0.0000        0.00         0.00         0.00
35152    Repair artery rupture, knee           C             C         0000       0.0000        0.00         0.00         0.00
35180    Repair blood vessel lesion            T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35182    Repair blood vessel lesion            C             C         0000       0.0000        0.00         0.00         0.00
35184    Repair blood vessel lesion            T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35188    Repair blood vessel lesion            T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
35189    Repair blood vessel lesion            C             C         0000       0.0000        0.00         0.00         0.00
35190    Repair blood vessel lesion            T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35201    Repair blood vessel lesion            T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35206    Repair blood vessel lesion            T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35207    Repair blood vessel lesion            T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
35211    Repair blood vessel lesion            C             C         0000       0.0000        0.00         0.00         0.00
35216    Repair blood vessel lesion            C             C         0000       0.0000        0.00         0.00         0.00
35221    Repair blood vessel lesion            C             C         0000       0.0000        0.00         0.00         0.00
35226    Repair blood vessel lesion            T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35231    Repair blood vessel lesion            T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35236    Repair blood vessel lesion            T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35241    Repair blood vessel lesion            C             C         0000       0.0000        0.00         0.00         0.00
35246    Repair blood vessel lesion            C             C         0000       0.0000        0.00         0.00         0.00
35251    Repair blood vessel lesion            C             C         0000       0.0000        0.00         0.00         0.00
35256    Repair blood vessel lesion            T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35261    Repair blood vessel lesion            T             T         0653      36.9427      1,635.82     3,758.92     4,307.52
35266    Repair blood vessel lesion            T             T         0653      36.9427      1,635.82     3,758.92     4,307.52
35271    Repair blood vessel lesion            C             C         0000       0.0000        0.00         0.00         0.00
35276    Repair blood vessel lesion            C             C         0000       0.0000        0.00         0.00         0.00
35281    Repair blood vessel lesion            C             C         0000       0.0000        0.00         0.00         0.00
35286    Repair blood vessel lesion            T             T         0653      36.9427      1,635.82     3,758.92     4,307.52
35301    Rechanneling of artery                C             C         0000       0.0000        0.00         0.00         0.00
35311    Rechanneling of artery                C             C         0000       0.0000        0.00         0.00         0.00
35321    Rechanneling of artery                T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35331    Rechanneling of artery                C             C         0000       0.0000        0.00         0.00         0.00
35341    Rechanneling of artery                C             C         0000       0.0000        0.00         0.00         0.00
35351    Rechanneling of artery                C             C         0000       0.0000        0.00         0.00         0.00
35355    Rechanneling of artery                C             C         0000       0.0000        0.00         0.00         0.00
35361    Rechanneling of artery                C             C         0000       0.0000        0.00         0.00         0.00
35363    Rechanneling of artery                C             C         0000       0.0000        0.00         0.00         0.00
35371    Rechanneling of artery                C             C         0000       0.0000        0.00         0.00         0.00
35372    Rechanneling of artery                C             C         0000       0.0000        0.00         0.00         0.00
35381    Rechanneling of artery                C             C         0000       0.0000        0.00         0.00         0.00
35390    Reoperation, carotid add-on           C             C         0000       0.0000        0.00         0.00         0.00
35400    Angioscopy                            C             C         0000       0.0000        0.00         0.00         0.00
35450    Repair arterial blockage              C             C         0000       0.0000        0.00         0.00         0.00
35452    Repair arterial blockage              C             C         0000       0.0000        0.00         0.00         0.00
35454    Repair arterial blockage              C             C         0000       0.0000        0.00         0.00         0.00
35456    Repair arterial blockage              C             C         0000       0.0000        0.00         0.00         0.00
35458    Repair arterial blockage              T             T         0081      42.2664      1,871.56     4,300.61     4,928.26


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  49 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

35459    Repair arterial blockage              T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35460    Repair venous blockage                T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35470    Repair arterial blockage              T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35471    Repair arterial blockage              T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35472    Repair arterial blockage              T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35473    Repair arterial blockage              T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35474    Repair arterial blockage              T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35475    Repair arterial blockage              T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35476    Repair venous blockage                T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35480    Atherectomy, open                     C             C         0000       0.0000        0.00         0.00         0.00
35481    Atherectomy, open                     C             C         0000       0.0000        0.00         0.00         0.00
35482    Atherectomy, open                     C             C         0000       0.0000        0.00         0.00         0.00
35483    Atherectomy, open                     C             C         0000       0.0000        0.00         0.00         0.00
35484    Atherectomy, open                     T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35485    Atherectomy, open                     T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35490    Atherectomy, percutaneous             T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35491    Atherectomy, percutaneous             T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35492    Atherectomy, percutaneous             T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35493    Atherectomy, percutaneous             T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35494    Atherectomy, percutaneous             T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35495    Atherectomy, percutaneous             T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35500    Harvest vein for bypass               T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
35501    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35506    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35507    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35508    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35509    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35510    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35511    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35512    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35515    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35516    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35518    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35521    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35522    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35525    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35526    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35531    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35533    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35536    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35541    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35546    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35548    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35549    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35551    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35556    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35558    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35560    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35563    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35565    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35566    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35571    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35572    Harvest femoropopliteal vein          N             N         0000       0.0000        0.00         0.00         0.00
35583    Vein bypass graft                     C             C         0000       0.0000        0.00         0.00         0.00
35585    Vein bypass graft                     C             C         0000       0.0000        0.00         0.00         0.00
35587    Vein bypass graft                     C             C         0000       0.0000        0.00         0.00         0.00
35600    Harvest artery for cabg               C             C         0000       0.0000        0.00         0.00         0.00
35601    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  50 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

35606    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35612    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35616    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35621    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35623    Bypass graft, not vein                C             C         0000       0.0000        0.00         0.00         0.00
35626    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35631    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35636    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35641    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35642    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35645    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35646    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35647    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35650    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35651    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35654    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35656    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35661    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35663    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35665    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35666    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35671    Artery bypass graft                   C             C         0000       0.0000        0.00         0.00         0.00
35681    Composite bypass graft                C             C         0000       0.0000        0.00         0.00         0.00
35682    Composite bypass graft                C             C         0000       0.0000        0.00         0.00         0.00
35683    Composite bypass graft                C             C         0000       0.0000        0.00         0.00         0.00
35685    Bypass graft patency/patch            T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35686    Bypass graft/av fist patency          T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35691    Arterial transposition                C             C         0000       0.0000        0.00         0.00         0.00
35693    Arterial transposition                C             C         0000       0.0000        0.00         0.00         0.00
35694    Arterial transposition                C             C         0000       0.0000        0.00         0.00         0.00
35695    Arterial transposition                C             C         0000       0.0000        0.00         0.00         0.00
35697    Reimplant artery each                 C             C         0000       0.0000        0.00         0.00         0.00
35700    Reoperation, bypass graft             C             C         0000       0.0000        0.00         0.00         0.00
35701    Exploration, carotid artery           C             C         0000       0.0000        0.00         0.00         0.00
35721    Exploration, femoral artery           C             C         0000       0.0000        0.00         0.00         0.00
35741    Exploration popliteal artery          C             C         0000       0.0000        0.00         0.00         0.00
35761    Exploration of artery/vein            T             T         0115      36.9806      1,637.50     3,762.78     4,311.94
35800    Explore neck vessels                  C             C         0000       0.0000        0.00         0.00         0.00
35820    Explore chest vessels                 C             C         0000       0.0000        0.00         0.00         0.00
35840    Explore abdominal vessels             C             C         0000       0.0000        0.00         0.00         0.00
35860    Explore limb vessels                  T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
35870    Repair vessel graft defect            C             C         0000       0.0000        0.00         0.00         0.00
35875    Removal of clot in graft              T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
35876    Removal of clot in graft              T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
35879    Revise graft w/vein                   T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
35881    Revise graft w/vein                   T             T         0088      36.5126      1,616.78     3,715.16     4,257.37
35901    Excision, graft, neck                 C             C         0000       0.0000        0.00         0.00         0.00
35903    Excision, graft, extremity            T             T         0115      36.9806      1,637.50     3,762.78     4,311.94
35905    Excision, graft, thorax               C             C         0000       0.0000        0.00         0.00         0.00
35907    Excision, graft, abdomen              C             C         0000       0.0000        0.00         0.00         0.00
36000    Place needle in vein                  N             N         0000       0.0000        0.00         0.00         0.00
36002    Pseudoaneurysm injection trt          S             S         0267       2.5543       113.10       259.90       297.83
36005    Injection ext venography              N             N         0000       0.0000        0.00         0.00         0.00
36010    Place catheter in vein                N             N         0000       0.0000        0.00         0.00         0.00
36011    Place catheter in vein                N             N         0000       0.0000        0.00         0.00         0.00
36012    Place catheter in vein                N             N         0000       0.0000        0.00         0.00         0.00
36013    Place catheter in artery              N             N         0000       0.0000        0.00         0.00         0.00
36014    Place catheter in artery              N             N         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  51 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

36015    Place catheter in artery              N             N         0000       0.0000        0.00         0.00         0.00
36100    Establish access to artery            N             N         0000       0.0000        0.00         0.00         0.00
36120    Establish access to artery            N             N         0000       0.0000        0.00         0.00         0.00
36140    Establish access to artery            N             N         0000       0.0000        0.00         0.00         0.00
36145    Artery to vein shunt                  N             N         0000       0.0000        0.00         0.00         0.00
36160    Establish access to aorta             N             N         0000       0.0000        0.00         0.00         0.00
36200    Place catheter in aorta               N             N         0000       0.0000        0.00         0.00         0.00
36215    Place catheter in artery              N             N         0000       0.0000        0.00         0.00         0.00
36216    Place catheter in artery              N             N         0000       0.0000        0.00         0.00         0.00
36217    Place catheter in artery              N             N         0000       0.0000        0.00         0.00         0.00
36218    Place catheter in artery              N             N         0000       0.0000        0.00         0.00         0.00
36245    Place catheter in artery              N             N         0000       0.0000        0.00         0.00         0.00
36246    Place catheter in artery              N             N         0000       0.0000        0.00         0.00         0.00
36247    Place catheter in artery              N             N         0000       0.0000        0.00         0.00         0.00
36248    Place catheter in artery              N             N         0000       0.0000        0.00         0.00         0.00
36260    Insertion of infusion pump            T             T         0623      27.1472      1,202.08     2,762.23     3,165.36
36261    Revision of infusion pump             T             T         0623      27.1472      1,202.08     2,762.23     3,165.36
36262    Removal of infusion pump              T             T         0622      21.2464       940.79      2,161.82     2,477.33
36299    Vessel injection procedure            N             1         0000       0.0000        0.00         0.00         0.00
36400    Bl draw < 3 yrs fem/jugular           N             N         0000       0.0000        0.00         0.00         0.00
36405    Bl draw < 3 yrs scalp vein            N             N         0000       0.0000        0.00         0.00         0.00
36406    Bl draw < 3 yrs other vein            N             N         0000       0.0000        0.00         0.00         0.00
36410    Non-routine bl draw > 3 yrs           N             N         0000       0.0000        0.00         0.00         0.00
36415    Routine venipuncture                  A             3         0000       0.0000        M01          M01          M01
36416    Capillary blood draw                  N             N         0000       0.0000        0.00         0.00         0.00
36420    Vein access cutdown < 1 yr            T             T         0035       0.0834        3.69         8.49         9.72
36425    Vein access cutdown > 1 yr            T             T         0035       0.0834        3.69         8.49         9.72
36430    Blood transfusion service             S             S         0110       3.6419       161.26       370.56       424.65
36440    Bl push transfuse, 2 yr or <          S             S         0110       3.6419       161.26       370.56       424.65
36450    Bl exchange/transfuse, nb             S             S         0110       3.6419       161.26       370.56       424.65
36455    Bl exchange/transfuse non-nb          S             S         0110       3.6419       161.26       370.56       424.65
36460    Transfusion service, fetal            S             S         0110       3.6419       161.26       370.56       424.65
36468    Injection(s), spider veins            T             1         0000       0.0000        0.00         0.00         0.00
36469    Injection(s), spider veins            T             1         0000       0.0000        0.00         0.00         0.00
36470    Injection therapy of vein             T             1         0000       0.0000        0.00         0.00         0.00
36471    Injection therapy of veins            T             1         0000       0.0000        0.00         0.00         0.00
36475    Endovenous rf, 1st vein               T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
36476    Endovenous rf, vein add-on            T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
36478    Endovenous laser, 1st vein            T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
36479    Endovenous laser vein addon           T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
36481    Insertion of catheter, vein           N             N         0000       0.0000        0.00         0.00         0.00
36500    Insertion of catheter, vein           N             N         0000       0.0000        0.00         0.00         0.00
36510    Insertion of catheter, vein           N             N         0000       0.0000        0.00         0.00         0.00
36511    Apheresis wbc                         S             S         0111      12.0768       534.76      1,228.81     1,408.15
36512    Apheresis rbc                         S             S         0111      12.0768       534.76      1,228.81     1,408.15
36513    Apheresis platelets                   S             S         0111      12.0768       534.76      1,228.81     1,408.15
36514    Apheresis plasma                      S             S         0111      12.0768       534.76      1,228.81     1,408.15
36515    Apheresis, adsorp/reinfuse            S             S         0112      26.3750      1,167.89     2,683.66     3,075.33
36516    Apheresis, selective                  S             S         0112      26.3750      1,167.89     2,683.66     3,075.33
36522    Photopheresis                         S             S         0112      26.3750      1,167.89     2,683.66     3,075.33
36540    Collect blood venous device           N             N         0000       0.0000        0.00         0.00         0.00
36550    Declot vascular device                T             T         0676       2.2742       100.70       231.40       265.17
36555    Insert non-tunnel cv cath             T             T         0621       8.2313       364.48       837.53       959.77
36556    Insert non-tunnel cv cath             T             T         0621       8.2313       364.48       837.53       959.77
36557    Insert tunneled cv cath               T             T         0622      21.2464       940.79      2,161.82     2,477.33
36558    Insert tunneled cv cath               T             T         0622      21.2464       940.79      2,161.82     2,477.33
36560    Insert tunneled cv cath               T             T         0623      27.1472      1,202.08     2,762.23     3,165.36
36561    Insert tunneled cv cath               T             T         0623      27.1472      1,202.08     2,762.23     3,165.36


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  52 of 223
State of Wyoming Oupatient Prospective Payment System                                                           Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                       Critical
                                                                                              General        Children's                 Change
                                               2006      WY 2006                                                           Access
 CPT/                                                                           APC Relative Hospital         Hospital                   from
                 Description (short)          Status       Status       APC                                                Hospital
HCPCS                                                                             Weight     Outpatient      Outpatient                 4-14-06
                                            Indicator    Indicator                                                        Outpatient
                                                                                                Fee             Fee                    Schedule
                                           (FYI Only)                                                                        Fee

36563    Insert tunneled cv cath               T             T         0623      27.1472          1,202.08    2,762.23     3,165.36
36565    Insert tunneled cv cath               T             T         0623      27.1472          1,202.08    2,762.23     3,165.36
36566    Insert tunneled cv cath               T             T         1564      79.8172      *   3,534.31    8,121.40     9,306.69
36568    Insert picc cath                      T             T         0621       8.2313           364.48      837.53       959.77
36569    Insert picc cath                      T             T         0621       8.2313           364.48      837.53       959.77
36570    Insert picvad cath                    T             T         0622      21.2464           940.79     2,161.82     2,477.33
36571    Insert picvad cath                    T             T         0622      21.2464           940.79     2,161.82     2,477.33
36575    Repair tunneled cv cath               T             T         0621       8.2313           364.48      837.53       959.77
36576    Repair tunneled cv cath               T             T         0621       8.2313           364.48      837.53       959.77
36578    Replace tunneled cv cath              T             T         0622      21.2464           940.79     2,161.82     2,477.33
36580    Replace cvad cath                     T             T         0621       8.2313           364.48      837.53       959.77
36581    Replace tunneled cv cath              T             T         0622      21.2464           940.79     2,161.82     2,477.33
36582    Replace tunneled cv cath              T             T         0623      27.1472          1,202.08    2,762.23     3,165.36
36583    Replace tunneled cv cath              T             T         0623      27.1472          1,202.08    2,762.23     3,165.36
36584    Replace picc cath                     T             T         0621       8.2313           364.48      837.53       959.77
36585    Replace picvad cath                   T             T         0622      21.2464           940.79     2,161.82     2,477.33
36589    Removal tunneled cv cath              T             T         0621       8.2313           364.48      837.53       959.77
36590    Removal tunneled cv cath              T             T         0621       8.2313           364.48      837.53       959.77
36595    Mech remov tunneled cv cath           T             T         0622      21.2464           940.79     2,161.82     2,477.33
36596    Mech remov tunneled cv cath           T             T         0621       8.2313           364.48      837.53       959.77
36597    Reposition venous catheter            T             T         0621       8.2313           364.48      837.53       959.77
36598    Inj w/fluor, eval cv device           X             X         0340       0.6137            27.17      62.44        71.56
36600    Withdrawal of arterial blood          N             N         0000       0.0000            0.00        0.00         0.00
36620    Insertion catheter, artery            N             N         0000       0.0000            0.00        0.00         0.00
36625    Insertion catheter, artery            N             N         0000       0.0000            0.00        0.00         0.00
36640    Insertion catheter, artery            T             T         0623      27.1472          1,202.08    2,762.23     3,165.36
36660    Insertion catheter, artery            C             C         0000       0.0000            0.00        0.00         0.00
36680    Insert needle, bone cavity            T             T         0002       0.9357            41.43      95.21        109.10
36800    Insertion of cannula                  T             T         0115      36.9806          1,637.50    3,762.78     4,311.94
36810    Insertion of cannula                  T             T         0115      36.9806          1,637.50    3,762.78     4,311.94
36815    Insertion of cannula                  T             T         0115      36.9806          1,637.50    3,762.78     4,311.94
36818    Av fuse, uppr arm, cephalic           T             T         0088      36.5126          1,616.78    3,715.16     4,257.37
36819    Av fuse, uppr arm, basilic            T             T         0088      36.5126          1,616.78    3,715.16     4,257.37
36820    Av fusion/forearm vein                T             T         0088      36.5126          1,616.78    3,715.16     4,257.37
36821    Av fusion direct any site             T             T         0088      36.5126          1,616.78    3,715.16     4,257.37
36822    Insertion of cannula(s)               C             C         0000       0.0000            0.00        0.00         0.00
36823    Insertion of cannula(s)               C             C         0000       0.0000            0.00        0.00         0.00
36825    Artery-vein autograft                 T             T         0088      36.5126          1,616.78    3,715.16     4,257.37
36830    Artery-vein nonautograft              T             T         0088      36.5126          1,616.78    3,715.16     4,257.37
36831    Open thrombect av fistula             T             T         0088      36.5126          1,616.78    3,715.16     4,257.37
36832    Av fistula revision, open             T             T         0088      36.5126          1,616.78    3,715.16     4,257.37
36833    Av fistula revision                   T             T         0088      36.5126          1,616.78    3,715.16     4,257.37
36834    Repair A-V aneurysm                   T             T         0088      36.5126          1,616.78    3,715.16     4,257.37
36835    Artery to vein shunt                  T             T         0115      36.9806          1,637.50    3,762.78     4,311.94
36838    Dist revas ligation, hemo             T             T         0088      36.5126          1,616.78    3,715.16     4,257.37
36860    External cannula declotting           T             T         0676       2.2742           100.70      231.40       265.17
36861    Cannula declotting                    T             T         0115      36.9806          1,637.50    3,762.78     4,311.94
36870    Percut thrombect av fistula           T             T         0653      36.9427          1,635.82    3,758.92     4,307.52
37140    Revision of circulation               C             C         0000       0.0000            0.00        0.00         0.00
37145    Revision of circulation               C             C         0000       0.0000            0.00        0.00         0.00
37160    Revision of circulation               C             C         0000       0.0000            0.00        0.00         0.00
37180    Revision of circulation               C             C         0000       0.0000            0.00        0.00         0.00
37181    Splice spleen/kidney veins            C             C         0000       0.0000            0.00        0.00         0.00
37182    Insert hepatic shunt (tips)           C             C         0000       0.0000            0.00        0.00         0.00
37183    Remove hepatic shunt (tips)           T             T         0229      66.3380          2,937.45    6,749.89     7,735.01
37184    Prim art mech thrombectomy            T             T         0653      36.9427          1,635.82    3,758.92     4,307.52
37185    Prim art m-thrombect add-on           T             T         0103      15.0428           666.10     1,530.60     1,753.99
37186    Sec art m-thrombect add-on            T             T         0103      15.0428           666.10     1,530.60     1,753.99


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                     53 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

37187    Venous mech thrombectomy              T             T         0653      36.9427      1,635.82     3,758.92     4,307.52
37188    Venous m-thrombectomy add-on          T             T         0653      36.9427      1,635.82     3,758.92     4,307.52
37195    Thrombolytic therapy, stroke          T             T         0676       2.2742       100.70       231.40       265.17
37200    Transcatheter biopsy                  T             T         0685       6.0034       265.83       610.85       700.00
37201    Transcatheter therapy infuse          T             T         0676       2.2742       100.70       231.40       265.17
37202    Transcatheter therapy infuse          T             T         0676       2.2742       100.70       231.40       265.17
37203    Transcatheter retrieval               T             T         0103      15.0428       666.10      1,530.60     1,753.99
37204    Transcatheter occlusion               T             T         0115      36.9806      1,637.50     3,762.78     4,311.94
37205    Transcath iv stent, percut            T             T         0229      66.3380      2,937.45     6,749.89     7,735.01
37206    Transcath iv stent/perc addl          T             T         0229      66.3380      2,937.45     6,749.89     7,735.01
37207    Transcath iv stent, open              T             T         0229      66.3380      2,937.45     6,749.89     7,735.01
37208    Transcath iv stent/open addl          T             T         0229      66.3380      2,937.45     6,749.89     7,735.01
37209    Exchange arterial catheter            T             T         0103      15.0428       666.10      1,530.60     1,753.99
37215    Transcath stent, cca w/eps            C             C         0000       0.0000        0.00         0.00         0.00
37216    Transcath stent, cca w/o eps          C             C         0000       0.0000        0.00         0.00         0.00
37250    Iv us first vessel add-on             S             S         0416      16.4464       728.25      1,673.42     1,917.65
37251    Iv us each add vessel add-on          S             S         0416      16.4464       728.25      1,673.42     1,917.65
37500    Endoscopy ligate perf veins           T             T         0092      26.5104      1,173.88     2,697.43     3,091.11
37501    Vascular endoscopy procedure          T             1         0000       0.0000        0.00         0.00         0.00
37565    Ligation of neck vein                 T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
37600    Ligation of neck artery               T             T         0093      23.3101      1,032.17     2,371.80     2,717.96
37605    Ligation of neck artery               T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
37606    Ligation of neck artery               T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
37607    Ligation of a-v fistula               T             T         0092      26.5104      1,173.88     2,697.43     3,091.11
37609    Temporal artery procedure             T             T         0021      14.9984       664.13      1,526.09     1,748.81
37615    Ligation of neck artery               T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
37616    Ligation of chest artery              C             C         0000       0.0000        0.00         0.00         0.00
37617    Ligation of abdomen artery            C             C         0000       0.0000        0.00         0.00         0.00
37618    Ligation of extremity artery          C             C         0000       0.0000        0.00         0.00         0.00
37620    Revision of major vein                T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
37650    Revision of major vein                T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
37660    Revision of major vein                C             C         0000       0.0000        0.00         0.00         0.00
37700    Revise leg vein                       T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
37718    Ligate/strip short leg vein           T             T         0092      26.5104      1,173.88     2,697.43     3,091.11
37722    Ligate/strip long leg vein            T             T         0092      26.5104      1,173.88     2,697.43     3,091.11
37735    Removal of leg veins/lesion           T             T         0092      26.5104      1,173.88     2,697.43     3,091.11
37760    Ligation, leg veins, open             T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
37765    Phleb veins - extrem - to 20          T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
37766    Phleb veins - extrem 20+              T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
37780    Revision of leg vein                  T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
37785    Ligate/divide/excise vein             T             T         0091      28.8805      1,278.83     2,938.59     3,367.47
37788    Revascularization, penis              C             C         0000       0.0000        0.00         0.00         0.00
37790    Penile venous occlusion               T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
37799    Vascular surgery procedure            T             1         0000       0.0000        0.00         0.00         0.00
38100    Removal of spleen, total              C             C         0000       0.0000        0.00         0.00         0.00
38101    Removal of spleen, partial            C             C         0000       0.0000        0.00         0.00         0.00
38102    Removal of spleen, total              C             C         0000       0.0000        0.00         0.00         0.00
38115    Repair of ruptured spleen             C             C         0000       0.0000        0.00         0.00         0.00
38120    Laparoscopy, splenectomy              T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
38129    Laparoscope proc, spleen              T             1         0000       0.0000        0.00         0.00         0.00
38200    Injection for spleen x-ray            N             N         0000       0.0000        0.00         0.00         0.00
38204    Bl donor search management            N             N         0000       0.0000        0.00         0.00         0.00
38205    Harvest allogenic stem cells          S             S         0111      12.0768       534.76      1,228.81     1,408.15
38206    Harvest auto stem cells               S             S         0111      12.0768       534.76      1,228.81     1,408.15
38207    Cryopreserve stem cells               E             3         0000       0.0000        M01          M01          M01
38208    Thaw preserved stem cells             E             3         0000       0.0000        M01          M01          M01
38209    Wash harvest stem cells               E             1         0000       0.0000        0.00         0.00         0.00
38210    T-cell depletion of harvest           E             1         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  54 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

38211    Tumor cell deplete of harvst          E             1         0000       0.0000        0.00         0.00         0.00
38212    Rbc depletion of harvest              E             1         0000       0.0000        0.00         0.00         0.00
38213    Platelet deplete of harvest           E             1         0000       0.0000        0.00         0.00         0.00
38214    Volume deplete of harvest             E             1         0000       0.0000        0.00         0.00         0.00
38215    Harvest stem cell concentrte          E             1         0000       0.0000        0.00         0.00         0.00
38220    Bone marrow aspiration                T             T         0003       2.6756       118.48       272.24       311.97
38221    Bone marrow biopsy                    T             T         0003       2.6756       118.48       272.24       311.97
38230    Bone marrow collection                S             S         0123      24.4820      1,084.06     2,491.04     2,854.60
38240    Bone marrow/stem transplant           S             S         0123      24.4820      1,084.06     2,491.04     2,854.60
38241    Bone marrow/stem transplant           S             S         0123      24.4820      1,084.06     2,491.04     2,854.60
38242    Lymphocyte infuse transplant          S             S         0111      12.0768       534.76      1,228.81     1,408.15
38300    Drainage, lymph node lesion           T             T         0007      11.6717       516.82      1,187.60     1,360.92
38305    Drainage, lymph node lesion           T             T         0008      16.2953       721.56      1,658.05     1,900.03
38308    Incision of lymph channels            T             T         0113      21.4112       948.09      2,178.59     2,496.55
38380    Thoracic duct procedure               C             C         0000       0.0000        0.00         0.00         0.00
38381    Thoracic duct procedure               C             C         0000       0.0000        0.00         0.00         0.00
38382    Thoracic duct procedure               C             C         0000       0.0000        0.00         0.00         0.00
38500    Biopsy/removal, lymph nodes           T             T         0113      21.4112       948.09      2,178.59     2,496.55
38505    Needle biopsy, lymph nodes            T             T         0005       3.5834       158.67       364.61       417.82
38510    Biopsy/removal, lymph nodes           T             T         0113      21.4112       948.09      2,178.59     2,496.55
38520    Biopsy/removal, lymph nodes           T             T         0113      21.4112       948.09      2,178.59     2,496.55
38525    Biopsy/removal, lymph nodes           T             T         0113      21.4112       948.09      2,178.59     2,496.55
38530    Biopsy/removal, lymph nodes           T             T         0113      21.4112       948.09      2,178.59     2,496.55
38542    Explore deep node(s), neck            T             T         0114      40.4596      1,791.55     4,116.76     4,717.59
38550    Removal, neck/armpit lesion           T             T         0113      21.4112       948.09      2,178.59     2,496.55
38555    Removal, neck/armpit lesion           T             T         0113      21.4112       948.09      2,178.59     2,496.55
38562    Removal, pelvic lymph nodes           C             C         0000       0.0000        0.00         0.00         0.00
38564    Removal, abdomen lymph nodes          C             C         0000       0.0000        0.00         0.00         0.00
38570    Laparoscopy, lymph node biop          T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
38571    Laparoscopy, lymphadenectomy          T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
38572    Laparoscopy, lymphadenectomy          T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
38589    Laparoscope proc, lymphatic           T             1         0000       0.0000        0.00         0.00         0.00
38700    Removal of lymph nodes, neck          T             T         0113      21.4112       948.09      2,178.59     2,496.55
38720    Removal of lymph nodes, neck          T             T         0113      21.4112       948.09      2,178.59     2,496.55
38724    Removal of lymph nodes, neck          C             C         0000       0.0000        0.00         0.00         0.00
38740    Remove armpit lymph nodes             T             T         0114      40.4596      1,791.55     4,116.76     4,717.59
38745    Remove armpit lymph nodes             T             T         0114      40.4596      1,791.55     4,116.76     4,717.59
38746    Remove thoracic lymph nodes           C             C         0000       0.0000        0.00         0.00         0.00
38747    Remove abdominal lymph nodes          C             C         0000       0.0000        0.00         0.00         0.00
38760    Remove groin lymph nodes              T             T         0113      21.4112       948.09      2,178.59     2,496.55
38765    Remove groin lymph nodes              C             C         0000       0.0000        0.00         0.00         0.00
38770    Remove pelvis lymph nodes             C             C         0000       0.0000        0.00         0.00         0.00
38780    Remove abdomen lymph nodes            C             C         0000       0.0000        0.00         0.00         0.00
38790    Inject for lymphatic x-ray            N             N         0000       0.0000        0.00         0.00         0.00
38792    Identify sentinel node                N             N         0000       0.0000        0.00         0.00         0.00
38794    Access thoracic lymph duct            N             N         0000       0.0000        0.00         0.00         0.00
38999    Blood/lymph system procedure          S             1         0000       0.0000        0.00         0.00         0.00
39000    Exploration of chest                  C             C         0000       0.0000        0.00         0.00         0.00
39010    Exploration of chest                  C             C         0000       0.0000        0.00         0.00         0.00
39200    Removal chest lesion                  C             C         0000       0.0000        0.00         0.00         0.00
39220    Removal chest lesion                  C             C         0000       0.0000        0.00         0.00         0.00
39400    Visualization of chest                T             T         0069      30.9541      1,370.65     3,149.58     3,609.25
39499    Chest procedure                       C             1         0000       0.0000        0.00         0.00         0.00
39501    Repair diaphragm laceration           C             C         0000       0.0000        0.00         0.00         0.00
39502    Repair paraesophageal hernia          C             C         0000       0.0000        0.00         0.00         0.00
39503    Repair of diaphragm hernia            C             C         0000       0.0000        0.00         0.00         0.00
39520    Repair of diaphragm hernia            C             C         0000       0.0000        0.00         0.00         0.00
39530    Repair of diaphragm hernia            C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  55 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

39531    Repair of diaphragm hernia            C             C         0000       0.0000        0.00         0.00         0.00
39540    Repair of diaphragm hernia            C             C         0000       0.0000        0.00         0.00         0.00
39541    Repair of diaphragm hernia            C             C         0000       0.0000        0.00         0.00         0.00
39545    Revision of diaphragm                 C             C         0000       0.0000        0.00         0.00         0.00
39560    Resect diaphragm, simple              C             C         0000       0.0000        0.00         0.00         0.00
39561    Resect diaphragm, complex             C             C         0000       0.0000        0.00         0.00         0.00
39599    Diaphragm surgery procedure           C             1         0000       0.0000        0.00         0.00         0.00
40490    Biopsy of lip                         T             T         0251       2.0789        92.05       211.53       242.40
40500    Partial excision of lip               T             T         0253      16.0740       711.76      1,635.53     1,874.23
40510    Partial excision of lip               T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
40520    Partial excision of lip               T             T         0253      16.0740       711.76      1,635.53     1,874.23
40525    Reconstruct lip with flap             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
40527    Reconstruct lip with flap             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
40530    Partial removal of lip                T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
40650    Repair lip                            T             T         0252       8.1033       358.81       824.51       944.84
40652    Repair lip                            T             T         0252       8.1033       358.81       824.51       944.84
40654    Repair lip                            T             T         0252       8.1033       358.81       824.51       944.84
40700    Repair cleft lip/nasal                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
40701    Repair cleft lip/nasal                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
40702    Repair cleft lip/nasal                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
40720    Repair cleft lip/nasal                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
40761    Repair cleft lip/nasal                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
40799    Lip surgery procedure                 T             1         0000       0.0000        0.00         0.00         0.00
40800    Drainage of mouth lesion              T             T         0251       2.0789        92.05       211.53       242.40
40801    Drainage of mouth lesion              T             T         0252       8.1033       358.81       824.51       944.84
40804    Removal, foreign body, mouth          X             X         0340       0.6137        27.17       62.44        71.56
40805    Removal, foreign body, mouth          T             T         0252       8.1033       358.81       824.51       944.84
40806    Incision of lip fold                  T             T         0251       2.0789        92.05       211.53       242.40
40808    Biopsy of mouth lesion                T             T         0251       2.0789        92.05       211.53       242.40
40810    Excision of mouth lesion              T             T         0253      16.0740       711.76      1,635.53     1,874.23
40812    Excise/repair mouth lesion            T             T         0253      16.0740       711.76      1,635.53     1,874.23
40814    Excise/repair mouth lesion            T             T         0253      16.0740       711.76      1,635.53     1,874.23
40816    Excision of mouth lesion              T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
40818    Excise oral mucosa for graft          T             T         0251       2.0789        92.05       211.53       242.40
40819    Excise lip or cheek fold              T             T         0252       8.1033       358.81       824.51       944.84
40820    Treatment of mouth lesion             T             T         0253      16.0740       711.76      1,635.53     1,874.23
40830    Repair mouth laceration               T             T         0251       2.0789        92.05       211.53       242.40
40831    Repair mouth laceration               T             T         0252       8.1033       358.81       824.51       944.84
40840    Reconstruction of mouth               T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
40842    Reconstruction of mouth               T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
40843    Reconstruction of mouth               T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
40844    Reconstruction of mouth               T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
40845    Reconstruction of mouth               T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
40899    Mouth surgery procedure               T             1         0000       0.0000        0.00         0.00         0.00
41000    Drainage of mouth lesion              T             T         0253      16.0740       711.76      1,635.53     1,874.23
41005    Drainage of mouth lesion              T             T         0251       2.0789        92.05       211.53       242.40
41006    Drainage of mouth lesion              T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
41007    Drainage of mouth lesion              T             T         0253      16.0740       711.76      1,635.53     1,874.23
41008    Drainage of mouth lesion              T             T         0253      16.0740       711.76      1,635.53     1,874.23
41009    Drainage of mouth lesion              T             T         0251       2.0789        92.05       211.53       242.40
41010    Incision of tongue fold               T             T         0252       8.1033       358.81       824.51       944.84
41015    Drainage of mouth lesion              T             T         0251       2.0789        92.05       211.53       242.40
41016    Drainage of mouth lesion              T             T         0252       8.1033       358.81       824.51       944.84
41017    Drainage of mouth lesion              T             T         0252       8.1033       358.81       824.51       944.84
41018    Drainage of mouth lesion              T             T         0252       8.1033       358.81       824.51       944.84
41100    Biopsy of tongue                      T             T         0252       8.1033       358.81       824.51       944.84
41105    Biopsy of tongue                      T             T         0253      16.0740       711.76      1,635.53     1,874.23
41108    Biopsy of floor of mouth              T             T         0252       8.1033       358.81       824.51       944.84


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  56 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

41110    Excision of tongue lesion             T             T         0253      16.0740       711.76      1,635.53     1,874.23
41112    Excision of tongue lesion             T             T         0253      16.0740       711.76      1,635.53     1,874.23
41113    Excision of tongue lesion             T             T         0253      16.0740       711.76      1,635.53     1,874.23
41114    Excision of tongue lesion             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
41115    Excision of tongue fold               T             T         0252       8.1033       358.81       824.51       944.84
41116    Excision of mouth lesion              T             T         0253      16.0740       711.76      1,635.53     1,874.23
41120    Partial removal of tongue             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
41130    Partial removal of tongue             C             C         0000       0.0000        0.00         0.00         0.00
41135    Tongue and neck surgery               C             C         0000       0.0000        0.00         0.00         0.00
41140    Removal of tongue                     C             C         0000       0.0000        0.00         0.00         0.00
41145    Tongue removal, neck surgery          C             C         0000       0.0000        0.00         0.00         0.00
41150    Tongue, mouth, jaw surgery            C             C         0000       0.0000        0.00         0.00         0.00
41153    Tongue, mouth, neck surgery           C             C         0000       0.0000        0.00         0.00         0.00
41155    Tongue, jaw, & neck surgery           C             C         0000       0.0000        0.00         0.00         0.00
41250    Repair tongue laceration              T             T         0251       2.0789        92.05       211.53       242.40
41251    Repair tongue laceration              T             T         0251       2.0789        92.05       211.53       242.40
41252    Repair tongue laceration              T             T         0252       8.1033       358.81       824.51       944.84
41500    Fixation of tongue                    T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
41510    Tongue to lip surgery                 T             T         0253      16.0740       711.76      1,635.53     1,874.23
41520    Reconstruction, tongue fold           T             T         0252       8.1033       358.81       824.51       944.84
41599    Tongue and mouth surgery              T             1         0000       0.0000        0.00         0.00         0.00
41800    Drainage of gum lesion                T             T         0251       2.0789        92.05       211.53       242.40
41805    Removal foreign body, gum             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
41806    Removal foreign body,jawbone          T             T         0253      16.0740       711.76      1,635.53     1,874.23
41820    Excision, gum, each quadrant          T             T         0252       8.1033       358.81       824.51       944.84
41821    Excision of gum flap                  T             T         0252       8.1033       358.81       824.51       944.84
41822    Excision of gum lesion                T             T         0253      16.0740       711.76      1,635.53     1,874.23
41823    Excision of gum lesion                T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
41825    Excision of gum lesion                T             T         0253      16.0740       711.76      1,635.53     1,874.23
41826    Excision of gum lesion                T             T         0253      16.0740       711.76      1,635.53     1,874.23
41827    Excision of gum lesion                T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
41828    Excision of gum lesion                T             T         0253      16.0740       711.76      1,635.53     1,874.23
41830    Removal of gum tissue                 T             T         0253      16.0740       711.76      1,635.53     1,874.23
41850    Treatment of gum lesion               T             T         0253      16.0740       711.76      1,635.53     1,874.23
41870    Gum graft                             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
41872    Repair gum                            T             T         0253      16.0740       711.76      1,635.53     1,874.23
41874    Repair tooth socket                   T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
41899    Dental surgery procedure              T             2         0000       0.0000        0.00         0.00         0.00
42000    Drainage mouth roof lesion            T             T         0251       2.0789        92.05       211.53       242.40
42100    Biopsy roof of mouth                  T             T         0252       8.1033       358.81       824.51       944.84
42104    Excision lesion, mouth roof           T             T         0253      16.0740       711.76      1,635.53     1,874.23
42106    Excision lesion, mouth roof           T             T         0253      16.0740       711.76      1,635.53     1,874.23
42107    Excision lesion, mouth roof           T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
42120    Remove palate/lesion                  T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42140    Excision of uvula                     T             T         0252       8.1033       358.81       824.51       944.84
42145    Repair palate, pharynx/uvula          T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
42160    Treatment mouth roof lesion           T             T         0253      16.0740       711.76      1,635.53     1,874.23
42180    Repair palate                         T             T         0251       2.0789        92.05       211.53       242.40
42182    Repair palate                         T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42200    Reconstruct cleft palate              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42205    Reconstruct cleft palate              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42210    Reconstruct cleft palate              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42215    Reconstruct cleft palate              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42220    Reconstruct cleft palate              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42225    Reconstruct cleft palate              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42226    Lengthening of palate                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42227    Lengthening of palate                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42235    Repair palate                         T             T         0253      16.0740       711.76      1,635.53     1,874.23


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  57 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

42260    Repair nose to lip fistula            T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
42280    Preparation, palate mold              T             T         0251       2.0789        92.05       211.53       242.40
42281    Insertion, palate prosthesis          T             T         0253      16.0740       711.76      1,635.53     1,874.23
42299    Palate/uvula surgery                  T             1         0000       0.0000        0.00         0.00         0.00
42300    Drainage of salivary gland            T             T         0253      16.0740       711.76      1,635.53     1,874.23
42305    Drainage of salivary gland            T             T         0253      16.0740       711.76      1,635.53     1,874.23
42310    Drainage of salivary gland            T             T         0251       2.0789        92.05       211.53       242.40
42320    Drainage of salivary gland            T             T         0251       2.0789        92.05       211.53       242.40
42330    Removal of salivary stone             T             T         0253      16.0740       711.76      1,635.53     1,874.23
42335    Removal of salivary stone             T             T         0253      16.0740       711.76      1,635.53     1,874.23
42340    Removal of salivary stone             T             T         0253      16.0740       711.76      1,635.53     1,874.23
42400    Biopsy of salivary gland              T             T         0005       3.5834       158.67       364.61       417.82
42405    Biopsy of salivary gland              T             T         0253      16.0740       711.76      1,635.53     1,874.23
42408    Excision of salivary cyst             T             T         0253      16.0740       711.76      1,635.53     1,874.23
42409    Drainage of salivary cyst             T             T         0253      16.0740       711.76      1,635.53     1,874.23
42410    Excise parotid gland/lesion           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42415    Excise parotid gland/lesion           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42420    Excise parotid gland/lesion           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42425    Excise parotid gland/lesion           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42426    Excise parotid gland/lesion           C             C         0000       0.0000        0.00         0.00         0.00
42440    Excise submaxillary gland             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42450    Excise sublingual gland               T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
42500    Repair salivary duct                  T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
42505    Repair salivary duct                  T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42507    Parotid duct diversion                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42508    Parotid duct diversion                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42509    Parotid duct diversion                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42510    Parotid duct diversion                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42550    Injection for salivary x-ray          N             N         0000       0.0000        0.00         0.00         0.00
42600    Closure of salivary fistula           T             T         0253      16.0740       711.76      1,635.53     1,874.23
42650    Dilation of salivary duct             T             T         0252       8.1033       358.81       824.51       944.84
42660    Dilation of salivary duct             T             T         0251       2.0789        92.05       211.53       242.40
42665    Ligation of salivary duct             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
42699    Salivary surgery procedure            T             1         0000       0.0000        0.00         0.00         0.00
42700    Drainage of tonsil abscess            T             T         0251       2.0789        92.05       211.53       242.40
42720    Drainage of throat abscess            T             T         0253      16.0740       711.76      1,635.53     1,874.23
42725    Drainage of throat abscess            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42800    Biopsy of throat                      T             T         0253      16.0740       711.76      1,635.53     1,874.23
42802    Biopsy of throat                      T             T         0253      16.0740       711.76      1,635.53     1,874.23
42804    Biopsy of upper nose/throat           T             T         0253      16.0740       711.76      1,635.53     1,874.23
42806    Biopsy of upper nose/throat           T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
42808    Excise pharynx lesion                 T             T         0253      16.0740       711.76      1,635.53     1,874.23
42809    Remove pharynx foreign body           X             X         0340       0.6137        27.17       62.44        71.56
42810    Excision of neck cyst                 T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
42815    Excision of neck cyst                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42820    Remove tonsils and adenoids           T             T         0258      21.8761       968.67      2,225.89     2,550.75
42821    Remove tonsils and adenoids           T             T         0258      21.8761       968.67      2,225.89     2,550.75
42825    Removal of tonsils                    T             T         0258      21.8761       968.67      2,225.89     2,550.75
42826    Removal of tonsils                    T             T         0258      21.8761       968.67      2,225.89     2,550.75
42830    Removal of adenoids                   T             T         0258      21.8761       968.67      2,225.89     2,550.75
42831    Removal of adenoids                   T             T         0258      21.8761       968.67      2,225.89     2,550.75
42835    Removal of adenoids                   T             T         0258      21.8761       968.67      2,225.89     2,550.75
42836    Removal of adenoids                   T             T         0258      21.8761       968.67      2,225.89     2,550.75
42842    Extensive surgery of throat           T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
42844    Extensive surgery of throat           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42845    Extensive surgery of throat           C             C         0000       0.0000        0.00         0.00         0.00
42860    Excision of tonsil tags               T             T         0258      21.8761       968.67      2,225.89     2,550.75
42870    Excision of lingual tonsil            T             T         0258      21.8761       968.67      2,225.89     2,550.75


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  58 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

42890    Partial removal of pharynx            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42892    Revision of pharyngeal walls          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42894    Revision of pharyngeal walls          C             C         0000       0.0000        0.00         0.00         0.00
42900    Repair throat wound                   T             T         0252       8.1033       358.81       824.51       944.84
42950    Reconstruction of throat              T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
42953    Repair throat, esophagus              C             C         0000       0.0000        0.00         0.00         0.00
42955    Surgical opening of throat            T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
42960    Control throat bleeding               T             T         0250       1.2241        54.20       124.55       142.73
42961    Control throat bleeding               C             C         0000       0.0000        0.00         0.00         0.00
42962    Control throat bleeding               T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
42970    Control nose/throat bleeding          T             T         0250       1.2241        54.20       124.55       142.73
42971    Control nose/throat bleeding          C             C         0000       0.0000        0.00         0.00         0.00
42972    Control nose/throat bleeding          T             T         0253      16.0740       711.76      1,635.53     1,874.23
42999    Throat surgery procedure              T             1         0000       0.0000        0.00         0.00         0.00
43020    Incision of esophagus                 T             T         0252       8.1033       358.81       824.51       944.84
43030    Throat muscle surgery                 T             T         0253      16.0740       711.76      1,635.53     1,874.23
43045    Incision of esophagus                 C             C         0000       0.0000        0.00         0.00         0.00
43100    Excision of esophagus lesion          C             C         0000       0.0000        0.00         0.00         0.00
43101    Excision of esophagus lesion          C             C         0000       0.0000        0.00         0.00         0.00
43107    Removal of esophagus                  C             C         0000       0.0000        0.00         0.00         0.00
43108    Removal of esophagus                  C             C         0000       0.0000        0.00         0.00         0.00
43112    Removal of esophagus                  C             C         0000       0.0000        0.00         0.00         0.00
43113    Removal of esophagus                  C             C         0000       0.0000        0.00         0.00         0.00
43116    Partial removal of esophagus          C             C         0000       0.0000        0.00         0.00         0.00
43117    Partial removal of esophagus          C             C         0000       0.0000        0.00         0.00         0.00
43118    Partial removal of esophagus          C             C         0000       0.0000        0.00         0.00         0.00
43121    Partial removal of esophagus          C             C         0000       0.0000        0.00         0.00         0.00
43122    Partial removal of esophagus          C             C         0000       0.0000        0.00         0.00         0.00
43123    Partial removal of esophagus          C             C         0000       0.0000        0.00         0.00         0.00
43124    Removal of esophagus                  C             C         0000       0.0000        0.00         0.00         0.00
43130    Removal of esophagus pouch            T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
43135    Removal of esophagus pouch            C             C         0000       0.0000        0.00         0.00         0.00
43200    Esophagus endoscopy                   T             T         0141       8.0662       357.17       820.74       940.52
43201    Esoph scope w/submucous inj           T             T         0141       8.0662       357.17       820.74       940.52
43202    Esophagus endoscopy, biopsy           T             T         0141       8.0662       357.17       820.74       940.52
43204    Esoph scope w/sclerosis inj           T             T         0141       8.0662       357.17       820.74       940.52
43205    Esophagus endoscopy/ligation          T             T         0141       8.0662       357.17       820.74       940.52
43215    Esophagus endoscopy                   T             T         0141       8.0662       357.17       820.74       940.52
43216    Esophagus endoscopy/lesion            T             T         0141       8.0662       357.17       820.74       940.52
43217    Esophagus endoscopy                   T             T         0141       8.0662       357.17       820.74       940.52
43219    Esophagus endoscopy                   T             T         0384      26.8955      1,190.93     2,736.62     3,136.02
43220    Esoph endoscopy, dilation             T             T         0141       8.0662       357.17       820.74       940.52
43226    Esoph endoscopy, dilation             T             T         0141       8.0662       357.17       820.74       940.52
43227    Esoph endoscopy, repair               T             T         0141       8.0662       357.17       820.74       940.52
43228    Esoph endoscopy, ablation             T             T         0422      24.0525      1,065.04     2,447.34     2,804.52
43231    Esoph endoscopy w/us exam             T             T         0141       8.0662       357.17       820.74       940.52
43232    Esoph endoscopy w/us fn bx            T             T         0141       8.0662       357.17       820.74       940.52
43234    Upper GI endoscopy, exam              T             T         0141       8.0662       357.17       820.74       940.52
43235    Uppr gi endoscopy, diagnosis          T             T         0141       8.0662       357.17       820.74       940.52
43236    Uppr gi scope w/submuc inj            T             T         0141       8.0662       357.17       820.74       940.52
43237    Endoscopic us exam, esoph             T             T         0141       8.0662       357.17       820.74       940.52
43238    Uppr gi endoscopy w/us fn bx          T             T         0141       8.0662       357.17       820.74       940.52
43239    Upper GI endoscopy, biopsy            T             T         0141       8.0662       357.17       820.74       940.52
43240    Esoph endoscope w/drain cyst          T             T         0141       8.0662       357.17       820.74       940.52
43241    Upper GI endoscopy with tube          T             T         0141       8.0662       357.17       820.74       940.52
43242    Uppr gi endoscopy w/us fn bx          T             T         0141       8.0662       357.17       820.74       940.52
43243    Upper gi endoscopy & inject           T             T         0141       8.0662       357.17       820.74       940.52
43244    Upper GI endoscopy/ligation           T             T         0141       8.0662       357.17       820.74       940.52


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  59 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

43245    Uppr gi scope dilate strictr          T             T         0141       8.0662       357.17       820.74       940.52
43246    Place gastrostomy tube                T             T         0141       8.0662       357.17       820.74       940.52
43247    Operative upper GI endoscopy          T             T         0141       8.0662       357.17       820.74       940.52
43248    Uppr gi endoscopy/guide wire          T             T         0141       8.0662       357.17       820.74       940.52
43249    Esoph endoscopy, dilation             T             T         0141       8.0662       357.17       820.74       940.52
43250    Upper GI endoscopy/tumor              T             T         0141       8.0662       357.17       820.74       940.52
43251    Operative upper GI endoscopy          T             T         0141       8.0662       357.17       820.74       940.52
43255    Operative upper GI endoscopy          T             T         0141       8.0662       357.17       820.74       940.52
43256    Uppr gi endoscopy w/stent             T             T         0384      26.8955      1,190.93     2,736.62     3,136.02
43257    Uppr gi scope w/thrml txmnt           T             T         0422      24.0525      1,065.04     2,447.34     2,804.52
43258    Operative upper GI endoscopy          T             T         0141       8.0662       357.17       820.74       940.52
43259    Endoscopic ultrasound exam            T             T         0141       8.0662       357.17       820.74       940.52
43260    Endo cholangiopancreatograph          T             T         0151      18.6171       824.37      1,894.29     2,170.75
43261    Endo cholangiopancreatograph          T             T         0151      18.6171       824.37      1,894.29     2,170.75
43262    Endo cholangiopancreatograph          T             T         0151      18.6171       824.37      1,894.29     2,170.75
43263    Endo cholangiopancreatograph          T             T         0151      18.6171       824.37      1,894.29     2,170.75
43264    Endo cholangiopancreatograph          T             T         0151      18.6171       824.37      1,894.29     2,170.75
43265    Endo cholangiopancreatograph          T             T         0151      18.6171       824.37      1,894.29     2,170.75
43267    Endo cholangiopancreatograph          T             T         0151      18.6171       824.37      1,894.29     2,170.75
43268    Endo cholangiopancreatograph          T             T         0384      26.8955      1,190.93     2,736.62     3,136.02
43269    Endo cholangiopancreatograph          T             T         0384      26.8955      1,190.93     2,736.62     3,136.02
43271    Endo cholangiopancreatograph          T             T         0151      18.6171       824.37      1,894.29     2,170.75
43272    Endo cholangiopancreatograph          T             T         0151      18.6171       824.37      1,894.29     2,170.75
43280    Laparoscopy, fundoplasty              T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
43289    Laparoscope proc, esoph               T             1         0000       0.0000        0.00         0.00         0.00
43300    Repair of esophagus                   C             C         0000       0.0000        0.00         0.00         0.00
43305    Repair esophagus and fistula          C             C         0000       0.0000        0.00         0.00         0.00
43310    Repair of esophagus                   C             C         0000       0.0000        0.00         0.00         0.00
43312    Repair esophagus and fistula          C             C         0000       0.0000        0.00         0.00         0.00
43313    Esophagoplasty congenital             C             C         0000       0.0000        0.00         0.00         0.00
43314    Tracheo-esophagoplasty cong           C             C         0000       0.0000        0.00         0.00         0.00
43320    Fuse esophagus & stomach              C             C         0000       0.0000        0.00         0.00         0.00
43324    Revise esophagus & stomach            C             C         0000       0.0000        0.00         0.00         0.00
43325    Revise esophagus & stomach            C             C         0000       0.0000        0.00         0.00         0.00
43326    Revise esophagus & stomach            C             C         0000       0.0000        0.00         0.00         0.00
43330    Repair of esophagus                   C             C         0000       0.0000        0.00         0.00         0.00
43331    Repair of esophagus                   C             C         0000       0.0000        0.00         0.00         0.00
43340    Fuse esophagus & intestine            C             C         0000       0.0000        0.00         0.00         0.00
43341    Fuse esophagus & intestine            C             C         0000       0.0000        0.00         0.00         0.00
43350    Surgical opening, esophagus           C             C         0000       0.0000        0.00         0.00         0.00
43351    Surgical opening, esophagus           C             C         0000       0.0000        0.00         0.00         0.00
43352    Surgical opening, esophagus           C             C         0000       0.0000        0.00         0.00         0.00
43360    Gastrointestinal repair               C             C         0000       0.0000        0.00         0.00         0.00
43361    Gastrointestinal repair               C             C         0000       0.0000        0.00         0.00         0.00
43400    Ligate esophagus veins                C             C         0000       0.0000        0.00         0.00         0.00
43401    Esophagus surgery for veins           C             C         0000       0.0000        0.00         0.00         0.00
43405    Ligate/staple esophagus               C             C         0000       0.0000        0.00         0.00         0.00
43410    Repair esophagus wound                C             C         0000       0.0000        0.00         0.00         0.00
43415    Repair esophagus wound                C             C         0000       0.0000        0.00         0.00         0.00
43420    Repair esophagus opening              C             C         0000       0.0000        0.00         0.00         0.00
43425    Repair esophagus opening              C             C         0000       0.0000        0.00         0.00         0.00
43450    Dilate esophagus                      T             T         0140       5.2970       234.55       538.97       617.63
43453    Dilate esophagus                      T             T         0140       5.2970       234.55       538.97       617.63
43456    Dilate esophagus                      T             T         0140       5.2970       234.55       538.97       617.63
43458    Dilate esophagus                      T             T         0140       5.2970       234.55       538.97       617.63
43460    Pressure treatment esophagus          C             C         0000       0.0000        0.00         0.00         0.00
43496    Free jejunum flap, microvasc          C             C         0000       0.0000        0.00         0.00         0.00
43499    Esophagus surgery procedure           T             1         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  60 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

43500    Surgical opening of stomach           C             C         0000       0.0000        0.00         0.00         0.00
43501    Surgical repair of stomach            C             C         0000       0.0000        0.00         0.00         0.00
43502    Surgical repair of stomach            C             C         0000       0.0000        0.00         0.00         0.00
43510    Surgical opening of stomach           T             T         0141       8.0662       357.17       820.74       940.52
43520    Incision of pyloric muscle            C             C         0000       0.0000        0.00         0.00         0.00
43600    Biopsy of stomach                     T             T         0141       8.0662       357.17       820.74       940.52
43605    Biopsy of stomach                     C             C         0000       0.0000        0.00         0.00         0.00
43610    Excision of stomach lesion            C             C         0000       0.0000        0.00         0.00         0.00
43611    Excision of stomach lesion            C             C         0000       0.0000        0.00         0.00         0.00
43620    Removal of stomach                    C             C         0000       0.0000        0.00         0.00         0.00
43621    Removal of stomach                    C             C         0000       0.0000        0.00         0.00         0.00
43622    Removal of stomach                    C             C         0000       0.0000        0.00         0.00         0.00
43631    Removal of stomach, partial           C             C         0000       0.0000        0.00         0.00         0.00
43632    Removal of stomach, partial           C             C         0000       0.0000        0.00         0.00         0.00
43633    Removal of stomach, partial           C             C         0000       0.0000        0.00         0.00         0.00
43634    Removal of stomach, partial           C             C         0000       0.0000        0.00         0.00         0.00
43635    Removal of stomach, partial           C             C         0000       0.0000        0.00         0.00         0.00
43640    Vagotomy & pylorus repair             C             C         0000       0.0000        0.00         0.00         0.00
43641    Vagotomy & pylorus repair             C             C         0000       0.0000        0.00         0.00         0.00
43644    Lap gastric bypass/roux-en-y          C             C         0000       0.0000        0.00         0.00         0.00
43645    Lap gastr bypass incl smll i          C             C         0000       0.0000        0.00         0.00         0.00
43651    Laparoscopy, vagus nerve              T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
43652    Laparoscopy, vagus nerve              T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
43653    Laparoscopy, gastrostomy              T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
43659    Laparoscope proc, stom                T             1         0000       0.0000        0.00         0.00         0.00
43750    Place gastrostomy tube                T             T         0141       8.0662       357.17       820.74       940.52
43752    Nasal/orogastric w/stent              X             X         0272       1.3291        58.85       135.24       154.97
43760    Change gastrostomy tube               T             T         0121       2.2374        99.07       227.66       260.88
43761    Reposition gastrostomy tube           T             T         0122       6.9179       306.32       703.90       806.63
43770    Lap, place gastr adjust band          C             C         0000       0.0000        0.00         0.00         0.00
43771    Lap, revise adjust gast band          C             C         0000       0.0000        0.00         0.00         0.00
43772    Lap, remove adjust gast band          C             C         0000       0.0000        0.00         0.00         0.00
43773    Lap, change adjust gast band          C             C         0000       0.0000        0.00         0.00         0.00
43774    Lap remov adj gast band/port          C             C         0000       0.0000        0.00         0.00         0.00
43800    Reconstruction of pylorus             C             C         0000       0.0000        0.00         0.00         0.00
43810    Fusion of stomach and bowel           C             C         0000       0.0000        0.00         0.00         0.00
43820    Fusion of stomach and bowel           C             C         0000       0.0000        0.00         0.00         0.00
43825    Fusion of stomach and bowel           C             C         0000       0.0000        0.00         0.00         0.00
43830    Place gastrostomy tube                T             T         0422      24.0525      1,065.04     2,447.34     2,804.52
43831    Place gastrostomy tube                T             T         0141       8.0662       357.17       820.74       940.52
43832    Place gastrostomy tube                C             C         0000       0.0000        0.00         0.00         0.00
43840    Repair of stomach lesion              C             C         0000       0.0000        0.00         0.00         0.00
43842    V-band gastroplasty                   C             C         0000       0.0000        0.00         0.00         0.00
43843    Gastroplasty w/o v-band               C             C         0000       0.0000        0.00         0.00         0.00
43845    Gastroplasty duodenal switch          C             C         0000       0.0000        0.00         0.00         0.00
43846    Gastric bypass for obesity            C             C         0000       0.0000        0.00         0.00         0.00
43847    Gastric bypass incl small i           C             C         0000       0.0000        0.00         0.00         0.00
43848    Revision gastroplasty                 C             C         0000       0.0000        0.00         0.00         0.00
43850    Revise stomach-bowel fusion           C             C         0000       0.0000        0.00         0.00         0.00
43855    Revise stomach-bowel fusion           C             C         0000       0.0000        0.00         0.00         0.00
43860    Revise stomach-bowel fusion           C             C         0000       0.0000        0.00         0.00         0.00
43865    Revise stomach-bowel fusion           C             C         0000       0.0000        0.00         0.00         0.00
43870    Repair stomach opening                T             T         0141       8.0662       357.17       820.74       940.52
43880    Repair stomach-bowel fistula          C             C         0000       0.0000        0.00         0.00         0.00
43886    Revise gastric port, open             T             T         0025       5.3051       234.91       539.79       618.57
43887    Remove gastric port, open             T             T         0025       5.3051       234.91       539.79       618.57
43888    Change gastric port, open             T             T         0686      13.4973       597.66      1,373.35     1,573.79
43999    Stomach surgery procedure             T             1         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  61 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

44005    Freeing of bowel adhesion             C             C         0000       0.0000        0.00         0.00         0.00
44010    Incision of small bowel               C             C         0000       0.0000        0.00         0.00         0.00
44015    Insert needle cath bowel              C             C         0000       0.0000        0.00         0.00         0.00
44020    Explore small intestine               C             C         0000       0.0000        0.00         0.00         0.00
44021    Decompress small bowel                C             C         0000       0.0000        0.00         0.00         0.00
44025    Incision of large bowel               C             C         0000       0.0000        0.00         0.00         0.00
44050    Reduce bowel obstruction              C             C         0000       0.0000        0.00         0.00         0.00
44055    Correct malrotation of bowel          C             C         0000       0.0000        0.00         0.00         0.00
44100    Biopsy of bowel                       T             T         0141       8.0662       357.17       820.74       940.52
44110    Excise intestine lesion(s)            C             C         0000       0.0000        0.00         0.00         0.00
44111    Excision of bowel lesion(s)           C             C         0000       0.0000        0.00         0.00         0.00
44120    Removal of small intestine            C             C         0000       0.0000        0.00         0.00         0.00
44121    Removal of small intestine            C             C         0000       0.0000        0.00         0.00         0.00
44125    Removal of small intestine            C             C         0000       0.0000        0.00         0.00         0.00
44126    Enterectomy w/o taper, cong           C             C         0000       0.0000        0.00         0.00         0.00
44127    Enterectomy w/taper, cong             C             C         0000       0.0000        0.00         0.00         0.00
44128    Enterectomy cong, add-on              C             C         0000       0.0000        0.00         0.00         0.00
44130    Bowel to bowel fusion                 C             C         0000       0.0000        0.00         0.00         0.00
44132    Enterectomy, cadaver donor            C             1         0000       0.0000        0.00         0.00         0.00
44133    Enterectomy, live donor               C             1         0000       0.0000        0.00         0.00         0.00
44135    Intestine transplnt, cadaver          C             1         0000       0.0000        0.00         0.00         0.00
44136    Intestine transplant, live            C             1         0000       0.0000        0.00         0.00         0.00
44137    Remove intestinal allograft           C             1         0000       0.0000        0.00         0.00         0.00
44139    Mobilization of colon                 C             C         0000       0.0000        0.00         0.00         0.00
44140    Partial removal of colon              C             C         0000       0.0000        0.00         0.00         0.00
44141    Partial removal of colon              C             C         0000       0.0000        0.00         0.00         0.00
44143    Partial removal of colon              C             C         0000       0.0000        0.00         0.00         0.00
44144    Partial removal of colon              C             C         0000       0.0000        0.00         0.00         0.00
44145    Partial removal of colon              C             C         0000       0.0000        0.00         0.00         0.00
44146    Partial removal of colon              C             C         0000       0.0000        0.00         0.00         0.00
44147    Partial removal of colon              C             C         0000       0.0000        0.00         0.00         0.00
44150    Removal of colon                      C             C         0000       0.0000        0.00         0.00         0.00
44151    Removal of colon/ileostomy            C             C         0000       0.0000        0.00         0.00         0.00
44152    Removal of colon/ileostomy            C             C         0000       0.0000        0.00         0.00         0.00
44153    Removal of colon/ileostomy            C             C         0000       0.0000        0.00         0.00         0.00
44155    Removal of colon/ileostomy            C             C         0000       0.0000        0.00         0.00         0.00
44156    Removal of colon/ileostomy            C             C         0000       0.0000        0.00         0.00         0.00
44160    Removal of colon                      C             C         0000       0.0000        0.00         0.00         0.00
44180    Lap, enterolysis                      T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
44186    Lap, jejunostomy                      T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
44187    Lap, ileo/jejuno-stomy                C             C         0000       0.0000        0.00         0.00         0.00
44188    Lap, colostomy                        C             C         0000       0.0000        0.00         0.00         0.00
44202    Lap resect s/intestine singl          C             C         0000       0.0000        0.00         0.00         0.00
44203    Lap resect s/intestine, addl          C             C         0000       0.0000        0.00         0.00         0.00
44204    Laparo partial colectomy              C             C         0000       0.0000        0.00         0.00         0.00
44205    Lap colectomy part w/ileum            C             C         0000       0.0000        0.00         0.00         0.00
44206    Lap part colectomy w/stoma            T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
44207    L colectomy/coloproctostomy           T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
44208    L colectomy/coloproctostomy           T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
44210    Laparo total proctocolectomy          C             C         0000       0.0000        0.00         0.00         0.00
44211    Laparo total proctocolectomy          C             C         0000       0.0000        0.00         0.00         0.00
44212    Laparo total proctocolectomy          C             C         0000       0.0000        0.00         0.00         0.00
44213    Lap, mobil splenic fl add-on          T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
44227    Lap, close enterostomy                C             C         0000       0.0000        0.00         0.00         0.00
44238    Laparoscope proc, intestine           T             1         0000       0.0000        0.00         0.00         0.00
44300    Open bowel to skin                    C             C         0000       0.0000        0.00         0.00         0.00
44310    Ileostomy/jejunostomy                 C             C         0000       0.0000        0.00         0.00         0.00
44312    Revision of ileostomy                 T             T         0027      18.1956       805.70      1,851.40     2,121.61


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  62 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

44314    Revision of ileostomy                 C             C         0000       0.0000        0.00         0.00         0.00
44316    Devise bowel pouch                    C             C         0000       0.0000        0.00         0.00         0.00
44320    Colostomy                             C             C         0000       0.0000        0.00         0.00         0.00
44322    Colostomy with biopsies               C             C         0000       0.0000        0.00         0.00         0.00
44340    Revision of colostomy                 T             T         0027      18.1956       805.70      1,851.40     2,121.61
44345    Revision of colostomy                 C             C         0000       0.0000        0.00         0.00         0.00
44346    Revision of colostomy                 C             C         0000       0.0000        0.00         0.00         0.00
44360    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44361    Small bowel endoscopy/biopsy          T             T         0142       9.0564       401.02       921.49      1,055.98
44363    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44364    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44365    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44366    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44369    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44370    Small bowel endoscopy/stent           T             T         0384      26.8955      1,190.93     2,736.62     3,136.02
44372    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44373    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44376    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44377    Small bowel endoscopy/biopsy          T             T         0142       9.0564       401.02       921.49      1,055.98
44378    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44379    S bowel endoscope w/stent             T             T         0384      26.8955      1,190.93     2,736.62     3,136.02
44380    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44382    Small bowel endoscopy                 T             T         0142       9.0564       401.02       921.49      1,055.98
44383    Ileoscopy w/stent                     T             T         0384      26.8955      1,190.93     2,736.62     3,136.02
44385    Endoscopy of bowel pouch              T             T         0143       8.5588       378.98       870.86       997.96
44386    Endoscopy, bowel pouch/biop           T             T         0143       8.5588       378.98       870.86       997.96
44388    Colonoscopy                           T             T         0143       8.5588       378.98       870.86       997.96
44389    Colonoscopy with biopsy               T             T         0143       8.5588       378.98       870.86       997.96
44390    Colonoscopy for foreign body          T             T         0143       8.5588       378.98       870.86       997.96
44391    Colonoscopy for bleeding              T             T         0143       8.5588       378.98       870.86       997.96
44392    Colonoscopy & polypectomy             T             T         0143       8.5588       378.98       870.86       997.96
44393    Colonoscopy, lesion removal           T             T         0143       8.5588       378.98       870.86       997.96
44394    Colonoscopy w/snare                   T             T         0143       8.5588       378.98       870.86       997.96
44397    Colonoscopy w/stent                   T             T         0384      26.8955      1,190.93     2,736.62     3,136.02
44500    Intro, gastrointestinal tube          T             T         0121       2.2374        99.07       227.66       260.88
44602    Suture, small intestine               C             C         0000       0.0000        0.00         0.00         0.00
44603    Suture, small intestine               C             C         0000       0.0000        0.00         0.00         0.00
44604    Suture, large intestine               C             C         0000       0.0000        0.00         0.00         0.00
44605    Repair of bowel lesion                C             C         0000       0.0000        0.00         0.00         0.00
44615    Intestinal stricturoplasty            C             C         0000       0.0000        0.00         0.00         0.00
44620    Repair bowel opening                  C             C         0000       0.0000        0.00         0.00         0.00
44625    Repair bowel opening                  C             C         0000       0.0000        0.00         0.00         0.00
44626    Repair bowel opening                  C             C         0000       0.0000        0.00         0.00         0.00
44640    Repair bowel-skin fistula             C             C         0000       0.0000        0.00         0.00         0.00
44650    Repair bowel fistula                  C             C         0000       0.0000        0.00         0.00         0.00
44660    Repair bowel-bladder fistula          C             C         0000       0.0000        0.00         0.00         0.00
44661    Repair bowel-bladder fistula          C             C         0000       0.0000        0.00         0.00         0.00
44680    Surgical revision, intestine          C             C         0000       0.0000        0.00         0.00         0.00
44700    Suspend bowel w/prosthesis            C             C         0000       0.0000        0.00         0.00         0.00
44701    Intraop colon lavage add-on           N             N         0000       0.0000        0.00         0.00         0.00
44715    Prepare donor intestine               C             1         0000       0.0000        0.00         0.00         0.00
44720    Prep donor intestine/venous           C             1         0000       0.0000        0.00         0.00         0.00
44721    Prep donor intestine/artery           C             1         0000       0.0000        0.00         0.00         0.00
44799    Unlisted procedure intestine          T             1         0000       0.0000        0.00         0.00         0.00
44800    Excision of bowel pouch               C             C         0000       0.0000        0.00         0.00         0.00
44820    Excision of mesentery lesion          C             C         0000       0.0000        0.00         0.00         0.00
44850    Repair of mesentery                   C             C         0000       0.0000        0.00         0.00         0.00
44899    Bowel surgery procedure               C             1         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  63 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

44900    Drain app abscess, open               C             C         0000       0.0000        0.00         0.00         0.00
44901    Drain app abscess, percut             T             T         0037       9.6103       425.54       977.85      1,120.56
44950    Appendectomy                          C             C         0000       0.0000        0.00         0.00         0.00
44955    Appendectomy add-on                   C             C         0000       0.0000        0.00         0.00         0.00
44960    Appendectomy                          C             C         0000       0.0000        0.00         0.00         0.00
44970    Laparoscopy, appendectomy             T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
44979    Laparoscope proc, app                 T             1         0000       0.0000        0.00         0.00         0.00
45000    Drainage of pelvic abscess            T             T         0148       3.5047       155.19       356.60       408.65
45005    Drainage of rectal abscess            T             T         0155      15.9499       706.26      1,622.90     1,859.76
45020    Drainage of rectal abscess            T             T         0155      15.9499       706.26      1,622.90     1,859.76
45100    Biopsy of rectum                      T             T         0149      18.0878       800.93      1,840.43     2,109.04
45108    Removal of anorectal lesion           T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
45110    Removal of rectum                     C             C         0000       0.0000        0.00         0.00         0.00
45111    Partial removal of rectum             C             C         0000       0.0000        0.00         0.00         0.00
45112    Removal of rectum                     C             C         0000       0.0000        0.00         0.00         0.00
45113    Partial proctectomy                   C             C         0000       0.0000        0.00         0.00         0.00
45114    Partial removal of rectum             C             C         0000       0.0000        0.00         0.00         0.00
45116    Partial removal of rectum             C             C         0000       0.0000        0.00         0.00         0.00
45119    Remove rectum w/reservoir             C             C         0000       0.0000        0.00         0.00         0.00
45120    Removal of rectum                     C             C         0000       0.0000        0.00         0.00         0.00
45121    Removal of rectum and colon           C             C         0000       0.0000        0.00         0.00         0.00
45123    Partial proctectomy                   C             C         0000       0.0000        0.00         0.00         0.00
45126    Pelvic exenteration                   C             C         0000       0.0000        0.00         0.00         0.00
45130    Excision of rectal prolapse           C             C         0000       0.0000        0.00         0.00         0.00
45135    Excision of rectal prolapse           C             C         0000       0.0000        0.00         0.00         0.00
45136    Excise ileoanal reservior             C             C         0000       0.0000        0.00         0.00         0.00
45150    Excision of rectal stricture          T             T         0149      18.0878       800.93      1,840.43     2,109.04
45160    Excision of rectal lesion             T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
45170    Excision of rectal lesion             T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
45190    Destruction, rectal tumor             T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
45300    Proctosigmoidoscopy dx                T             T         0146       4.7086       208.50       479.10       549.02
45303    Proctosigmoidoscopy dilate            T             T         0147       7.9652       352.70       810.46       928.74
45305    Proctosigmoidoscopy w/bx              T             T         0147       7.9652       352.70       810.46       928.74
45307    Proctosigmoidoscopy fb                T             T         0428      20.0871       889.46      2,043.86     2,342.16
45308    Proctosigmoidoscopy removal           T             T         0147       7.9652       352.70       810.46       928.74
45309    Proctosigmoidoscopy removal           T             T         0147       7.9652       352.70       810.46       928.74
45315    Proctosigmoidoscopy removal           T             T         0147       7.9652       352.70       810.46       928.74
45317    Proctosigmoidoscopy bleed             T             T         0147       7.9652       352.70       810.46       928.74
45320    Proctosigmoidoscopy ablate            T             T         0428      20.0871       889.46      2,043.86     2,342.16
45321    Proctosigmoidoscopy volvul            T             T         0428      20.0871       889.46      2,043.86     2,342.16
45327    Proctosigmoidoscopy w/stent           T             T         0384      26.8955      1,190.93     2,736.62     3,136.02
45330    Diagnostic sigmoidoscopy              T             T         0146       4.7086       208.50       479.10       549.02
45331    Sigmoidoscopy and biopsy              T             T         0146       4.7086       208.50       479.10       549.02
45332    Sigmoidoscopy w/fb removal            T             T         0146       4.7086       208.50       479.10       549.02
45333    Sigmoidoscopy & polypectomy           T             T         0147       7.9652       352.70       810.46       928.74
45334    Sigmoidoscopy for bleeding            T             T         0147       7.9652       352.70       810.46       928.74
45335    Sigmoidoscopy w/submuc inj            T             T         0146       4.7086       208.50       479.10       549.02
45337    Sigmoidoscopy & decompress            T             T         0146       4.7086       208.50       479.10       549.02
45338    Sigmoidoscopy w/tumr remove           T             T         0147       7.9652       352.70       810.46       928.74
45339    Sigmoidoscopy w/ablate tumr           T             T         0147       7.9652       352.70       810.46       928.74
45340    Sig w/balloon dilation                T             T         0147       7.9652       352.70       810.46       928.74
45341    Sigmoidoscopy w/ultrasound            T             T         0147       7.9652       352.70       810.46       928.74
45342    Sigmoidoscopy w/us guide bx           T             T         0147       7.9652       352.70       810.46       928.74
45345    Sigmoidoscopy w/stent                 T             T         0384      26.8955      1,190.93     2,736.62     3,136.02
45355    Surgical colonoscopy                  T             T         0143       8.5588       378.98       870.86       997.96
45378    Diagnostic colonoscopy                T             T         0143       8.5588       378.98       870.86       997.96
45379    Colonoscopy w/fb removal              T             T         0143       8.5588       378.98       870.86       997.96
45380    Colonoscopy and biopsy                T             T         0143       8.5588       378.98       870.86       997.96


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  64 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

45381    Colonoscopy, submucous inj            T             T         0143       8.5588       378.98       870.86       997.96
45382    Colonoscopy/control bleeding          T             T         0143       8.5588       378.98       870.86       997.96
45383    Lesion removal colonoscopy            T             T         0143       8.5588       378.98       870.86       997.96
45384    Lesion remove colonoscopy             T             T         0143       8.5588       378.98       870.86       997.96
45385    Lesion removal colonoscopy            T             T         0143       8.5588       378.98       870.86       997.96
45386    Colonoscopy dilate stricture          T             T         0143       8.5588       378.98       870.86       997.96
45387    Colonoscopy w/stent                   T             T         0384      26.8955      1,190.93     2,736.62     3,136.02
45391    Colonoscopy w/endoscope us            T             T         0143       8.5588       378.98       870.86       997.96
45392    Colonoscopy w/endoscopic fnb          T             T         0143       8.5588       378.98       870.86       997.96
45395    Lap, removal of rectum                C             C         0000       0.0000        0.00         0.00         0.00
45397    Lap, remove rectum w/pouch            C             C         0000       0.0000        0.00         0.00         0.00
45400    Laparoscopic proctopexy               C             C         0000       0.0000        0.00         0.00         0.00
45402    Lap proctopexy w/sig resect           C             C         0000       0.0000        0.00         0.00         0.00
45499    Laparoscope proc, rectum              T             1         0000       0.0000        0.00         0.00         0.00
45500    Repair of rectum                      T             T         0149      18.0878       800.93      1,840.43     2,109.04
45505    Repair of rectum                      T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
45520    Treatment of rectal prolapse          T             T         0098       1.1444        50.67       116.44       133.44
45540    Correct rectal prolapse               C             C         0000       0.0000        0.00         0.00         0.00
45541    Correct rectal prolapse               T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
45550    Repair rectum/remove sigmoid          C             C         0000       0.0000        0.00         0.00         0.00
45560    Repair of rectocele                   T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
45562    Exploration/repair of rectum          C             C         0000       0.0000        0.00         0.00         0.00
45563    Exploration/repair of rectum          C             C         0000       0.0000        0.00         0.00         0.00
45800    Repair rect/bladder fistula           C             C         0000       0.0000        0.00         0.00         0.00
45805    Repair fistula w/colostomy            C             C         0000       0.0000        0.00         0.00         0.00
45820    Repair rectourethral fistula          C             C         0000       0.0000        0.00         0.00         0.00
45825    Repair fistula w/colostomy            C             C         0000       0.0000        0.00         0.00         0.00
45900    Reduction of rectal prolapse          T             T         0148       3.5047       155.19       356.60       408.65
45905    Dilation of anal sphincter            T             T         0149      18.0878       800.93      1,840.43     2,109.04
45910    Dilation of rectal narrowing          T             T         0149      18.0878       800.93      1,840.43     2,109.04
45915    Remove rectal obstruction             T             T         0148       3.5047       155.19       356.60       408.65
45990    Surg dx exam, anorectal               T             T         0148       3.5047       155.19       356.60       408.65
45999    Rectum surgery procedure              T             1         0000       0.0000        0.00         0.00         0.00
46020    Placement of seton                    T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46030    Removal of rectal marker              T             T         0148       3.5047       155.19       356.60       408.65
46040    Incision of rectal abscess            T             T         0149      18.0878       800.93      1,840.43     2,109.04
46045    Incision of rectal abscess            T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46050    Incision of anal abscess              T             T         0148       3.5047       155.19       356.60       408.65
46060    Incision of rectal abscess            T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46070    Incision of anal septum               T             T         0155      15.9499       706.26      1,622.90     1,859.76
46080    Incision of anal sphincter            T             T         0149      18.0878       800.93      1,840.43     2,109.04
46083    Incise external hemorrhoid            T             T         0148       3.5047       155.19       356.60       408.65
46200    Removal of anal fissure               T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46210    Removal of anal crypt                 T             T         0149      18.0878       800.93      1,840.43     2,109.04
46211    Removal of anal crypts                T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46220    Removal of anal tag                   T             T         0149      18.0878       800.93      1,840.43     2,109.04
46221    Ligation of hemorrhoid(s)             T             T         0148       3.5047       155.19       356.60       408.65
46230    Removal of anal tags                  T             T         0149      18.0878       800.93      1,840.43     2,109.04
46250    Hemorrhoidectomy                      T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46255    Hemorrhoidectomy                      T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46257    Remove hemorrhoids & fissure          T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46258    Remove hemorrhoids & fistula          T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46260    Hemorrhoidectomy                      T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46261    Remove hemorrhoids & fissure          T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46262    Remove hemorrhoids & fistula          T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46270    Removal of anal fistula               T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46275    Removal of anal fistula               T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46280    Removal of anal fistula               T             T         0150      23.8736      1,057.12     2,429.14     2,783.66


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  65 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

46285    Removal of anal fistula               T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46288    Repair anal fistula                   T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46320    Removal of hemorrhoid clot            T             T         0148       3.5047       155.19       356.60       408.65
46500    Injection into hemorrhoid(s)          T             T         0155      15.9499       706.26      1,622.90     1,859.76
46505    Chemodenervation anal musc            T             T         0148       3.5047       155.19       356.60       408.65
46600    Diagnostic anoscopy                   X             X         0340       0.6137        27.17       62.44        71.56
46604    Anoscopy and dilation                 T             T         0147       7.9652       352.70       810.46       928.74
46606    Anoscopy and biopsy                   T             T         0146       4.7086       208.50       479.10       549.02
46608    Anoscopy, remove for body             T             T         0147       7.9652       352.70       810.46       928.74
46610    Anoscopy, remove lesion               T             T         0428      20.0871       889.46      2,043.86     2,342.16
46611    Anoscopy                              T             T         0147       7.9652       352.70       810.46       928.74
46612    Anoscopy, remove lesions              T             T         0428      20.0871       889.46      2,043.86     2,342.16
46614    Anoscopy, control bleeding            T             T         0146       4.7086       208.50       479.10       549.02
46615    Anoscopy                              T             T         0428      20.0871       889.46      2,043.86     2,342.16
46700    Repair of anal stricture              T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46705    Repair of anal stricture              C             C         0000       0.0000        0.00         0.00         0.00
46706    Repr of anal fistula w/glue           T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46710    Repr per/vag pouch sngl proc          C             C         0000       0.0000        0.00         0.00         0.00
46712    Repr per/vag pouch dbl proc           C             C         0000       0.0000        0.00         0.00         0.00
46715    Rep perf anoper fistu                 C             C         0000       0.0000        0.00         0.00         0.00
46716    Rep perf anoper/vestib fistu          C             C         0000       0.0000        0.00         0.00         0.00
46730    Construction of absent anus           C             C         0000       0.0000        0.00         0.00         0.00
46735    Construction of absent anus           C             C         0000       0.0000        0.00         0.00         0.00
46740    Construction of absent anus           C             C         0000       0.0000        0.00         0.00         0.00
46742    Repair of imperforated anus           C             C         0000       0.0000        0.00         0.00         0.00
46744    Repair of cloacal anomaly             C             C         0000       0.0000        0.00         0.00         0.00
46746    Repair of cloacal anomaly             C             C         0000       0.0000        0.00         0.00         0.00
46748    Repair of cloacal anomaly             C             C         0000       0.0000        0.00         0.00         0.00
46750    Repair of anal sphincter              T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46751    Repair of anal sphincter              C             C         0000       0.0000        0.00         0.00         0.00
46753    Reconstruction of anus                T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46754    Removal of suture from anus           T             T         0149      18.0878       800.93      1,840.43     2,109.04
46760    Repair of anal sphincter              T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46761    Repair of anal sphincter              T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46762    Implant artificial sphincter          T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46900    Destruction, anal lesion(s)           T             T         0016       2.5080       111.05       255.19       292.43
46910    Destruction, anal lesion(s)           T             T         0017      17.9937       796.76      1,830.86     2,098.07
46916    Cryosurgery, anal lesion(s)           T             T         0013       1.0603        46.95       107.89       123.63
46917    Laser surgery, anal lesions           T             T         0695      20.2372       896.10      2,059.14     2,359.66
46922    Excision of anal lesion(s)            T             T         0695      20.2372       896.10      2,059.14     2,359.66
46924    Destruction, anal lesion(s)           T             T         0695      20.2372       896.10      2,059.14     2,359.66
46934    Destruction of hemorrhoids            T             T         0155      15.9499       706.26      1,622.90     1,859.76
46935    Destruction of hemorrhoids            T             T         0155      15.9499       706.26      1,622.90     1,859.76
46936    Destruction of hemorrhoids            T             T         0149      18.0878       800.93      1,840.43     2,109.04
46937    Cryotherapy of rectal lesion          T             T         0149      18.0878       800.93      1,840.43     2,109.04
46938    Cryotherapy of rectal lesion          T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46940    Treatment of anal fissure             T             T         0149      18.0878       800.93      1,840.43     2,109.04
46942    Treatment of anal fissure             T             T         0148       3.5047       155.19       356.60       408.65
46945    Ligation of hemorrhoids               T             T         0155      15.9499       706.26      1,622.90     1,859.76
46946    Ligation of hemorrhoids               T             T         0155      15.9499       706.26      1,622.90     1,859.76
46947    Hemorrhoidopexy by stapling           T             T         0150      23.8736      1,057.12     2,429.14     2,783.66
46999    Anus surgery procedure                T             1         0000       0.0000        0.00         0.00         0.00
47000    Needle biopsy of liver                T             T         0685       6.0034       265.83       610.85       700.00
47001    Needle biopsy, liver add-on           N             N         0000       0.0000        0.00         0.00         0.00
47010    Open drainage, liver lesion           C             C         0000       0.0000        0.00         0.00         0.00
47011    Percut drain, liver lesion            T             T         0037       9.6103       425.54       977.85      1,120.56
47015    Inject/aspirate liver cyst            C             C         0000       0.0000        0.00         0.00         0.00
47100    Wedge biopsy of liver                 C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  66 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

47120    Partial removal of liver              C             C         0000       0.0000        0.00         0.00         0.00
47122    Extensive removal of liver            C             C         0000       0.0000        0.00         0.00         0.00
47125    Partial removal of liver              C             C         0000       0.0000        0.00         0.00         0.00
47130    Partial removal of liver              C             C         0000       0.0000        0.00         0.00         0.00
47133    Removal of donor liver                C             C         0000       0.0000        0.00         0.00         0.00
47135    Transplantation of liver              C             C         0000       0.0000        0.00         0.00         0.00
47136    Transplantation of liver              C             C         0000       0.0000        0.00         0.00         0.00
47140    Partial removal, donor liver          C             C         0000       0.0000        0.00         0.00         0.00
47141    Partial removal, donor liver          C             C         0000       0.0000        0.00         0.00         0.00
47142    Partial removal, donor liver          C             C         0000       0.0000        0.00         0.00         0.00
47143    Prep donor liver, whole               C             C         0000       0.0000        0.00         0.00         0.00
47144    Prep donor liver, 3-segment           C             C         0000       0.0000        0.00         0.00         0.00
47145    Prep donor liver, lobe split          C             C         0000       0.0000        0.00         0.00         0.00
47146    Prep donor liver/venous               C             C         0000       0.0000        0.00         0.00         0.00
47147    Prep donor liver/arterial             C             C         0000       0.0000        0.00         0.00         0.00
47300    Surgery for liver lesion              C             C         0000       0.0000        0.00         0.00         0.00
47350    Repair liver wound                    C             C         0000       0.0000        0.00         0.00         0.00
47360    Repair liver wound                    C             C         0000       0.0000        0.00         0.00         0.00
47361    Repair liver wound                    C             C         0000       0.0000        0.00         0.00         0.00
47362    Repair liver wound                    C             C         0000       0.0000        0.00         0.00         0.00
47370    Laparo ablate liver tumor rf          T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
47371    Laparo ablate liver cryosurg          T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
47379    Laparoscope procedure, liver          T             1         0000       0.0000        0.00         0.00         0.00
47380    Open ablate liver tumor rf            C             C         0000       0.0000        0.00         0.00         0.00
47381    Open ablate liver tumor cryo          C             C         0000       0.0000        0.00         0.00         0.00
47382    Percut ablate liver rf                T             T         0423      39.5881      1,752.96     4,028.09     4,615.97
47399    Liver surgery procedure               T             1         0000       0.0000        0.00         0.00         0.00
47400    Incision of liver duct                C             C         0000       0.0000        0.00         0.00         0.00
47420    Incision of bile duct                 C             C         0000       0.0000        0.00         0.00         0.00
47425    Incision of bile duct                 C             C         0000       0.0000        0.00         0.00         0.00
47460    Incise bile duct sphincter            C             C         0000       0.0000        0.00         0.00         0.00
47480    Incision of gallbladder               C             C         0000       0.0000        0.00         0.00         0.00
47490    Incision of gallbladder               T             T         0152      18.2391       807.63      1,855.83     2,126.68
47500    Injection for liver x-rays            N             N         0000       0.0000        0.00         0.00         0.00
47505    Injection for liver x-rays            N             N         0000       0.0000        0.00         0.00         0.00
47510    Insert catheter, bile duct            T             T         0152      18.2391       807.63      1,855.83     2,126.68
47511    Insert bile duct drain                T             T         0152      18.2391       807.63      1,855.83     2,126.68
47525    Change bile duct catheter             T             T         0427      10.0109       443.28      1,018.61     1,167.27
47530    Revise/reinsert bile tube             T             T         0427      10.0109       443.28      1,018.61     1,167.27
47550    Bile duct endoscopy add-on            C             C         0000       0.0000        0.00         0.00         0.00
47552    Biliary endoscopy thru skin           T             T         0152      18.2391       807.63      1,855.83     2,126.68
47553    Biliary endoscopy thru skin           T             T         0152      18.2391       807.63      1,855.83     2,126.68
47554    Biliary endoscopy thru skin           T             T         0152      18.2391       807.63      1,855.83     2,126.68
47555    Biliary endoscopy thru skin           T             T         0152      18.2391       807.63      1,855.83     2,126.68
47556    Biliary endoscopy thru skin           T             T         0152      18.2391       807.63      1,855.83     2,126.68
47560    Laparoscopy w/cholangio               T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
47561    Laparo w/cholangio/biopsy             T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
47562    Laparoscopic cholecystectomy          T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
47563    Laparo cholecystectomy/graph          T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
47564    Laparo cholecystectomy/explr          T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
47570    Laparo cholecystoenterostomy          C             C         0000       0.0000        0.00         0.00         0.00
47579    Laparoscope proc, biliary             T             1         0000       0.0000        0.00         0.00         0.00
47600    Removal of gallbladder                C             C         0000       0.0000        0.00         0.00         0.00
47605    Removal of gallbladder                C             C         0000       0.0000        0.00         0.00         0.00
47610    Removal of gallbladder                C             C         0000       0.0000        0.00         0.00         0.00
47612    Removal of gallbladder                C             C         0000       0.0000        0.00         0.00         0.00
47620    Removal of gallbladder                C             C         0000       0.0000        0.00         0.00         0.00
47630    Remove bile duct stone                T             T         0152      18.2391       807.63      1,855.83     2,126.68


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  67 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

47700    Exploration of bile ducts             C             C         0000       0.0000        0.00        0.00          0.00
47701    Bile duct revision                    C             C         0000       0.0000        0.00        0.00          0.00
47711    Excision of bile duct tumor           C             C         0000       0.0000        0.00        0.00          0.00
47712    Excision of bile duct tumor           C             C         0000       0.0000        0.00        0.00          0.00
47715    Excision of bile duct cyst            C             C         0000       0.0000        0.00        0.00          0.00
47716    Fusion of bile duct cyst              C             C         0000       0.0000        0.00        0.00          0.00
47720    Fuse gallbladder & bowel              C             C         0000       0.0000        0.00        0.00          0.00
47721    Fuse upper gi structures              C             C         0000       0.0000        0.00        0.00          0.00
47740    Fuse gallbladder & bowel              C             C         0000       0.0000        0.00        0.00          0.00
47741    Fuse gallbladder & bowel              C             C         0000       0.0000        0.00        0.00          0.00
47760    Fuse bile ducts and bowel             C             C         0000       0.0000        0.00        0.00          0.00
47765    Fuse liver ducts & bowel              C             C         0000       0.0000        0.00        0.00          0.00
47780    Fuse bile ducts and bowel             C             C         0000       0.0000        0.00        0.00          0.00
47785    Fuse bile ducts and bowel             C             C         0000       0.0000        0.00        0.00          0.00
47800    Reconstruction of bile ducts          C             C         0000       0.0000        0.00        0.00          0.00
47801    Placement, bile duct support          C             C         0000       0.0000        0.00        0.00          0.00
47802    Fuse liver duct & intestine           C             C         0000       0.0000        0.00        0.00          0.00
47900    Suture bile duct injury               C             C         0000       0.0000        0.00        0.00          0.00
47999    Bile tract surgery procedure          T             1         0000       0.0000        0.00        0.00          0.00
48000    Drainage of abdomen                   C             C         0000       0.0000        0.00        0.00          0.00
48001    Placement of drain, pancreas          C             C         0000       0.0000        0.00        0.00          0.00
48005    Resect/debride pancreas               C             C         0000       0.0000        0.00        0.00          0.00
48020    Removal of pancreatic stone           C             C         0000       0.0000        0.00        0.00          0.00
48100    Biopsy of pancreas, open              C             C         0000       0.0000        0.00        0.00          0.00
48102    Needle biopsy, pancreas               T             T         0685       6.0034       265.83      610.85        700.00
48120    Removal of pancreas lesion            C             C         0000       0.0000        0.00        0.00          0.00
48140    Partial removal of pancreas           C             C         0000       0.0000        0.00        0.00          0.00
48145    Partial removal of pancreas           C             C         0000       0.0000        0.00        0.00          0.00
48146    Pancreatectomy                        C             C         0000       0.0000        0.00        0.00          0.00
48148    Removal of pancreatic duct            C             C         0000       0.0000        0.00        0.00          0.00
48150    Partial removal of pancreas           C             C         0000       0.0000        0.00        0.00          0.00
48152    Pancreatectomy                        C             C         0000       0.0000        0.00        0.00          0.00
48153    Pancreatectomy                        C             C         0000       0.0000        0.00        0.00          0.00
48154    Pancreatectomy                        C             C         0000       0.0000        0.00        0.00          0.00
48155    Removal of pancreas                   C             C         0000       0.0000        0.00        0.00          0.00
48160    Pancreas removal/transplant           E             3         0000       0.0000        M01         M01           M01
48180    Fuse pancreas and bowel               C             C         0000       0.0000        0.00        0.00          0.00
48400    Injection, intraop add-on             C             C         0000       0.0000        0.00        0.00          0.00
48500    Surgery of pancreatic cyst            C             C         0000       0.0000        0.00        0.00          0.00
48510    Drain pancreatic pseudocyst           C             C         0000       0.0000        0.00        0.00          0.00
48511    Drain pancreatic pseudocyst           T             T         0037       9.6103       425.54      977.85       1,120.56
48520    Fuse pancreas cyst and bowel          C             C         0000       0.0000        0.00        0.00          0.00
48540    Fuse pancreas cyst and bowel          C             C         0000       0.0000        0.00        0.00          0.00
48545    Pancreatorrhaphy                      C             C         0000       0.0000        0.00        0.00          0.00
48547    Duodenal exclusion                    C             C         0000       0.0000        0.00        0.00          0.00
48550    Donor pancreatectomy                  E             3         0000       0.0000        M01         M01           M01
48551    Prep donor pancreas                   C             C         0000       0.0000        0.00        0.00          0.00
48552    Prep donor pancreas/venous            C             C         0000       0.0000        0.00        0.00          0.00
48554    Transpl allograft pancreas            C             C         0000       0.0000        0.00        0.00          0.00
48556    Removal, allograft pancreas           C             C         0000       0.0000        0.00        0.00          0.00
48999    Pancreas surgery procedure            T             1         0000       0.0000        0.00        0.00          0.00
49000    Exploration of abdomen                C             C         0000       0.0000        0.00        0.00          0.00
49002    Reopening of abdomen                  C             C         0000       0.0000        0.00        0.00          0.00
49010    Exploration behind abdomen            C             C         0000       0.0000        0.00        0.00          0.00
49020    Drain abdominal abscess               C             C         0000       0.0000        0.00        0.00          0.00
49021    Drain abdominal abscess               T             T         0037       9.6103       425.54      977.85       1,120.56
49040    Drain, open, abdom abscess            C             C         0000       0.0000        0.00        0.00          0.00
49041    Drain, percut, abdom abscess          T             T         0037       9.6103       425.54      977.85       1,120.56


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  68 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

49060    Drain, open, retrop abscess           C             C         0000       0.0000        0.00         0.00         0.00
49061    Drain, percut, retroper absc          T             T         0037       9.6103       425.54       977.85      1,120.56
49062    Drain to peritoneal cavity            C             C         0000       0.0000        0.00         0.00         0.00
49080    Puncture, peritoneal cavity           T             T         0070       3.2141       142.32       327.03       374.76
49081    Removal of abdominal fluid            T             T         0070       3.2141       142.32       327.03       374.76
49085    Remove abdomen foreign body           T             T         0153      22.4936       996.02      2,288.72     2,622.75
49180    Biopsy, abdominal mass                T             T         0685       6.0034       265.83       610.85       700.00
49200    Removal of abdominal lesion           T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
49201    Remove abdom lesion, complex          C             C         0000       0.0000        0.00         0.00         0.00
49215    Excise sacral spine tumor             C             C         0000       0.0000        0.00         0.00         0.00
49220    Multiple surgery, abdomen             C             C         0000       0.0000        0.00         0.00         0.00
49250    Excision of umbilicus                 T             T         0153      22.4936       996.02      2,288.72     2,622.75
49255    Removal of omentum                    C             C         0000       0.0000        0.00         0.00         0.00
49320    Diag laparo separate proc             T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
49321    Laparoscopy, biopsy                   T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
49322    Laparoscopy, aspiration               T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
49323    Laparo drain lymphocele               T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
49329    Laparo proc, abdm/per/oment           T             1         0000       0.0000        0.00         0.00         0.00
49400    Air injection into abdomen            N             N         0000       0.0000        0.00         0.00         0.00
49419    Insrt abdom cath for chemotx          T             T         0115      36.9806      1,637.50     3,762.78     4,311.94
49420    Insert abdom drain, temp              T             T         0652      29.3648      1,300.27     2,987.87     3,423.94
49421    Insert abdom drain, perm              T             T         0652      29.3648      1,300.27     2,987.87     3,423.94
49422    Remove perm cannula/catheter          T             T         0105      21.9865       973.56      2,237.13     2,563.63
49423    Exchange drainage catheter            T             T         0427      10.0109       443.28      1,018.61     1,167.27
49424    Assess cyst, contrast inject          N             N         0000       0.0000        0.00         0.00         0.00
49425    Insert abdomen-venous drain           C             C         0000       0.0000        0.00         0.00         0.00
49426    Revise abdomen-venous shunt           T             T         0153      22.4936       996.02      2,288.72     2,622.75
49427    Injection, abdominal shunt            N             N         0000       0.0000        0.00         0.00         0.00
49428    Ligation of shunt                     C             C         0000       0.0000        0.00         0.00         0.00
49429    Removal of shunt                      T             T         0105      21.9865       973.56      2,237.13     2,563.63
49491    Rpr hern preemie reduc                T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49492    Rpr ing hern premie, blocked          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49495    Rpr ing hernia baby, reduc            T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49496    Rpr ing hernia baby, blocked          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49500    Rpr ing hernia, init, reduce          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49501    Rpr ing hernia, init blocked          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49505    Prp i/hern init reduc >5 yr           T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49507    Prp i/hern init block >5 yr           T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49520    Rerepair ing hernia, reduce           T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49521    Rerepair ing hernia, blocked          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49525    Repair ing hernia, sliding            T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49540    Repair lumbar hernia                  T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49550    Rpr rem hernia, init, reduce          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49553    Rpr fem hernia, init blocked          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49555    Rerepair fem hernia, reduce           T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49557    Rerepair fem hernia, blocked          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49560    Rpr ventral hern init, reduc          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49561    Rpr ventral hern init, block          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49565    Rerepair ventrl hern, reduce          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49566    Rerepair ventrl hern, block           T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49568    Hernia repair w/mesh                  T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49570    Rpr epigastric hern, reduce           T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49572    Rpr epigastric hern, blocked          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49580    Rpr umbil hern, reduc < 5 yr          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49582    Rpr umbil hern, block < 5 yr          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49585    Rpr umbil hern, reduc > 5 yr          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49587    Rpr umbil hern, block > 5 yr          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49590    Repair spigelian hernia               T             T         0154      28.6432      1,268.32     2,914.45     3,339.80


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  69 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

49600    Repair umbilical lesion               T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
49605    Repair umbilical lesion               C             C         0000       0.0000        0.00         0.00         0.00
49606    Repair umbilical lesion               C             C         0000       0.0000        0.00         0.00         0.00
49610    Repair umbilical lesion               C             C         0000       0.0000        0.00         0.00         0.00
49611    Repair umbilical lesion               C             C         0000       0.0000        0.00         0.00         0.00
49650    Laparo hernia repair initial          T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
49651    Laparo hernia repair recur            T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
49659    Laparo proc, hernia repair            T             1         0000       0.0000        0.00         0.00         0.00
49900    Repair of abdominal wall              C             C         0000       0.0000        0.00         0.00         0.00
49904    Omental flap, extra-abdom             C             C         0000       0.0000        0.00         0.00         0.00
49905    Omental flap, intra-abdom             C             C         0000       0.0000        0.00         0.00         0.00
49906    Free omental flap, microvasc          C             C         0000       0.0000        0.00         0.00         0.00
49999    Abdomen surgery procedure             T             1         0000       0.0000        0.00         0.00         0.00
50010    Exploration of kidney                 C             C         0000       0.0000        0.00         0.00         0.00
50020    Renal abscess, open drain             T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
50021    Renal abscess, percut drain           T             T         0037       9.6103       425.54       977.85      1,120.56
50040    Drainage of kidney                    C             C         0000       0.0000        0.00         0.00         0.00
50045    Exploration of kidney                 C             C         0000       0.0000        0.00         0.00         0.00
50060    Removal of kidney stone               C             C         0000       0.0000        0.00         0.00         0.00
50065    Incision of kidney                    C             C         0000       0.0000        0.00         0.00         0.00
50070    Incision of kidney                    C             C         0000       0.0000        0.00         0.00         0.00
50075    Removal of kidney stone               C             C         0000       0.0000        0.00         0.00         0.00
50080    Removal of kidney stone               T             T         0429      42.0802      1,863.31     4,281.66     4,906.55
50081    Removal of kidney stone               T             T         0429      42.0802      1,863.31     4,281.66     4,906.55
50100    Revise kidney blood vessels           C             C         0000       0.0000        0.00         0.00         0.00
50120    Exploration of kidney                 C             C         0000       0.0000        0.00         0.00         0.00
50125    Explore and drain kidney              C             C         0000       0.0000        0.00         0.00         0.00
50130    Removal of kidney stone               C             C         0000       0.0000        0.00         0.00         0.00
50135    Exploration of kidney                 C             C         0000       0.0000        0.00         0.00         0.00
50200    Biopsy of kidney                      T             T         0685       6.0034       265.83       610.85       700.00
50205    Biopsy of kidney                      C             C         0000       0.0000        0.00         0.00         0.00
50220    Remove kidney, open                   C             C         0000       0.0000        0.00         0.00         0.00
50225    Removal kidney open, complex          C             C         0000       0.0000        0.00         0.00         0.00
50230    Removal kidney open, radical          C             C         0000       0.0000        0.00         0.00         0.00
50234    Removal of kidney & ureter            C             C         0000       0.0000        0.00         0.00         0.00
50236    Removal of kidney & ureter            C             C         0000       0.0000        0.00         0.00         0.00
50240    Partial removal of kidney             C             C         0000       0.0000        0.00         0.00         0.00
50250    Cryoablate renal mass open            C             C         0000       0.0000        0.00         0.00         0.00
50280    Removal of kidney lesion              C             C         0000       0.0000        0.00         0.00         0.00
50290    Removal of kidney lesion              C             C         0000       0.0000        0.00         0.00         0.00
50300    Remove cadaver donor kidney           C             C         0000       0.0000        0.00         0.00         0.00
50320    Remove kidney, living donor           C             C         0000       0.0000        0.00         0.00         0.00
50323    Prep cadaver renal allograft          C             C         0000       0.0000        0.00         0.00         0.00
50325    Prep donor renal graft                C             C         0000       0.0000        0.00         0.00         0.00
50327    Prep renal graft/venous               C             C         0000       0.0000        0.00         0.00         0.00
50328    Prep renal graft/arterial             C             C         0000       0.0000        0.00         0.00         0.00
50329    Prep renal graft/ureteral             C             C         0000       0.0000        0.00         0.00         0.00
50340    Removal of kidney                     C             C         0000       0.0000        0.00         0.00         0.00
50360    Transplantation of kidney             C             C         0000       0.0000        0.00         0.00         0.00
50365    Transplantation of kidney             C             C         0000       0.0000        0.00         0.00         0.00
50370    Remove transplanted kidney            C             C         0000       0.0000        0.00         0.00         0.00
50380    Reimplantation of kidney              C             C         0000       0.0000        0.00         0.00         0.00
50382    Change ureter stent, percut           T             T         0161      18.5804       822.74      1,890.56     2,166.47
50384    Remove ureter stent, percut           T             T         0161      18.5804       822.74      1,890.56     2,166.47
50387    Change ext/int ureter stent           T             T         0122       6.9179       306.32       703.90       806.63
50389    Remove renal tube w/fluoro            T             T         0156       2.6123       115.67       265.80       304.59
50390    Drainage of kidney lesion             T             T         0685       6.0034       265.83       610.85       700.00
50391    Instll rx agnt into rnal tub          T             T         0156       2.6123       115.67       265.80       304.59


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  70 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

50392    Insert kidney drain                   T             T         0161      18.5804       822.74      1,890.56     2,166.47
50393    Insert ureteral tube                  T             T         0161      18.5804       822.74      1,890.56     2,166.47
50394    Injection for kidney x-ray            N             N         0000       0.0000        0.00         0.00         0.00
50395    Create passage to kidney              T             T         0161      18.5804       822.74      1,890.56     2,166.47
50396    Measure kidney pressure               T             T         0164       1.1600        51.36       118.03       135.26
50398    Change kidney tube                    T             T         0122       6.9179       306.32       703.90       806.63
50400    Revision of kidney/ureter             C             C         0000       0.0000        0.00         0.00         0.00
50405    Revision of kidney/ureter             C             C         0000       0.0000        0.00         0.00         0.00
50500    Repair of kidney wound                C             C         0000       0.0000        0.00         0.00         0.00
50520    Close kidney-skin fistula             C             C         0000       0.0000        0.00         0.00         0.00
50525    Repair renal-abdomen fistula          C             C         0000       0.0000        0.00         0.00         0.00
50526    Repair renal-abdomen fistula          C             C         0000       0.0000        0.00         0.00         0.00
50540    Revision of horseshoe kidney          C             C         0000       0.0000        0.00         0.00         0.00
50541    Laparo ablate renal cyst              T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
50542    Laparo ablate renal mass              T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
50543    Laparo partial nephrectomy            T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
50544    Laparoscopy, pyeloplasty              T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
50545    Laparo radical nephrectomy            C             C         0000       0.0000        0.00         0.00         0.00
50546    Laparoscopic nephrectomy              C             C         0000       0.0000        0.00         0.00         0.00
50547    Laparo removal donor kidney           C             C         0000       0.0000        0.00         0.00         0.00
50548    Laparo remove w/ureter                C             C         0000       0.0000        0.00         0.00         0.00
50549    Laparoscope proc, renal               T             1         0000       0.0000        0.00         0.00         0.00
50551    Kidney endoscopy                      T             T         0160       6.9387       307.25       706.01       809.05
50553    Kidney endoscopy                      T             T         0161      18.5804       822.74      1,890.56     2,166.47
50555    Kidney endoscopy & biopsy             T             T         0160       6.9387       307.25       706.01       809.05
50557    Kidney endoscopy & treatment          T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
50561    Kidney endoscopy & treatment          T             T         0161      18.5804       822.74      1,890.56     2,166.47
50562    Renal scope w/tumor resect            T             T         0160       6.9387       307.25       706.01       809.05
50570    Kidney endoscopy                      T             T         0160       6.9387       307.25       706.01       809.05
50572    Kidney endoscopy                      T             T         0160       6.9387       307.25       706.01       809.05
50574    Kidney endoscopy & biopsy             T             T         0160       6.9387       307.25       706.01       809.05
50575    Kidney endoscopy                      T             T         0163      33.5963      1,487.64     3,418.42     3,917.33
50576    Kidney endoscopy & treatment          T             T         0161      18.5804       822.74      1,890.56     2,166.47
50580    Kidney endoscopy & treatment          C             C         0000       0.0000        0.00         0.00         0.00
50590    Fragmenting of kidney stone           T             T         0169      42.4073      1,877.80     4,314.94     4,944.69
50592    Perc rf ablate renal tumor            T             T         0423      39.5881      1,752.96     4,028.09     4,615.97
50600    Exploration of ureter                 C             C         0000       0.0000        0.00         0.00         0.00
50605    Insert ureteral support               C             C         0000       0.0000        0.00         0.00         0.00
50610    Removal of ureter stone               C             C         0000       0.0000        0.00         0.00         0.00
50620    Removal of ureter stone               C             C         0000       0.0000        0.00         0.00         0.00
50630    Removal of ureter stone               C             C         0000       0.0000        0.00         0.00         0.00
50650    Removal of ureter                     C             C         0000       0.0000        0.00         0.00         0.00
50660    Removal of ureter                     C             C         0000       0.0000        0.00         0.00         0.00
50684    Injection for ureter x-ray            N             N         0000       0.0000        0.00         0.00         0.00
50686    Measure ureter pressure               T             T         0164       1.1600        51.36       118.03       135.26
50688    Change of ureter tube                 T             T         0122       6.9179       306.32       703.90       806.63
50690    Injection for ureter x-ray            N             N         0000       0.0000        0.00         0.00         0.00
50700    Revision of ureter                    C             C         0000       0.0000        0.00         0.00         0.00
50715    Release of ureter                     C             C         0000       0.0000        0.00         0.00         0.00
50722    Release of ureter                     C             C         0000       0.0000        0.00         0.00         0.00
50725    Release/revise ureter                 C             C         0000       0.0000        0.00         0.00         0.00
50727    Revise ureter                         C             C         0000       0.0000        0.00         0.00         0.00
50728    Revise ureter                         C             C         0000       0.0000        0.00         0.00         0.00
50740    Fusion of ureter & kidney             C             C         0000       0.0000        0.00         0.00         0.00
50750    Fusion of ureter & kidney             C             C         0000       0.0000        0.00         0.00         0.00
50760    Fusion of ureters                     C             C         0000       0.0000        0.00         0.00         0.00
50770    Splicing of ureters                   C             C         0000       0.0000        0.00         0.00         0.00
50780    Reimplant ureter in bladder           C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  71 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

50782    Reimplant ureter in bladder           C             C         0000       0.0000        0.00         0.00         0.00
50783    Reimplant ureter in bladder           C             C         0000       0.0000        0.00         0.00         0.00
50785    Reimplant ureter in bladder           C             C         0000       0.0000        0.00         0.00         0.00
50800    Implant ureter in bowel               C             C         0000       0.0000        0.00         0.00         0.00
50810    Fusion of ureter & bowel              C             C         0000       0.0000        0.00         0.00         0.00
50815    Urine shunt to intestine              C             C         0000       0.0000        0.00         0.00         0.00
50820    Construct bowel bladder               C             C         0000       0.0000        0.00         0.00         0.00
50825    Construct bowel bladder               C             C         0000       0.0000        0.00         0.00         0.00
50830    Revise urine flow                     C             C         0000       0.0000        0.00         0.00         0.00
50840    Replace ureter by bowel               C             C         0000       0.0000        0.00         0.00         0.00
50845    Appendico-vesicostomy                 C             C         0000       0.0000        0.00         0.00         0.00
50860    Transplant ureter to skin             C             C         0000       0.0000        0.00         0.00         0.00
50900    Repair of ureter                      C             C         0000       0.0000        0.00         0.00         0.00
50920    Closure ureter/skin fistula           C             C         0000       0.0000        0.00         0.00         0.00
50930    Closure ureter/bowel fistula          C             C         0000       0.0000        0.00         0.00         0.00
50940    Release of ureter                     C             C         0000       0.0000        0.00         0.00         0.00
50945    Laparoscopy ureterolithotomy          T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
50947    Laparo new ureter/bladder             T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
50948    Laparo new ureter/bladder             T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
50949    Laparoscope proc, ureter              T             1         0000       0.0000        0.00         0.00         0.00
50951    Endoscopy of ureter                   T             T         0160       6.9387       307.25       706.01       809.05
50953    Endoscopy of ureter                   T             T         0160       6.9387       307.25       706.01       809.05
50955    Ureter endoscopy & biopsy             T             T         0161      18.5804       822.74      1,890.56     2,166.47
50957    Ureter endoscopy & treatment          T             T         0161      18.5804       822.74      1,890.56     2,166.47
50961    Ureter endoscopy & treatment          T             T         0161      18.5804       822.74      1,890.56     2,166.47
50970    Ureter endoscopy                      T             T         0160       6.9387       307.25       706.01       809.05
50972    Ureter endoscopy & catheter           T             T         0160       6.9387       307.25       706.01       809.05
50974    Ureter endoscopy & biopsy             T             T         0161      18.5804       822.74      1,890.56     2,166.47
50976    Ureter endoscopy & treatment          T             T         0161      18.5804       822.74      1,890.56     2,166.47
50980    Ureter endoscopy & treatment          T             T         0161      18.5804       822.74      1,890.56     2,166.47
51000    Drainage of bladder                   T             T         0164       1.1600        51.36       118.03       135.26
51005    Drainage of bladder                   T             T         0164       1.1600        51.36       118.03       135.26
51010    Drainage of bladder                   T             T         0165      16.5343       732.14      1,682.37     1,927.90
51020    Incise & treat bladder                T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
51030    Incise & treat bladder                T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
51040    Incise & drain bladder                T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
51045    Incise bladder/drain ureter           T             T         0160       6.9387       307.25       706.01       809.05
51050    Removal of bladder stone              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
51060    Removal of ureter stone               C             C         0000       0.0000        0.00         0.00         0.00
51065    Remove ureter calculus                T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
51080    Drainage of bladder abscess           T             T         0008      16.2953       721.56      1,658.05     1,900.03
51500    Removal of bladder cyst               T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
51520    Removal of bladder lesion             T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
51525    Removal of bladder lesion             C             C         0000       0.0000        0.00         0.00         0.00
51530    Removal of bladder lesion             C             C         0000       0.0000        0.00         0.00         0.00
51535    Repair of ureter lesion               C             C         0000       0.0000        0.00         0.00         0.00
51550    Partial removal of bladder            C             C         0000       0.0000        0.00         0.00         0.00
51555    Partial removal of bladder            C             C         0000       0.0000        0.00         0.00         0.00
51565    Revise bladder & ureter(s)            C             C         0000       0.0000        0.00         0.00         0.00
51570    Removal of bladder                    C             C         0000       0.0000        0.00         0.00         0.00
51575    Removal of bladder & nodes            C             C         0000       0.0000        0.00         0.00         0.00
51580    Remove bladder/revise tract           C             C         0000       0.0000        0.00         0.00         0.00
51585    Removal of bladder & nodes            C             C         0000       0.0000        0.00         0.00         0.00
51590    Remove bladder/revise tract           C             C         0000       0.0000        0.00         0.00         0.00
51595    Remove bladder/revise tract           C             C         0000       0.0000        0.00         0.00         0.00
51596    Remove bladder/create pouch           C             C         0000       0.0000        0.00         0.00         0.00
51597    Removal of pelvic structures          C             C         0000       0.0000        0.00         0.00         0.00
51600    Injection for bladder x-ray           N             N         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  72 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

51605    Preparation for bladder xray          N             N         0000       0.0000        0.00         0.00         0.00
51610    Injection for bladder x-ray           N             N         0000       0.0000        0.00         0.00         0.00
51700    Irrigation of bladder                 T             T         0164       1.1600        51.36       118.03       135.26
51701    Insert bladder catheter               X             X         0340       0.6137        27.17       62.44        71.56
51702    Insert temp bladder cath              X             X         0340       0.6137        27.17       62.44        71.56
51703    Insert bladder cath, complex          T             T         0164       1.1600        51.36       118.03       135.26
51705    Change of bladder tube                T             T         0121       2.2374        99.07       227.66       260.88
51710    Change of bladder tube                T             T         0122       6.9179       306.32       703.90       806.63
51715    Endoscopic injection/implant          T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
51720    Treatment of bladder lesion           T             T         0156       2.6123       115.67       265.80       304.59
51725    Simple cystometrogram                 T             T         0156       2.6123       115.67       265.80       304.59
51726    Complex cystometrogram                T             T         0156       2.6123       115.67       265.80       304.59
51736    Urine flow measurement                T             T         0164       1.1600        51.36       118.03       135.26
51741    Electro-uroflowmetry, first           T             T         0164       1.1600        51.36       118.03       135.26
51772    Urethra pressure profile              T             T         0156       2.6123       115.67       265.80       304.59
51784    Anal/urinary muscle study             T             T         0164       1.1600        51.36       118.03       135.26
51785    Anal/urinary muscle study             T             T         0164       1.1600        51.36       118.03       135.26
51792    Urinary reflex study                  T             T         0164       1.1600        51.36       118.03       135.26
51795    Urine voiding pressure study          T             T         0164       1.1600        51.36       118.03       135.26
51797    Intraabdominal pressure test          T             T         0164       1.1600        51.36       118.03       135.26
51798    Us urine capacity measure             X             X         0340       0.6137        27.17       62.44        71.56
51800    Revision of bladder/urethra           C             C         0000       0.0000        0.00         0.00         0.00
51820    Revision of urinary tract             C             C         0000       0.0000        0.00         0.00         0.00
51840    Attach bladder/urethra                C             C         0000       0.0000        0.00         0.00         0.00
51841    Attach bladder/urethra                C             C         0000       0.0000        0.00         0.00         0.00
51845    Repair bladder neck                   C             C         0000       0.0000        0.00         0.00         0.00
51860    Repair of bladder wound               C             C         0000       0.0000        0.00         0.00         0.00
51865    Repair of bladder wound               C             C         0000       0.0000        0.00         0.00         0.00
51880    Repair of bladder opening             T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
51900    Repair bladder/vagina lesion          C             C         0000       0.0000        0.00         0.00         0.00
51920    Close bladder-uterus fistula          C             C         0000       0.0000        0.00         0.00         0.00
51925    Hysterectomy/bladder repair           C             C         0000       0.0000        0.00         0.00         0.00
51940    Correction of bladder defect          C             C         0000       0.0000        0.00         0.00         0.00
51960    Revision of bladder & bowel           C             C         0000       0.0000        0.00         0.00         0.00
51980    Construct bladder opening             C             C         0000       0.0000        0.00         0.00         0.00
51990    Laparo urethral suspension            T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
51992    Laparo sling operation                T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
51999    Laparoscope proc, bladder             T             1         0000       0.0000        0.00         0.00         0.00
52000    Cystoscopy                            T             T         0160       6.9387       307.25       706.01       809.05
52001    Cystoscopy, removal of clots          T             T         0160       6.9387       307.25       706.01       809.05
52005    Cystoscopy & ureter catheter          T             T         0161      18.5804       822.74      1,890.56     2,166.47
52007    Cystoscopy and biopsy                 T             T         0161      18.5804       822.74      1,890.56     2,166.47
52010    Cystoscopy & duct catheter            T             T         0160       6.9387       307.25       706.01       809.05
52204    Cystoscopy                            T             T         0161      18.5804       822.74      1,890.56     2,166.47
52214    Cystoscopy and treatment              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52224    Cystoscopy and treatment              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52234    Cystoscopy and treatment              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52235    Cystoscopy and treatment              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52240    Cystoscopy and treatment              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52250    Cystoscopy and radiotracer            T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52260    Cystoscopy and treatment              T             T         0161      18.5804       822.74      1,890.56     2,166.47
52265    Cystoscopy and treatment              T             T         0160       6.9387       307.25       706.01       809.05
52270    Cystoscopy & revise urethra           T             T         0161      18.5804       822.74      1,890.56     2,166.47
52275    Cystoscopy & revise urethra           T             T         0161      18.5804       822.74      1,890.56     2,166.47
52276    Cystoscopy and treatment              T             T         0161      18.5804       822.74      1,890.56     2,166.47
52277    Cystoscopy and treatment              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52281    Cystoscopy and treatment              T             T         0161      18.5804       822.74      1,890.56     2,166.47
52282    Cystoscopy, implant stent             T             T         0163      33.5963      1,487.64     3,418.42     3,917.33


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  73 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

52283    Cystoscopy and treatment              T             T         0161      18.5804       822.74      1,890.56     2,166.47
52285    Cystoscopy and treatment              T             T         0161      18.5804       822.74      1,890.56     2,166.47
52290    Cystoscopy and treatment              T             T         0161      18.5804       822.74      1,890.56     2,166.47
52300    Cystoscopy and treatment              T             T         0161      18.5804       822.74      1,890.56     2,166.47
52301    Cystoscopy and treatment              T             T         0161      18.5804       822.74      1,890.56     2,166.47
52305    Cystoscopy and treatment              T             T         0161      18.5804       822.74      1,890.56     2,166.47
52310    Cystoscopy and treatment              T             T         0160       6.9387       307.25       706.01       809.05
52315    Cystoscopy and treatment              T             T         0161      18.5804       822.74      1,890.56     2,166.47
52317    Remove bladder stone                  T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52318    Remove bladder stone                  T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52320    Cystoscopy and treatment              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52325    Cystoscopy, stone removal             T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52327    Cystoscopy, inject material           T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52330    Cystoscopy and treatment              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52332    Cystoscopy and treatment              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52334    Create passage to kidney              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52341    Cysto w/ureter stricture tx           T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52342    Cysto w/up stricture tx               T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52343    Cysto w/renal stricture tx            T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52344    Cysto/uretero, stricture tx           T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52345    Cysto/uretero w/up stricture          T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52346    Cystouretero w/renal strict           T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52351    Cystouretero & or pyeloscope          T             T         0161      18.5804       822.74      1,890.56     2,166.47
52352    Cystouretero w/stone remove           T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52353    Cystouretero w/lithotripsy            T             T         0163      33.5963      1,487.64     3,418.42     3,917.33
52354    Cystouretero w/biopsy                 T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52355    Cystouretero w/excise tumor           T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52400    Cystouretero w/congen repr            T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52402    Cystourethro cut ejacul duct          T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52450    Incision of prostate                  T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52500    Revision of bladder neck              T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52510    Dilation prostatic urethra            T             T         0161      18.5804       822.74      1,890.56     2,166.47
52601    Prostatectomy (TURP)                  T             T         0163      33.5963      1,487.64     3,418.42     3,917.33
52606    Control postop bleeding               T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52612    Prostatectomy, first stage            T             T         0163      33.5963      1,487.64     3,418.42     3,917.33
52614    Prostatectomy, second stage           T             T         0163      33.5963      1,487.64     3,418.42     3,917.33
52620    Remove residual prostate              T             T         0163      33.5963      1,487.64     3,418.42     3,917.33
52630    Remove prostate regrowth              T             T         0163      33.5963      1,487.64     3,418.42     3,917.33
52640    Relieve bladder contracture           T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
52647    Laser surgery of prostate             T             T         0429      42.0802      1,863.31     4,281.66     4,906.55
52648    Laser surgery of prostate             T             T         0429      42.0802      1,863.31     4,281.66     4,906.55
52700    Drainage of prostate abscess          T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
53000    Incision of urethra                   T             T         0166      17.7635       786.57      1,807.44     2,071.22
53010    Incision of urethra                   T             T         0166      17.7635       786.57      1,807.44     2,071.22
53020    Incision of urethra                   T             T         0166      17.7635       786.57      1,807.44     2,071.22
53025    Incision of urethra                   T             T         0166      17.7635       786.57      1,807.44     2,071.22
53040    Drainage of urethra abscess           T             T         0166      17.7635       786.57      1,807.44     2,071.22
53060    Drainage of urethra abscess           T             T         0166      17.7635       786.57      1,807.44     2,071.22
53080    Drainage of urinary leakage           T             T         0166      17.7635       786.57      1,807.44     2,071.22
53085    Drainage of urinary leakage           T             T         0166      17.7635       786.57      1,807.44     2,071.22
53200    Biopsy of urethra                     T             T         0166      17.7635       786.57      1,807.44     2,071.22
53210    Removal of urethra                    T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53215    Removal of urethra                    T             T         0166      17.7635       786.57      1,807.44     2,071.22
53220    Treatment of urethra lesion           T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53230    Removal of urethra lesion             T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53235    Removal of urethra lesion             T             T         0166      17.7635       786.57      1,807.44     2,071.22
53240    Surgery for urethra pouch             T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53250    Removal of urethra gland              T             T         0166      17.7635       786.57      1,807.44     2,071.22


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  74 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

53260    Treatment of urethra lesion           T             T         0166      17.7635       786.57      1,807.44     2,071.22
53265    Treatment of urethra lesion           T             T         0166      17.7635       786.57      1,807.44     2,071.22
53270    Removal of urethra gland              T             T         0166      17.7635       786.57      1,807.44     2,071.22
53275    Repair of urethra defect              T             T         0166      17.7635       786.57      1,807.44     2,071.22
53400    Revise urethra, stage 1               T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53405    Revise urethra, stage 2               T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53410    Reconstruction of urethra             T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53415    Reconstruction of urethra             C             C         0000       0.0000        0.00         0.00         0.00
53420    Reconstruct urethra, stage 1          T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53425    Reconstruct urethra, stage 2          T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53430    Reconstruction of urethra             T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53431    Reconstruct urethra/bladder           T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53440    Male sling procedure                  S             S         0385      73.7498      3,265.64     7,504.04     8,599.23
53442    Remove/revise male sling              T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53444    Insert tandem cuff                    S             S         0385      73.7498      3,265.64     7,504.04     8,599.23
53445    Insert uro/ves nck sphincter          S             S         0386      126.9292     5,620.42    12,915.05    14,799.94
53446    Remove uro sphincter                  T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53447    Remove/replace ur sphincter           S             S         0386      126.9292     5,620.42    12,915.05    14,799.94
53448    Remov/replc ur sphinctr comp          C             C         0000       0.0000        0.00         0.00         0.00
53449    Repair uro sphincter                  T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53450    Revision of urethra                   T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53460    Revision of urethra                   T             T         0166      17.7635       786.57      1,807.44     2,071.22
53500    Urethrlys, transvag w/ scope          T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53502    Repair of urethra injury              T             T         0166      17.7635       786.57      1,807.44     2,071.22
53505    Repair of urethra injury              T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53510    Repair of urethra injury              T             T         0166      17.7635       786.57      1,807.44     2,071.22
53515    Repair of urethra injury              T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53520    Repair of urethra defect              T             T         0168      28.1985      1,248.63     2,869.20     3,287.95
53600    Dilate urethra stricture              T             T         0156       2.6123       115.67       265.80       304.59
53601    Dilate urethra stricture              T             T         0164       1.1600        51.36       118.03       135.26
53605    Dilate urethra stricture              T             T         0161      18.5804       822.74      1,890.56     2,166.47
53620    Dilate urethra stricture              T             T         0165      16.5343       732.14      1,682.37     1,927.90
53621    Dilate urethra stricture              T             T         0164       1.1600        51.36       118.03       135.26
53660    Dilation of urethra                   T             T         0164       1.1600        51.36       118.03       135.26
53661    Dilation of urethra                   T             T         0164       1.1600        51.36       118.03       135.26
53665    Dilation of urethra                   T             T         0166      17.7635       786.57      1,807.44     2,071.22
53850    Prostatic microwave thermotx          T             T         0675      44.8197      1,984.62     4,560.40     5,225.98
53852    Prostatic rf thermotx                 T             T         0675      44.8197      1,984.62     4,560.40     5,225.98
53853    Prostatic water thermother            T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
53899    Urology surgery procedure             T             1         0000       0.0000        0.00         0.00         0.00
54000    Slitting of prepuce                   T             T         0166      17.7635       786.57      1,807.44     2,071.22
54001    Slitting of prepuce                   T             T         0166      17.7635       786.57      1,807.44     2,071.22
54015    Drain penis lesion                    T             T         0008      16.2953       721.56      1,658.05     1,900.03
54050    Destruction, penis lesion(s)          T             T         0013       1.0603        46.95       107.89       123.63
54055    Destruction, penis lesion(s)          T             T         0017      17.9937       796.76      1,830.86     2,098.07
54056    Cryosurgery, penis lesion(s)          T             T         0012       0.8477        37.54       86.25        98.84
54057    Laser surg, penis lesion(s)           T             T         0017      17.9937       796.76      1,830.86     2,098.07
54060    Excision of penis lesion(s)           T             T         0017      17.9937       796.76      1,830.86     2,098.07
54065    Destruction, penis lesion(s)          T             T         0695      20.2372       896.10      2,059.14     2,359.66
54100    Biopsy of penis                       T             T         0021      14.9984       664.13      1,526.09     1,748.81
54105    Biopsy of penis                       T             T         0022      19.5716       866.63      1,991.41     2,282.05
54110    Treatment of penis lesion             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54111    Treat penis lesion, graft             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54112    Treat penis lesion, graft             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54115    Treatment of penis lesion             T             T         0008      16.2953       721.56      1,658.05     1,900.03
54120    Partial removal of penis              T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54125    Removal of penis                      C             C         0000       0.0000        0.00         0.00         0.00
54130    Remove penis & nodes                  C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  75 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

54135    Remove penis & nodes                  C             C         0000       0.0000        0.00         0.00         0.00
54150    Circumcision                          T             T         0180      19.7721       875.51      2,011.81     2,305.43
54152    Circumcision                          T             T         0180      19.7721       875.51      2,011.81     2,305.43
54160    Circumcision                          T             T         0180      19.7721       875.51      2,011.81     2,305.43
54161    Circumcision                          T             T         0180      19.7721       875.51      2,011.81     2,305.43
54162    Lysis penil circumic lesion           T             T         0180      19.7721       875.51      2,011.81     2,305.43
54163    Repair of circumcision                T             T         0180      19.7721       875.51      2,011.81     2,305.43
54164    Frenulotomy of penis                  T             T         0180      19.7721       875.51      2,011.81     2,305.43
54200    Treatment of penis lesion             T             T         0156       2.6123       115.67       265.80       304.59
54205    Treatment of penis lesion             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54220    Treatment of penis lesion             T             T         0156       2.6123       115.67       265.80       304.59
54230    Prepare penis study                   N             N         0000       0.0000        0.00         0.00         0.00
54231    Dynamic cavernosometry                T             T         0165      16.5343       732.14      1,682.37     1,927.90
54235    Penile injection                      T             T         0164       1.1600        51.36       118.03       135.26
54240    Penis study                           T             1         0000       0.0000        0.00         0.00         0.00
54250    Penis study                           T             1         0000       0.0000        0.00         0.00         0.00
54300    Revision of penis                     T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54304    Revision of penis                     T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54308    Reconstruction of urethra             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54312    Reconstruction of urethra             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54316    Reconstruction of urethra             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54318    Reconstruction of urethra             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54322    Reconstruction of urethra             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54324    Reconstruction of urethra             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54326    Reconstruction of urethra             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54328    Revise penis/urethra                  T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54332    Revise penis/urethra                  C             C         0000       0.0000        0.00         0.00         0.00
54336    Revise penis/urethra                  C             C         0000       0.0000        0.00         0.00         0.00
54340    Secondary urethral surgery            T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54344    Secondary urethral surgery            T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54348    Secondary urethral surgery            T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54352    Reconstruct urethra/penis             T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54360    Penis plastic surgery                 T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54380    Repair penis                          T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54385    Repair penis                          T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54390    Repair penis and bladder              C             C         0000       0.0000        0.00         0.00         0.00
54400    Insert semi-rigid prosthesis          S             1         0000       0.0000        0.00         0.00         0.00
54401    Insert self-contd prosthesis          S             1         0000       0.0000        0.00         0.00         0.00
54405    Insert multi-comp penis pros          S             1         0000       0.0000        0.00         0.00         0.00
54406    Remove muti-comp penis pros           T             1         0000       0.0000        0.00         0.00         0.00
54408    Repair multi-comp penis pros          T             1         0000       0.0000        0.00         0.00         0.00
54410    Remove/replace penis prosth           S             1         0000       0.0000        0.00         0.00         0.00
54411    Remov/replc penis pros, comp          C             1         0000       0.0000        0.00         0.00         0.00
54415    Remove self-contd penis pros          T             1         0000       0.0000        0.00         0.00         0.00
54416    Remv/repl penis contain pros          S             1         0000       0.0000        0.00         0.00         0.00
54417    Remv/replc penis pros, compl          C             1         0000       0.0000        0.00         0.00         0.00
54420    Revision of penis                     T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54430    Revision of penis                     C             C         0000       0.0000        0.00         0.00         0.00
54435    Revision of penis                     T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54440    Repair of penis                       T             T         0181      30.9472      1,370.34     3,148.88     3,608.44
54450    Preputial stretching                  T             T         0156       2.6123       115.67       265.80       304.59
54500    Biopsy of testis                      T             T         0037       9.6103       425.54       977.85      1,120.56
54505    Biopsy of testis                      T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54512    Excise lesion testis                  T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54520    Removal of testis                     T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54522    Orchiectomy, partial                  T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54530    Removal of testis                     T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
54535    Extensive testis surgery              C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  76 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

54550    Exploration for testis                T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
54560    Exploration for testis                T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54600    Reduce testis torsion                 T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54620    Suspension of testis                  T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54640    Suspension of testis                  T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
54650    Orchiopexy (Fowler-Stephens)          C             C         0000       0.0000        0.00         0.00         0.00
54660    Revision of testis                    T             1         0000       0.0000        0.00         0.00         0.00
54670    Repair testis injury                  T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54680    Relocation of testis(es)              T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54690    Laparoscopy, orchiectomy              T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
54692    Laparoscopy, orchiopexy               T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
54699    Laparoscope proc, testis              T             1         0000       0.0000        0.00         0.00         0.00
54700    Drainage of scrotum                   T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54800    Biopsy of epididymis                  T             T         0004       1.7771        78.69       180.82       207.21
54820    Exploration of epididymis             T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54830    Remove epididymis lesion              T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54840    Remove epididymis lesion              T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54860    Removal of epididymis                 T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54861    Removal of epididymis                 T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54900    Fusion of spermatic ducts             T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
54901    Fusion of spermatic ducts             T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55000    Drainage of hydrocele                 T             T         0004       1.7771        78.69       180.82       207.21
55040    Removal of hydrocele                  T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
55041    Removal of hydroceles                 T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
55060    Repair of hydrocele                   T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55100    Drainage of scrotum abscess           T             T         0008      16.2953       721.56      1,658.05     1,900.03
55110    Explore scrotum                       T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55120    Removal of scrotum lesion             T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55150    Removal of scrotum                    T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55175    Revision of scrotum                   T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55180    Revision of scrotum                   T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55200    Incision of sperm duct                T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55250    Removal of sperm duct(s)              T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55300    Prepare, sperm duct x-ray             N             N         0000       0.0000        0.00         0.00         0.00
55400    Repair of sperm duct                  T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55450    Ligation of sperm duct                T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55500    Removal of hydrocele                  T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55520    Removal of sperm cord lesion          T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55530    Revise spermatic cord veins           T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55535    Revise spermatic cord veins           T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
55540    Revise hernia & sperm veins           T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
55550    Laparo ligate spermatic vein          T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
55559    Laparo proc, spermatic cord           T             1         0000       0.0000        0.00         0.00         0.00
55600    Incise sperm duct pouch               T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55605    Incise sperm duct pouch               C             C         0000       0.0000        0.00         0.00         0.00
55650    Remove sperm duct pouch               C             C         0000       0.0000        0.00         0.00         0.00
55680    Remove sperm pouch lesion             T             T         0183      23.3500      1,033.94     2,375.86     2,722.61
55700    Biopsy of prostate                    T             T         0184       4.4432       196.74       452.10       518.08
55705    Biopsy of prostate                    T             T         0184       4.4432       196.74       452.10       518.08
55720    Drainage of prostate abscess          T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
55725    Drainage of prostate abscess          T             T         0162      23.3383      1,033.42     2,374.67     2,721.25
55801    Removal of prostate                   C             C         0000       0.0000        0.00         0.00         0.00
55810    Extensive prostate surgery            C             C         0000       0.0000        0.00         0.00         0.00
55812    Extensive prostate surgery            C             C         0000       0.0000        0.00         0.00         0.00
55815    Extensive prostate surgery            C             C         0000       0.0000        0.00         0.00         0.00
55821    Removal of prostate                   C             C         0000       0.0000        0.00         0.00         0.00
55831    Removal of prostate                   C             C         0000       0.0000        0.00         0.00         0.00
55840    Extensive prostate surgery            C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  77 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

55842    Extensive prostate surgery            C             C         0000       0.0000        0.00         0.00         0.00
55845    Extensive prostate surgery            C             C         0000       0.0000        0.00         0.00         0.00
55859    Percut/needle insert, pros            T             T         0163      33.5963      1,487.64     3,418.42     3,917.33
55860    Surgical exposure, prostate           T             T         0165      16.5343       732.14      1,682.37     1,927.90
55862    Extensive prostate surgery            C             C         0000       0.0000        0.00         0.00         0.00
55865    Extensive prostate surgery            C             C         0000       0.0000        0.00         0.00         0.00
55866    Laparo radical prostatectomy          C             C         0000       0.0000        0.00         0.00         0.00
55870    Electroejaculation                    T             1         0000       0.0000        0.00         0.00         0.00
55873    Cryoablate prostate                   T             T         0674      111.3747     4,931.67    11,332.38    12,986.29
55899    Genital surgery procedure             T             1         0000       0.0000        0.00         0.00         0.00
55970    Sex transformation, M to F            E             1         0000       0.0000        0.00         0.00         0.00
55980    Sex transformation, F to M            E             1         0000       0.0000        0.00         0.00         0.00
56405    I & D of vulva/perineum               T             T         0189       2.3805       105.41       242.22       277.57
56420    Drainage of gland abscess             T             T         0189       2.3805       105.41       242.22       277.57
56440    Surgery for vulva lesion              T             T         0194      20.6573       914.71      2,101.88     2,408.64
56441    Lysis of labial lesion(s)             T             T         0193      14.6385       648.19      1,489.47     1,706.85
56501    Destroy, vulva lesions, sim           T             T         0017      17.9937       796.76      1,830.86     2,098.07
56515    Destroy vulva lesion/s compl          T             T         0695      20.2372       896.10      2,059.14     2,359.66
56605    Biopsy of vulva/perineum              T             T         0019       4.1481       183.68       422.07       483.67
56606    Biopsy of vulva/perineum              T             T         0019       4.1481       183.68       422.07       483.67
56620    Partial removal of vulva              T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
56625    Complete removal of vulva             T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
56630    Extensive vulva surgery               C             C         0000       0.0000        0.00         0.00         0.00
56631    Extensive vulva surgery               C             C         0000       0.0000        0.00         0.00         0.00
56632    Extensive vulva surgery               C             C         0000       0.0000        0.00         0.00         0.00
56633    Extensive vulva surgery               C             C         0000       0.0000        0.00         0.00         0.00
56634    Extensive vulva surgery               C             C         0000       0.0000        0.00         0.00         0.00
56637    Extensive vulva surgery               C             C         0000       0.0000        0.00         0.00         0.00
56640    Extensive vulva surgery               C             C         0000       0.0000        0.00         0.00         0.00
56700    Partial removal of hymen              T             T         0194      20.6573       914.71      2,101.88     2,408.64
56720    Incision of hymen                     T             T         0193      14.6385       648.19      1,489.47     1,706.85
56740    Remove vagina gland lesion            T             T         0194      20.6573       914.71      2,101.88     2,408.64
56800    Repair of vagina                      T             T         0194      20.6573       914.71      2,101.88     2,408.64
56805    Repair clitoris                       T             T         0193      14.6385       648.19      1,489.47     1,706.85
56810    Repair of perineum                    T             T         0194      20.6573       914.71      2,101.88     2,408.64
56820    Exam of vulva w/scope                 T             T         0188       1.2615        55.86       128.36       147.09
56821    Exam/biopsy of vulva w/scope          T             T         0189       2.3805       105.41       242.22       277.57
57000    Exploration of vagina                 T             T         0193      14.6385       648.19      1,489.47     1,706.85
57010    Drainage of pelvic abscess            T             T         0193      14.6385       648.19      1,489.47     1,706.85
57020    Drainage of pelvic fluid              T             T         0192       4.1597       184.19       423.25       485.02
57022    I & d vaginal hematoma, pp            T             T         0007      11.6717       516.82      1,187.60     1,360.92
57023    I & d vag hematoma, non-ob            T             T         0008      16.2953       721.56      1,658.05     1,900.03
57061    Destroy vag lesions, simple           T             T         0194      20.6573       914.71      2,101.88     2,408.64
57065    Destroy vag lesions, complex          T             T         0194      20.6573       914.71      2,101.88     2,408.64
57100    Biopsy of vagina                      T             T         0192       4.1597       184.19       423.25       485.02
57105    Biopsy of vagina                      T             T         0194      20.6573       914.71      2,101.88     2,408.64
57106    Remove vagina wall, partial           T             T         0194      20.6573       914.71      2,101.88     2,408.64
57107    Remove vagina tissue, part            T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57109    Vaginectomy partial w/nodes           T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57110    Remove vagina wall, complete          C             C         0000       0.0000        0.00         0.00         0.00
57111    Remove vagina tissue, compl           C             C         0000       0.0000        0.00         0.00         0.00
57112    Vaginectomy w/nodes, compl            C             C         0000       0.0000        0.00         0.00         0.00
57120    Closure of vagina                     T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57130    Remove vagina lesion                  T             T         0194      20.6573       914.71      2,101.88     2,408.64
57135    Remove vagina lesion                  T             T         0194      20.6573       914.71      2,101.88     2,408.64
57150    Treat vagina infection                T             T         0191       0.1702        7.54        17.32        19.85
57155    Insert uteri tandems/ovoids           T             T         0192       4.1597       184.19       423.25       485.02
57160    Insert pessary/other device           T             T         0188       1.2615        55.86       128.36       147.09


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  78 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

57170    Fitting of diaphragm/cap              T             T         0191       0.1702        7.54        17.32        19.85
57180    Treat vaginal bleeding                T             T         0189       2.3805       105.41       242.22       277.57
57200    Repair of vagina                      T             T         0194      20.6573       914.71      2,101.88     2,408.64
57210    Repair vagina/perineum                T             T         0194      20.6573       914.71      2,101.88     2,408.64
57220    Revision of urethra                   T             T         0202      41.2319      1,825.75     4,195.35     4,807.64
57230    Repair of urethral lesion             T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57240    Repair bladder & vagina               T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57250    Repair rectum & vagina                T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57260    Repair of vagina                      T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57265    Extensive repair of vagina            T             T         0202      41.2319      1,825.75     4,195.35     4,807.64
57267    Insert mesh/pelvic flr addon          T             T         0154      28.6432      1,268.32     2,914.45     3,339.80
57268    Repair of bowel bulge                 T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57270    Repair of bowel pouch                 C             C         0000       0.0000        0.00         0.00         0.00
57280    Suspension of vagina                  C             C         0000       0.0000        0.00         0.00         0.00
57282    Colpopexy, extraperitoneal            C             C         0000       0.0000        0.00         0.00         0.00
57283    Colpopexy, intraperitoneal            C             C         0000       0.0000        0.00         0.00         0.00
57284    Repair paravaginal defect             T             T         0202      41.2319      1,825.75     4,195.35     4,807.64
57287    Revise/remove sling repair            T             T         0202      41.2319      1,825.75     4,195.35     4,807.64
57288    Repair bladder defect                 T             T         0202      41.2319      1,825.75     4,195.35     4,807.64
57289    Repair bladder & vagina               T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57291    Construction of vagina                T             1         0000       0.0000        0.00         0.00         0.00
57292    Construct vagina with graft           C             1         0000       0.0000        0.00         0.00         0.00
57295    Change vaginal graft                  T             1         0000       0.0000        0.00         0.00         0.00
57300    Repair rectum-vagina fistula          T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57305    Repair rectum-vagina fistula          C             C         0000       0.0000        0.00         0.00         0.00
57307    Fistula repair & colostomy            C             C         0000       0.0000        0.00         0.00         0.00
57308    Fistula repair, transperine           C             C         0000       0.0000        0.00         0.00         0.00
57310    Repair urethrovaginal lesion          T             T         0202      41.2319      1,825.75     4,195.35     4,807.64
57311    Repair urethrovaginal lesion          C             C         0000       0.0000        0.00         0.00         0.00
57320    Repair bladder-vagina lesion          T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57330    Repair bladder-vagina lesion          T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57335    Repair vagina                         C             C         0000       0.0000        0.00         0.00         0.00
57400    Dilation of vagina                    T             T         0194      20.6573       914.71      2,101.88     2,408.64
57410    Pelvic examination                    T             T         0193      14.6385       648.19      1,489.47     1,706.85
57415    Remove vaginal foreign body           T             T         0194      20.6573       914.71      2,101.88     2,408.64
57420    Exam of vagina w/scope                T             T         0189       2.3805       105.41       242.22       277.57
57421    Exam/biopsy of vag w/scope            T             T         0189       2.3805       105.41       242.22       277.57
57425    Laparoscopy, surg, colpopexy          T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
57452    Exam of cervix w/scope                T             T         0189       2.3805       105.41       242.22       277.57
57454    Bx/curett of cervix w/scope           T             T         0189       2.3805       105.41       242.22       277.57
57455    Biopsy of cervix w/scope              T             T         0189       2.3805       105.41       242.22       277.57
57456    Endocerv curettage w/scope            T             T         0189       2.3805       105.41       242.22       277.57
57460    Bx of cervix w/scope, leep            T             T         0193      14.6385       648.19      1,489.47     1,706.85
57461    Conz of cervix w/scope, leep          T             T         0194      20.6573       914.71      2,101.88     2,408.64
57500    Biopsy of cervix                      T             T         0192       4.1597       184.19       423.25       485.02
57505    Endocervical curettage                T             T         0189       2.3805       105.41       242.22       277.57
57510    Cauterization of cervix               T             T         0193      14.6385       648.19      1,489.47     1,706.85
57511    Cryocautery of cervix                 T             T         0189       2.3805       105.41       242.22       277.57
57513    Laser surgery of cervix               T             T         0193      14.6385       648.19      1,489.47     1,706.85
57520    Conization of cervix                  T             T         0194      20.6573       914.71      2,101.88     2,408.64
57522    Conization of cervix                  T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57530    Removal of cervix                     T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57531    Removal of cervix, radical            C             C         0000       0.0000        0.00         0.00         0.00
57540    Removal of residual cervix            C             C         0000       0.0000        0.00         0.00         0.00
57545    Remove cervix/repair pelvis           C             C         0000       0.0000        0.00         0.00         0.00
57550    Removal of residual cervix            T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57555    Remove cervix/repair vagina           T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
57556    Remove cervix, repair bowel           T             T         0202      41.2319      1,825.75     4,195.35     4,807.64


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  79 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

57700    Revision of cervix                    T             T         0194      20.6573       914.71      2,101.88     2,408.64
57720    Revision of cervix                    T             T         0194      20.6573       914.71      2,101.88     2,408.64
57800    Dilation of cervical canal            T             T         0193      14.6385       648.19      1,489.47     1,706.85
57820    D & c of residual cervix              T             T         0196      17.0012       752.81      1,729.87     1,982.34
58100    Biopsy of uterus lining               T             T         0188       1.2615        55.86       128.36       147.09
58110    Bx done w/colposcopy add-on           T             T         0188       1.2615        55.86       128.36       147.09
58120    Dilation and curettage                T             T         0196      17.0012       752.81      1,729.87     1,982.34
58140    Myomectomy abdom method               C             C         0000       0.0000        0.00         0.00         0.00
58145    Myomectomy vag method                 T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
58146    Myomectomy abdom complex              C             C         0000       0.0000        0.00         0.00         0.00
58150    Total hysterectomy                    C             C         0000       0.0000        0.00         0.00         0.00
58152    Total hysterectomy                    C             C         0000       0.0000        0.00         0.00         0.00
58180    Partial hysterectomy                  C             C         0000       0.0000        0.00         0.00         0.00
58200    Extensive hysterectomy                C             C         0000       0.0000        0.00         0.00         0.00
58210    Extensive hysterectomy                C             C         0000       0.0000        0.00         0.00         0.00
58240    Removal of pelvis contents            C             C         0000       0.0000        0.00         0.00         0.00
58260    Vaginal hysterectomy                  C             C         0000       0.0000        0.00         0.00         0.00
58262    Vag hyst including t/o                C             C         0000       0.0000        0.00         0.00         0.00
58263    Vag hyst w/t/o & vag repair           C             C         0000       0.0000        0.00         0.00         0.00
58267    Vag hyst w/urinary repair             C             C         0000       0.0000        0.00         0.00         0.00
58270    Vag hyst w/enterocele repair          C             C         0000       0.0000        0.00         0.00         0.00
58275    Hysterectomy/revise vagina            C             C         0000       0.0000        0.00         0.00         0.00
58280    Hysterectomy/revise vagina            C             C         0000       0.0000        0.00         0.00         0.00
58285    Extensive hysterectomy                C             C         0000       0.0000        0.00         0.00         0.00
58290    Vag hyst complex                      C             C         0000       0.0000        0.00         0.00         0.00
58291    Vag hyst incl t/o, complex            C             C         0000       0.0000        0.00         0.00         0.00
58292    Vag hyst t/o & repair, compl          C             C         0000       0.0000        0.00         0.00         0.00
58293    Vag hyst w/uro repair, compl          C             C         0000       0.0000        0.00         0.00         0.00
58294    Vag hyst w/enterocele, compl          C             C         0000       0.0000        0.00         0.00         0.00
58300    Insert intrauterine device            E             3         0000       0.0000         M01         M01          M01
58301    Remove intrauterine device            T             T         0189       2.3805       105.41       242.22       277.57
58321    Artificial insemination               T             1         0000       0.0000        0.00         0.00         0.00
58322    Artificial insemination               T             1         0000       0.0000        0.00         0.00         0.00
58323    Sperm washing                         T             1         0000       0.0000        0.00         0.00         0.00
58340    Catheter for hysterography            N             1         0000       0.0000        0.00         0.00         0.00
58345    Reopen fallopian tube                 T             1         0000       0.0000        0.00         0.00         0.00
58346    Insert heyman uteri capsule           T             1         0000       0.0000        0.00         0.00         0.00
58350    Reopen fallopian tube                 T             1         0000       0.0000        0.00         0.00         0.00
58353    Endometr ablate, thermal              T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
58356    Endometrial cryoablation              T             T         0202      41.2319      1,825.75     4,195.35     4,807.64
58400    Suspension of uterus                  C             C         0000       0.0000        0.00         0.00         0.00
58410    Suspension of uterus                  C             C         0000       0.0000        0.00         0.00         0.00
58520    Repair of ruptured uterus             C             C         0000       0.0000        0.00         0.00         0.00
58540    Revision of uterus                    C             C         0000       0.0000        0.00         0.00         0.00
58545    Laparoscopic myomectomy               T             T         0130      31.8753      1,411.44     3,243.31     3,716.66
58546    Laparo-myomectomy, complex            T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
58550    Laparo-asst vag hysterectomy          T             T         0132      63.6859      2,820.01     6,480.04     7,425.78
58552    Laparo-vag hyst incl t/o              T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
58553    Laparo-vag hyst, complex              T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
58554    Laparo-vag hyst w/t/o, compl          T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
58555    Hysteroscopy, dx, sep proc            T             T         0190      20.9198       926.33      2,128.59     2,439.25
58558    Hysteroscopy, biopsy                  T             T         0190      20.9198       926.33      2,128.59     2,439.25
58559    Hysteroscopy, lysis                   T             T         0190      20.9198       926.33      2,128.59     2,439.25
58560    Hysteroscopy, resect septum           T             T         0387      32.3170      1,431.00     3,288.25     3,768.16
58561    Hysteroscopy, remove myoma            T             T         0387      32.3170      1,431.00     3,288.25     3,768.16
58562    Hysteroscopy, remove fb               T             T         0190      20.9198       926.33      2,128.59     2,439.25
58563    Hysteroscopy, ablation                T             T         0387      32.3170      1,431.00     3,288.25     3,768.16
58565    Hysteroscopy, sterilization           T             T         0202      41.2319      1,825.75     4,195.35     4,807.64


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  80 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

58578    Laparo proc, uterus                   T             1         0000       0.0000        0.00         0.00         0.00
58579    Hysteroscope procedure                T             1         0000       0.0000        0.00         0.00         0.00
58600    Division of fallopian tube            T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
58605    Division of fallopian tube            C             C         0000       0.0000        0.00         0.00         0.00
58611    Ligate oviduct(s) add-on              C             C         0000       0.0000        0.00         0.00         0.00
58615    Occlude fallopian tube(s)             T             T         0194      20.6573       914.71      2,101.88     2,408.64
58660    Laparoscopy, lysis                    T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
58661    Laparoscopy, remove adnexa            T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
58662    Laparoscopy, excise lesions           T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
58670    Laparoscopy, tubal cautery            T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
58671    Laparoscopy, tubal block              T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
58672    Laparoscopy, fimbrioplasty            T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
58673    Laparoscopy, salpingostomy            T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
58679    Laparo proc, oviduct-ovary            T             1         0000       0.0000        0.00         0.00         0.00
58700    Removal of fallopian tube             C             C         0000       0.0000        0.00         0.00         0.00
58720    Removal of ovary/tube(s)              C             C         0000       0.0000        0.00         0.00         0.00
58740    Revise fallopian tube(s)              C             C         0000       0.0000        0.00         0.00         0.00
58750    Repair oviduct                        C             1         0000       0.0000        0.00         0.00         0.00
58752    Revise ovarian tube(s)                C             1         0000       0.0000        0.00         0.00         0.00
58760    Remove tubal obstruction              C             1         0000       0.0000        0.00         0.00         0.00
58770    Create new tubal opening              T             1         0000       0.0000        0.00         0.00         0.00
58800    Drainage of ovarian cyst(s)           T             T         0193      14.6385       648.19      1,489.47     1,706.85
58805    Drainage of ovarian cyst(s)           C             C         0000       0.0000        0.00         0.00         0.00
58820    Drain ovary abscess, open             T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
58822    Drain ovary abscess, percut           C             C         0000       0.0000        0.00         0.00         0.00
58823    Drain pelvic abscess, percut          T             T         0193      14.6385       648.19      1,489.47     1,706.85
58825    Transposition, ovary(s)               C             C         0000       0.0000        0.00         0.00         0.00
58900    Biopsy of ovary(s)                    T             T         0193      14.6385       648.19      1,489.47     1,706.85
58920    Partial removal of ovary(s)           T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
58925    Removal of ovarian cyst(s)            T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
58940    Removal of ovary(s)                   C             C         0000       0.0000        0.00         0.00         0.00
58943    Removal of ovary(s)                   C             C         0000       0.0000        0.00         0.00         0.00
58950    Resect ovarian malignancy             C             C         0000       0.0000        0.00         0.00         0.00
58951    Resect ovarian malignancy             C             C         0000       0.0000        0.00         0.00         0.00
58952    Resect ovarian malignancy             C             C         0000       0.0000        0.00         0.00         0.00
58953    Tah, rad dissect for debulk           C             C         0000       0.0000        0.00         0.00         0.00
58954    Tah rad debulk/lymph remove           C             C         0000       0.0000        0.00         0.00         0.00
58956    Bso, omentectomy w/tah                C             C         0000       0.0000        0.00         0.00         0.00
58960    Exploration of abdomen                C             C         0000       0.0000        0.00         0.00         0.00
58970    Retrieval of oocyte                   T             1         0000       0.0000        0.00         0.00         0.00
58974    Transfer of embryo                    T             1         0000       0.0000        0.00         0.00         0.00
58976    Transfer of embryo                    T             1         0000       0.0000        0.00         0.00         0.00
58999    Genital surgery procedure             T             1         0000       0.0000        0.00         0.00         0.00
59000    Amniocentesis, diagnostic             T             T         0198       1.3622        60.32       138.60       158.83
59001    Amniocentesis, therapeutic            T             T         0192       4.1597       184.19       423.25       485.02
59012    Fetal cord puncture,prenatal          T             T         0198       1.3622        60.32       138.60       158.83
59015    Chorion biopsy                        T             T         0198       1.3622        60.32       138.60       158.83
59020    Fetal contract stress test            T             T         0192       4.1597       184.19       423.25       485.02
59025    Fetal non-stress test                 T             T         0198       1.3622        60.32       138.60       158.83
59030    Fetal scalp blood sample              T             T         0198       1.3622        60.32       138.60       158.83
59050    Fetal monitor w/report                M             1         0000       0.0000        0.00         0.00         0.00
59051    Fetal monitor/interpret only          B             1         0000       0.0000        0.00         0.00         0.00
59070    Transabdom amnioinfus w/us            T             T         0198       1.3622        60.32       138.60       158.83
59072    Umbilical cord occlud w/us            T             T         0198       1.3622        60.32       138.60       158.83
59074    Fetal fluid drainage w/us             T             T         0198       1.3622        60.32       138.60       158.83
59076    Fetal shunt placement, w/us           T             T         0198       1.3622        60.32       138.60       158.83
59100    Remove uterus lesion                  T             T         0195      26.7972      1,186.58     2,726.62     3,124.55
59120    Treat ectopic pregnancy               C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  81 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

59121    Treat ectopic pregnancy               C             C         0000       0.0000        0.00         0.00         0.00
59130    Treat ectopic pregnancy               C             C         0000       0.0000        0.00         0.00         0.00
59135    Treat ectopic pregnancy               C             C         0000       0.0000        0.00         0.00         0.00
59136    Treat ectopic pregnancy               C             C         0000       0.0000        0.00         0.00         0.00
59140    Treat ectopic pregnancy               C             C         0000       0.0000        0.00         0.00         0.00
59150    Treat ectopic pregnancy               T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
59151    Treat ectopic pregnancy               T             T         0131      43.0498      1,906.25     4,380.32     5,019.61
59160    D & c after delivery                  T             T         0196      17.0012       752.81      1,729.87     1,982.34
59200    Insert cervical dilator               T             T         0189       2.3805       105.41       242.22       277.57
59300    Episiotomy or vaginal repair          T             T         0193      14.6385       648.19      1,489.47     1,706.85
59320    Revision of cervix                    T             T         0194      20.6573       914.71      2,101.88     2,408.64
59325    Revision of cervix                    C             C         0000       0.0000        0.00         0.00         0.00
59350    Repair of uterus                      C             C         0000       0.0000        0.00         0.00         0.00
59400    Obstetrical care                      B             1         0000       0.0000        0.00         0.00         0.00
59409    Obstetrical care                      T             T         0194      20.6573       914.71      2,101.88     2,408.64
59410    Obstetrical care                      B             1         0000       0.0000        0.00         0.00         0.00
59412    Antepartum manipulation               T             T         0700       4.1398       183.31       421.22       482.70
59414    Deliver placenta                      T             T         0193      14.6385       648.19      1,489.47     1,706.85
59425    Antepartum care only                  B             1         0000       0.0000        0.00         0.00         0.00
59426    Antepartum care only                  B             1         0000       0.0000        0.00         0.00         0.00
59430    Care after delivery                   B             1         0000       0.0000        0.00         0.00         0.00
59510    Cesarean delivery                     B             1         0000       0.0000        0.00         0.00         0.00
59514    Cesarean delivery only                C             C         0000       0.0000        0.00         0.00         0.00
59515    Cesarean delivery                     E             1         0000       0.0000        0.00         0.00         0.00
59525    Remove uterus after cesarean          C             C         0000       0.0000        0.00         0.00         0.00
59610    Vbac delivery                         E             1         0000       0.0000        0.00         0.00         0.00
59612    Vbac delivery only                    T             T         0194      20.6573       914.71      2,101.88     2,408.64
59614    Vbac care after delivery              E             1         0000       0.0000        0.00         0.00         0.00
59618    Attempted vbac delivery               E             1         0000       0.0000        0.00         0.00         0.00
59620    Attempted vbac delivery only          C             C         0000       0.0000        0.00         0.00         0.00
59622    Attempted vbac after care             E             1         0000       0.0000        0.00         0.00         0.00
59812    Treatment of miscarriage              T             T         0201      17.4749       773.79      1,778.07     2,037.57
59820    Care of miscarriage                   T             T         0201      17.4749       773.79      1,778.07     2,037.57
59821    Treatment of miscarriage              T             T         0201      17.4749       773.79      1,778.07     2,037.57
59830    Treat uterus infection                C             C         0000       0.0000        0.00         0.00         0.00
59840    Abortion                              T             T         0200      18.9518       839.19      1,928.35     2,209.78
59841    Abortion                              T             T         0200      18.9518       839.19      1,928.35     2,209.78
59850    Abortion                              C             C         0000       0.0000        0.00         0.00         0.00
59851    Abortion                              C             C         0000       0.0000        0.00         0.00         0.00
59852    Abortion                              C             C         0000       0.0000        0.00         0.00         0.00
59855    Abortion                              C             C         0000       0.0000        0.00         0.00         0.00
59856    Abortion                              C             C         0000       0.0000        0.00         0.00         0.00
59857    Abortion                              C             C         0000       0.0000        0.00         0.00         0.00
59866    Abortion (mpr)                        T             T         0198       1.3622        60.32       138.60       158.83
59870    Evacuate mole of uterus               T             T         0201      17.4749       773.79      1,778.07     2,037.57
59871    Remove cerclage suture                T             T         0194      20.6573       914.71      2,101.88     2,408.64
59897    Fetal invas px w/us                   T             1         0000       0.0000        0.00         0.00         0.00
59898    Laparo proc, ob care/deliver          T             1         0000       0.0000        0.00         0.00         0.00
59899    Maternity care procedure              T             1         0000       0.0000        0.00         0.00         0.00
60000    Drain thyroid/tongue cyst             T             T         0252       8.1033       358.81       824.51       944.84
60001    Aspirate/inject thyriod cyst          T             T         0004       1.7771        78.69       180.82       207.21
60100    Biopsy of thyroid                     T             T         0004       1.7771        78.69       180.82       207.21
60200    Remove thyroid lesion                 T             T         0114      40.4596      1,791.55     4,116.76     4,717.59
60210    Partial thyroid excision              T             T         0114      40.4596      1,791.55     4,116.76     4,717.59
60212    Partial thyroid excision              T             T         0114      40.4596      1,791.55     4,116.76     4,717.59
60220    Partial removal of thyroid            T             T         0114      40.4596      1,791.55     4,116.76     4,717.59
60225    Partial removal of thyroid            T             T         0114      40.4596      1,791.55     4,116.76     4,717.59
60240    Removal of thyroid                    T             T         0114      40.4596      1,791.55     4,116.76     4,717.59


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  82 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

60252    Removal of thyroid                    T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
60254    Extensive thyroid surgery             C             C         0000       0.0000        0.00         0.00         0.00
60260    Repeat thyroid surgery                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
60270    Removal of thyroid                    C             C         0000       0.0000        0.00         0.00         0.00
60271    Removal of thyroid                    C             C         0000       0.0000        0.00         0.00         0.00
60280    Remove thyroid duct lesion            T             T         0114      40.4596      1,791.55     4,116.76     4,717.59
60281    Remove thyroid duct lesion            T             T         0114      40.4596      1,791.55     4,116.76     4,717.59
60500    Explore parathyroid glands            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
60502    Re-explore parathyroids               C             C         0000       0.0000        0.00         0.00         0.00
60505    Explore parathyroid glands            C             C         0000       0.0000        0.00         0.00         0.00
60512    Autotransplant parathyroid            T             1         0000       0.0000        0.00         0.00         0.00
60520    Removal of thymus gland               C             C         0000       0.0000        0.00         0.00         0.00
60521    Removal of thymus gland               C             C         0000       0.0000        0.00         0.00         0.00
60522    Removal of thymus gland               C             C         0000       0.0000        0.00         0.00         0.00
60540    Explore adrenal gland                 C             C         0000       0.0000        0.00         0.00         0.00
60545    Explore adrenal gland                 C             C         0000       0.0000        0.00         0.00         0.00
60600    Remove carotid body lesion            C             C         0000       0.0000        0.00         0.00         0.00
60605    Remove carotid body lesion            C             C         0000       0.0000        0.00         0.00         0.00
60650    Laparoscopy adrenalectomy             C             C         0000       0.0000        0.00         0.00         0.00
60659    Laparo proc, endocrine                T             1         0000       0.0000        0.00         0.00         0.00
60699    Endocrine surgery procedure           T             1         0000       0.0000        0.00         0.00         0.00
61000    Remove cranial cavity fluid           T             T         0212       2.7712       122.71       281.97       323.12
61001    Remove cranial cavity fluid           T             T         0212       2.7712       122.71       281.97       323.12
61020    Remove brain cavity fluid             T             T         0212       2.7712       122.71       281.97       323.12
61026    Injection into brain canal            T             T         0212       2.7712       122.71       281.97       323.12
61050    Remove brain canal fluid              T             T         0212       2.7712       122.71       281.97       323.12
61055    Injection into brain canal            T             T         0212       2.7712       122.71       281.97       323.12
61070    Brain canal shunt procedure           T             T         0212       2.7712       122.71       281.97       323.12
61105    Twist drill hole                      C             C         0000       0.0000        0.00         0.00         0.00
61107    Drill skull for implantation          C             C         0000       0.0000        0.00         0.00         0.00
61108    Drill skull for drainage              C             C         0000       0.0000        0.00         0.00         0.00
61120    Burr hole for puncture                C             C         0000       0.0000        0.00         0.00         0.00
61140    Pierce skull for biopsy               C             C         0000       0.0000        0.00         0.00         0.00
61150    Pierce skull for drainage             C             C         0000       0.0000        0.00         0.00         0.00
61151    Pierce skull for drainage             C             C         0000       0.0000        0.00         0.00         0.00
61154    Pierce skull & remove clot            C             C         0000       0.0000        0.00         0.00         0.00
61156    Pierce skull for drainage             C             C         0000       0.0000        0.00         0.00         0.00
61210    Pierce skull, implant device          C             C         0000       0.0000        0.00         0.00         0.00
61215    Insert brain-fluid device             T             T         0224      41.1421      1,821.77     4,186.21     4,797.17
61250    Pierce skull & explore                C             C         0000       0.0000        0.00         0.00         0.00
61253    Pierce skull & explore                C             C         0000       0.0000        0.00         0.00         0.00
61304    Open skull for exploration            C             C         0000       0.0000        0.00         0.00         0.00
61305    Open skull for exploration            C             C         0000       0.0000        0.00         0.00         0.00
61312    Open skull for drainage               C             C         0000       0.0000        0.00         0.00         0.00
61313    Open skull for drainage               C             C         0000       0.0000        0.00         0.00         0.00
61314    Open skull for drainage               C             C         0000       0.0000        0.00         0.00         0.00
61315    Open skull for drainage               C             C         0000       0.0000        0.00         0.00         0.00
61316    Implt cran bone flap to abdo          C             C         0000       0.0000        0.00         0.00         0.00
61320    Open skull for drainage               C             C         0000       0.0000        0.00         0.00         0.00
61321    Open skull for drainage               C             C         0000       0.0000        0.00         0.00         0.00
61322    Decompressive craniotomy              C             C         0000       0.0000        0.00         0.00         0.00
61323    Decompressive lobectomy               C             C         0000       0.0000        0.00         0.00         0.00
61330    Decompress eye socket                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
61332    Explore/biopsy eye socket             C             C         0000       0.0000        0.00         0.00         0.00
61333    Explore orbit/remove lesion           C             C         0000       0.0000        0.00         0.00         0.00
61334    Explore orbit/remove object           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
61340    Subtemporal decompression             C             C         0000       0.0000        0.00         0.00         0.00
61343    Incise skull (press relief)           C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  83 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

61345    Relieve cranial pressure              C             C         0000       0.0000        0.00         0.00         0.00
61440    Incise skull for surgery              C             C         0000       0.0000        0.00         0.00         0.00
61450    Incise skull for surgery              C             C         0000       0.0000        0.00         0.00         0.00
61458    Incise skull for brain wound          C             C         0000       0.0000        0.00         0.00         0.00
61460    Incise skull for surgery              C             C         0000       0.0000        0.00         0.00         0.00
61470    Incise skull for surgery              C             C         0000       0.0000        0.00         0.00         0.00
61480    Incise skull for surgery              C             C         0000       0.0000        0.00         0.00         0.00
61490    Incise skull for surgery              C             C         0000       0.0000        0.00         0.00         0.00
61500    Removal of skull lesion               C             C         0000       0.0000        0.00         0.00         0.00
61501    Remove infected skull bone            C             C         0000       0.0000        0.00         0.00         0.00
61510    Removal of brain lesion               C             C         0000       0.0000        0.00         0.00         0.00
61512    Remove brain lining lesion            C             C         0000       0.0000        0.00         0.00         0.00
61514    Removal of brain abscess              C             C         0000       0.0000        0.00         0.00         0.00
61516    Removal of brain lesion               C             C         0000       0.0000        0.00         0.00         0.00
61517    Implt brain chemotx add-on            C             C         0000       0.0000        0.00         0.00         0.00
61518    Removal of brain lesion               C             C         0000       0.0000        0.00         0.00         0.00
61519    Remove brain lining lesion            C             C         0000       0.0000        0.00         0.00         0.00
61520    Removal of brain lesion               C             C         0000       0.0000        0.00         0.00         0.00
61521    Removal of brain lesion               C             C         0000       0.0000        0.00         0.00         0.00
61522    Removal of brain abscess              C             C         0000       0.0000        0.00         0.00         0.00
61524    Removal of brain lesion               C             C         0000       0.0000        0.00         0.00         0.00
61526    Removal of brain lesion               C             C         0000       0.0000        0.00         0.00         0.00
61530    Removal of brain lesion               C             C         0000       0.0000        0.00         0.00         0.00
61531    Implant brain electrodes              C             C         0000       0.0000        0.00         0.00         0.00
61533    Implant brain electrodes              C             C         0000       0.0000        0.00         0.00         0.00
61534    Removal of brain lesion               C             C         0000       0.0000        0.00         0.00         0.00
61535    Remove brain electrodes               C             C         0000       0.0000        0.00         0.00         0.00
61536    Removal of brain lesion               C             C         0000       0.0000        0.00         0.00         0.00
61537    Removal of brain tissue               C             C         0000       0.0000        0.00         0.00         0.00
61538    Removal of brain tissue               C             C         0000       0.0000        0.00         0.00         0.00
61539    Removal of brain tissue               C             C         0000       0.0000        0.00         0.00         0.00
61540    Removal of brain tissue               C             C         0000       0.0000        0.00         0.00         0.00
61541    Incision of brain tissue              C             C         0000       0.0000        0.00         0.00         0.00
61542    Removal of brain tissue               C             C         0000       0.0000        0.00         0.00         0.00
61543    Removal of brain tissue               C             C         0000       0.0000        0.00         0.00         0.00
61544    Remove & treat brain lesion           C             C         0000       0.0000        0.00         0.00         0.00
61545    Excision of brain tumor               C             C         0000       0.0000        0.00         0.00         0.00
61546    Removal of pituitary gland            C             C         0000       0.0000        0.00         0.00         0.00
61548    Removal of pituitary gland            C             C         0000       0.0000        0.00         0.00         0.00
61550    Release of skull seams                C             C         0000       0.0000        0.00         0.00         0.00
61552    Release of skull seams                C             C         0000       0.0000        0.00         0.00         0.00
61556    Incise skull/sutures                  C             C         0000       0.0000        0.00         0.00         0.00
61557    Incise skull/sutures                  C             C         0000       0.0000        0.00         0.00         0.00
61558    Excision of skull/sutures             C             C         0000       0.0000        0.00         0.00         0.00
61559    Excision of skull/sutures             C             C         0000       0.0000        0.00         0.00         0.00
61563    Excision of skull tumor               C             C         0000       0.0000        0.00         0.00         0.00
61564    Excision of skull tumor               C             C         0000       0.0000        0.00         0.00         0.00
61566    Removal of brain tissue               C             C         0000       0.0000        0.00         0.00         0.00
61567    Incision of brain tissue              C             C         0000       0.0000        0.00         0.00         0.00
61570    Remove foreign body, brain            C             C         0000       0.0000        0.00         0.00         0.00
61571    Incise skull for brain wound          C             C         0000       0.0000        0.00         0.00         0.00
61575    Skull base/brainstem surgery          C             C         0000       0.0000        0.00         0.00         0.00
61576    Skull base/brainstem surgery          C             C         0000       0.0000        0.00         0.00         0.00
61580    Craniofacial approach, skull          C             C         0000       0.0000        0.00         0.00         0.00
61581    Craniofacial approach, skull          C             C         0000       0.0000        0.00         0.00         0.00
61582    Craniofacial approach, skull          C             C         0000       0.0000        0.00         0.00         0.00
61583    Craniofacial approach, skull          C             C         0000       0.0000        0.00         0.00         0.00
61584    Orbitocranial approach/skull          C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  84 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

61585    Orbitocranial approach/skull          C             C         0000       0.0000        0.00         0.00         0.00
61586    Resect nasopharynx, skull             C             C         0000       0.0000        0.00         0.00         0.00
61590    Infratemporal approach/skull          C             C         0000       0.0000        0.00         0.00         0.00
61591    Infratemporal approach/skull          C             C         0000       0.0000        0.00         0.00         0.00
61592    Orbitocranial approach/skull          C             C         0000       0.0000        0.00         0.00         0.00
61595    Transtemporal approach/skull          C             C         0000       0.0000        0.00         0.00         0.00
61596    Transcochlear approach/skull          C             C         0000       0.0000        0.00         0.00         0.00
61597    Transcondylar approach/skull          C             C         0000       0.0000        0.00         0.00         0.00
61598    Transpetrosal approach/skull          C             C         0000       0.0000        0.00         0.00         0.00
61600    Resect/excise cranial lesion          C             C         0000       0.0000        0.00         0.00         0.00
61601    Resect/excise cranial lesion          C             C         0000       0.0000        0.00         0.00         0.00
61605    Resect/excise cranial lesion          C             C         0000       0.0000        0.00         0.00         0.00
61606    Resect/excise cranial lesion          C             C         0000       0.0000        0.00         0.00         0.00
61607    Resect/excise cranial lesion          C             C         0000       0.0000        0.00         0.00         0.00
61608    Resect/excise cranial lesion          C             C         0000       0.0000        0.00         0.00         0.00
61609    Transect artery, sinus                C             C         0000       0.0000        0.00         0.00         0.00
61610    Transect artery, sinus                C             C         0000       0.0000        0.00         0.00         0.00
61611    Transect artery, sinus                C             C         0000       0.0000        0.00         0.00         0.00
61612    Transect artery, sinus                C             C         0000       0.0000        0.00         0.00         0.00
61613    Remove aneurysm, sinus                C             C         0000       0.0000        0.00         0.00         0.00
61615    Resect/excise lesion, skull           C             C         0000       0.0000        0.00         0.00         0.00
61616    Resect/excise lesion, skull           C             C         0000       0.0000        0.00         0.00         0.00
61618    Repair dura                           C             C         0000       0.0000        0.00         0.00         0.00
61619    Repair dura                           C             C         0000       0.0000        0.00         0.00         0.00
61623    Endovasc tempory vessel occl          T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
61624    Transcath occlusion, cns              C             C         0000       0.0000        0.00         0.00         0.00
61626    Transcath occlusion, non-cns          T             T         0081      42.2664      1,871.56     4,300.61     4,928.26
61630    Intracranial angioplasty              B             1         0000       0.0000        0.00         0.00         0.00
61635    Intracran angioplsty w/stent          B             1         0000       0.0000        0.00         0.00         0.00
61640    Dilate ic vasospasm, init             B             1         0000       0.0000        0.00         0.00         0.00
61641    Dilate ic vasospasm add-on            B             1         0000       0.0000        0.00         0.00         0.00
61642    Dilate ic vasospasm add-on            B             1         0000       0.0000        0.00         0.00         0.00
61680    Intracranial vessel surgery           C             C         0000       0.0000        0.00         0.00         0.00
61682    Intracranial vessel surgery           C             C         0000       0.0000        0.00         0.00         0.00
61684    Intracranial vessel surgery           C             C         0000       0.0000        0.00         0.00         0.00
61686    Intracranial vessel surgery           C             C         0000       0.0000        0.00         0.00         0.00
61690    Intracranial vessel surgery           C             C         0000       0.0000        0.00         0.00         0.00
61692    Intracranial vessel surgery           C             C         0000       0.0000        0.00         0.00         0.00
61697    Brain aneurysm repr, complx           C             C         0000       0.0000        0.00         0.00         0.00
61698    Brain aneurysm repr, complx           C             C         0000       0.0000        0.00         0.00         0.00
61700    Brain aneurysm repr, simple           C             C         0000       0.0000        0.00         0.00         0.00
61702    Inner skull vessel surgery            C             C         0000       0.0000        0.00         0.00         0.00
61703    Clamp neck artery                     C             C         0000       0.0000        0.00         0.00         0.00
61705    Revise circulation to head            C             C         0000       0.0000        0.00         0.00         0.00
61708    Revise circulation to head            C             C         0000       0.0000        0.00         0.00         0.00
61710    Revise circulation to head            C             C         0000       0.0000        0.00         0.00         0.00
61711    Fusion of skull arteries              C             C         0000       0.0000        0.00         0.00         0.00
61720    Incise skull/brain surgery            C             C         0000       0.0000        0.00         0.00         0.00
61735    Incise skull/brain surgery            C             C         0000       0.0000        0.00         0.00         0.00
61750    Incise skull/brain biopsy             C             C         0000       0.0000        0.00         0.00         0.00
61751    Brain biopsy w/ct/mr guide            C             C         0000       0.0000        0.00         0.00         0.00
61760    Implant brain electrodes              C             C         0000       0.0000        0.00         0.00         0.00
61770    Incise skull for treatment            C             C         0000       0.0000        0.00         0.00         0.00
61790    Treat trigeminal nerve                T             T         0220      17.3203       766.94      1,762.34     2,019.55
61791    Treat trigeminal tract                T             T         0206       5.4011       239.16       549.56       629.77
61793    Focus radiation beam                  E             1         0000       0.0000        0.00         0.00         0.00
61795    Brain surgery using computer          S             S         0302       4.6992       208.08       478.14       547.93
61850    Implant neuroelectrodes               C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  85 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

61860    Implant neuroelectrodes               C             C         0000       0.0000        0.00         0.00         0.00
61863    Implant neuroelectrode                C             C         0000       0.0000        0.00         0.00         0.00
61864    Implant neuroelectrde, add’l          C             C         0000       0.0000        0.00         0.00         0.00
61867    Implant neuroelectrode                C             C         0000       0.0000        0.00         0.00         0.00
61868    Implant neuroelectrde, add’l          C             C         0000       0.0000        0.00         0.00         0.00
61870    Implant neuroelectrodes               C             C         0000       0.0000        0.00         0.00         0.00
61875    Implant neuroelectrodes               C             C         0000       0.0000        0.00         0.00         0.00
61880    Revise/remove neuroelectrode          T             T         0687      19.1962       850.01      1,953.21     2,238.28
61885    Insrt/redo neurostim 1 array          S             S         0039      194.9690     8,633.23    19,838.10    22,733.39
61886    Implant neurostim arrays              T             T         0315      312.3876     13,832.52   31,785.44    36,424.39
61888    Revise/remove neuroreceiver           T             T         0688      42.8588      1,897.79     4,360.88     4,997.34
62000    Treat skull fracture                  C             C         0000       0.0000        0.00         0.00         0.00
62005    Treat skull fracture                  C             C         0000       0.0000        0.00         0.00         0.00
62010    Treatment of head injury              C             C         0000       0.0000        0.00         0.00         0.00
62100    Repair brain fluid leakage            C             C         0000       0.0000        0.00         0.00         0.00
62115    Reduction of skull defect             C             C         0000       0.0000        0.00         0.00         0.00
62116    Reduction of skull defect             C             C         0000       0.0000        0.00         0.00         0.00
62117    Reduction of skull defect             C             C         0000       0.0000        0.00         0.00         0.00
62120    Repair skull cavity lesion            C             C         0000       0.0000        0.00         0.00         0.00
62121    Incise skull repair                   C             C         0000       0.0000        0.00         0.00         0.00
62140    Repair of skull defect                C             C         0000       0.0000        0.00         0.00         0.00
62141    Repair of skull defect                C             C         0000       0.0000        0.00         0.00         0.00
62142    Remove skull plate/flap               C             C         0000       0.0000        0.00         0.00         0.00
62143    Replace skull plate/flap              C             C         0000       0.0000        0.00         0.00         0.00
62145    Repair of skull & brain               C             C         0000       0.0000        0.00         0.00         0.00
62146    Repair of skull with graft            C             C         0000       0.0000        0.00         0.00         0.00
62147    Repair of skull with graft            C             C         0000       0.0000        0.00         0.00         0.00
62148    Retr bone flap to fix skull           C             C         0000       0.0000        0.00         0.00         0.00
62160    Neuroendoscopy add-on                 T             T         0122       6.9179       306.32       703.90       806.63
62161    Dissect brain w/scope                 C             C         0000       0.0000        0.00         0.00         0.00
62162    Remove colloid cyst w/scope           C             C         0000       0.0000        0.00         0.00         0.00
62163    Neuroendoscopy w/fb removal           C             C         0000       0.0000        0.00         0.00         0.00
62164    Remove brain tumor w/scope            C             C         0000       0.0000        0.00         0.00         0.00
62165    Remove pituit tumor w/scope           C             C         0000       0.0000        0.00         0.00         0.00
62180    Establish brain cavity shunt          C             C         0000       0.0000        0.00         0.00         0.00
62190    Establish brain cavity shunt          C             C         0000       0.0000        0.00         0.00         0.00
62192    Establish brain cavity shunt          C             C         0000       0.0000        0.00         0.00         0.00
62194    Replace/irrigate catheter             T             T         0427      10.0109       443.28      1,018.61     1,167.27
62200    Establish brain cavity shunt          C             C         0000       0.0000        0.00         0.00         0.00
62201    Brain cavity shunt w/scope            C             C         0000       0.0000        0.00         0.00         0.00
62220    Establish brain cavity shunt          C             C         0000       0.0000        0.00         0.00         0.00
62223    Establish brain cavity shunt          C             C         0000       0.0000        0.00         0.00         0.00
62225    Replace/irrigate catheter             T             T         0427      10.0109       443.28      1,018.61     1,167.27
62230    Replace/revise brain shunt            T             T         0224      41.1421      1,821.77     4,186.21     4,797.17
62252    Csf shunt reprogram                   S             S         0691       2.5464       112.75       259.10       296.91
62256    Remove brain cavity shunt             C             C         0000       0.0000        0.00         0.00         0.00
62258    Replace brain cavity shunt            C             C         0000       0.0000        0.00         0.00         0.00
62263    Epidural lysis mult sessions          T             T         0203      10.0965       447.07      1,027.32     1,177.25
62264    Epidural lysis on single day          T             T         0203      10.0965       447.07      1,027.32     1,177.25
62268    Drain spinal cord cyst                T             T         0212       2.7712       122.71       281.97       323.12
62269    Needle biopsy, spinal cord            T             T         0685       6.0034       265.83       610.85       700.00
62270    Spinal fluid tap, diagnostic          T             T         0204       2.2667       100.37       230.64       264.30
62272    Drain cerebro spinal fluid            T             T         0204       2.2667       100.37       230.64       264.30
62273    Inject epidural patch                 T             T         0206       5.4011       239.16       549.56       629.77
62280    Treat spinal cord lesion              T             T         0207       6.0140       266.30       611.92       701.23
62281    Treat spinal cord lesion              T             T         0207       6.0140       266.30       611.92       701.23
62282    Treat spinal canal lesion             T             T         0207       6.0140       266.30       611.92       701.23
62284    Injection for myelogram               N             N         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  86 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

62287    Percutaneous diskectomy               T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
62290    Inject for spine disk x-ray           N             N         0000       0.0000        0.00         0.00         0.00
62291    Inject for spine disk x-ray           N             N         0000       0.0000        0.00         0.00         0.00
62292    Injection into disk lesion            T             T         0212       2.7712       122.71       281.97       323.12
62294    Injection into spinal artery          T             T         0212       2.7712       122.71       281.97       323.12
62310    Inject spine c/t                      T             T         0207       6.0140       266.30       611.92       701.23
62311    Inject spine l/s (cd)                 T             T         0207       6.0140       266.30       611.92       701.23
62318    Inject spine w/cath, c/t              T             T         0207       6.0140       266.30       611.92       701.23
62319    Inject spine w/cath l/s (cd)          T             T         0207       6.0140       266.30       611.92       701.23
62350    Implant spinal canal cath             T             T         0223      28.5636      1,264.80     2,906.35     3,330.52
62351    Implant spinal canal cath             T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
62355    Remove spinal canal catheter          T             T         0203      10.0965       447.07      1,027.32     1,177.25
62360    Insert spine infusion device          T             T         0226      72.5804      3,213.86     7,385.06     8,462.87
62361    Implant spine infusion pump           T             T         0227      155.0431     6,865.31    15,775.64    18,078.03
62362    Implant spine infusion pump           T             T         0227      155.0431     6,865.31    15,775.64    18,078.03
62365    Remove spine infusion device          T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
62367    Analyze spine infusion pump           S             S         0691       2.5464       112.75       259.10       296.91
62368    Analyze spine infusion pump           S             S         0691       2.5464       112.75       259.10       296.91
63001    Removal of spinal lamina              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63003    Removal of spinal lamina              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63005    Removal of spinal lamina              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63011    Removal of spinal lamina              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63012    Removal of spinal lamina              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63015    Removal of spinal lamina              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63016    Removal of spinal lamina              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63017    Removal of spinal lamina              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63020    Neck spine disk surgery               T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63030    Low back disk surgery                 T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63035    Spinal disk surgery add-on            T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63040    Laminotomy, single cervical           T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63042    Laminotomy, single lumbar             T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63043    Laminotomy, add’l cervical            C             C         0000       0.0000        0.00         0.00         0.00
63044    Laminotomy, add’l lumbar              C             C         0000       0.0000        0.00         0.00         0.00
63045    Removal of spinal lamina              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63046    Removal of spinal lamina              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63047    Removal of spinal lamina              T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63048    Remove spinal lamina add-on           T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63050    Cervical laminoplasty                 C             C         0000       0.0000        0.00         0.00         0.00
63051    C-laminoplasty w/graft/plate          C             C         0000       0.0000        0.00         0.00         0.00
63055    Decompress spinal cord                T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63056    Decompress spinal cord                T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63057    Decompress spine cord add-on          T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63064    Decompress spinal cord                T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63066    Decompress spine cord add-on          T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63075    Neck spine disk surgery               T             T         0208      42.5200      1,882.79     4,326.41     4,957.83
63076    Neck spine disk surgery               C             C         0000       0.0000        0.00         0.00         0.00
63077    Spine disk surgery, thorax            C             C         0000       0.0000        0.00         0.00         0.00
63078    Spine disk surgery, thorax            C             C         0000       0.0000        0.00         0.00         0.00
63081    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63082    Remove vertebral body add-on          C             C         0000       0.0000        0.00         0.00         0.00
63085    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63086    Remove vertebral body add-on          C             C         0000       0.0000        0.00         0.00         0.00
63087    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63088    Remove vertebral body add-on          C             C         0000       0.0000        0.00         0.00         0.00
63090    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63091    Remove vertebral body add-on          C             C         0000       0.0000        0.00         0.00         0.00
63101    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63102    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  87 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

63103    Remove vertebral body add-on          C             C         0000       0.0000        0.00         0.00         0.00
63170    Incise spinal cord tract(s)           C             C         0000       0.0000        0.00         0.00         0.00
63172    Drainage of spinal cyst               C             C         0000       0.0000        0.00         0.00         0.00
63173    Drainage of spinal cyst               C             C         0000       0.0000        0.00         0.00         0.00
63180    Revise spinal cord ligaments          C             C         0000       0.0000        0.00         0.00         0.00
63182    Revise spinal cord ligaments          C             C         0000       0.0000        0.00         0.00         0.00
63185    Incise spinal column/nerves           C             C         0000       0.0000        0.00         0.00         0.00
63190    Incise spinal column/nerves           C             C         0000       0.0000        0.00         0.00         0.00
63191    Incise spinal column/nerves           C             C         0000       0.0000        0.00         0.00         0.00
63194    Incise spinal column & cord           C             C         0000       0.0000        0.00         0.00         0.00
63195    Incise spinal column & cord           C             C         0000       0.0000        0.00         0.00         0.00
63196    Incise spinal column & cord           C             C         0000       0.0000        0.00         0.00         0.00
63197    Incise spinal column & cord           C             C         0000       0.0000        0.00         0.00         0.00
63198    Incise spinal column & cord           C             C         0000       0.0000        0.00         0.00         0.00
63199    Incise spinal column & cord           C             C         0000       0.0000        0.00         0.00         0.00
63200    Release of spinal cord                C             C         0000       0.0000        0.00         0.00         0.00
63250    Revise spinal cord vessels            C             C         0000       0.0000        0.00         0.00         0.00
63251    Revise spinal cord vessels            C             C         0000       0.0000        0.00         0.00         0.00
63252    Revise spinal cord vessels            C             C         0000       0.0000        0.00         0.00         0.00
63265    Excise intraspinal lesion             C             C         0000       0.0000        0.00         0.00         0.00
63266    Excise intraspinal lesion             C             C         0000       0.0000        0.00         0.00         0.00
63267    Excise intraspinal lesion             C             C         0000       0.0000        0.00         0.00         0.00
63268    Excise intraspinal lesion             C             C         0000       0.0000        0.00         0.00         0.00
63270    Excise intraspinal lesion             C             C         0000       0.0000        0.00         0.00         0.00
63271    Excise intraspinal lesion             C             C         0000       0.0000        0.00         0.00         0.00
63272    Excise intraspinal lesion             C             C         0000       0.0000        0.00         0.00         0.00
63273    Excise intraspinal lesion             C             C         0000       0.0000        0.00         0.00         0.00
63275    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63276    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63277    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63278    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63280    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63281    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63282    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63283    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63285    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63286    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63287    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63290    Biopsy/excise spinal tumor            C             C         0000       0.0000        0.00         0.00         0.00
63295    Repair of laminectomy defect          C             C         0000       0.0000        0.00         0.00         0.00
63300    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63301    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63302    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63303    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63304    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63305    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63306    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63307    Removal of vertebral body             C             C         0000       0.0000        0.00         0.00         0.00
63308    Remove vertebral body add-on          C             C         0000       0.0000        0.00         0.00         0.00
63600    Remove spinal cord lesion             T             T         0220      17.3203       766.94      1,762.34     2,019.55
63610    Stimulation of spinal cord            T             T         0220      17.3203       766.94      1,762.34     2,019.55
63615    Remove lesion of spinal cord          T             T         0220      17.3203       766.94      1,762.34     2,019.55
63650    Implant neuroelectrodes               S             S         0040      50.8322      2,250.85     5,172.18     5,927.03
63655    Implant neuroelectrodes               S             S         0061      93.4063      4,136.03     9,504.09    10,891.17
63660    Revise/remove neuroelectrode          T             T         0687      19.1962       850.01      1,953.21     2,238.28
63685    Insrt/redo spine n generator          T             T         0222      192.4950     8,523.68    19,586.37    22,444.92
63688    Revise/remove neuroreceiver           T             T         0688      42.8588      1,897.79     4,360.88     4,997.34
63700    Repair of spinal herniation           C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  88 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

63702    Repair of spinal herniation           C             C         0000       0.0000        0.00         0.00         0.00
63704    Repair of spinal herniation           C             C         0000       0.0000        0.00         0.00         0.00
63706    Repair of spinal herniation           C             C         0000       0.0000        0.00         0.00         0.00
63707    Repair spinal fluid leakage           C             C         0000       0.0000        0.00         0.00         0.00
63709    Repair spinal fluid leakage           C             C         0000       0.0000        0.00         0.00         0.00
63710    Graft repair of spine defect          C             C         0000       0.0000        0.00         0.00         0.00
63740    Install spinal shunt                  C             C         0000       0.0000        0.00         0.00         0.00
63741    Install spinal shunt                  T             T         0228      46.4126      2,055.15     4,722.48     5,411.71
63744    Revision of spinal shunt              T             T         0228      46.4126      2,055.15     4,722.48     5,411.71
63746    Removal of spinal shunt               T             T         0109      11.1714       494.67      1,136.69     1,302.59
64400    N block inj, trigeminal               T             T         0204       2.2667       100.37       230.64       264.30
64402    N block inj, facial                   T             T         0204       2.2667       100.37       230.64       264.30
64405    N block inj, occipital                T             T         0204       2.2667       100.37       230.64       264.30
64408    N block inj, vagus                    T             T         0204       2.2667       100.37       230.64       264.30
64410    N block inj, phrenic                  T             T         0206       5.4011       239.16       549.56       629.77
64412    N block inj, spinal accessor          T             T         0206       5.4011       239.16       549.56       629.77
64413    N block inj, cervical plexus          T             T         0204       2.2667       100.37       230.64       264.30
64415    N block inj, brachial plexus          T             T         0204       2.2667       100.37       230.64       264.30
64416    N block cont infuse, b plex           T             T         0204       2.2667       100.37       230.64       264.30
64417    N block inj, axillary                 T             T         0204       2.2667       100.37       230.64       264.30
64418    N block inj, suprascapular            T             T         0204       2.2667       100.37       230.64       264.30
64420    N block inj, intercost, sng           T             T         0204       2.2667       100.37       230.64       264.30
64421    N block inj, intercost, mlt           T             T         0206       5.4011       239.16       549.56       629.77
64425    N block inj, ilio-ing/hypogi          T             T         0204       2.2667       100.37       230.64       264.30
64430    N block inj, pudendal                 T             T         0204       2.2667       100.37       230.64       264.30
64435    N block inj, paracervical             T             T         0204       2.2667       100.37       230.64       264.30
64445    N block inj, sciatic, sng             T             T         0204       2.2667       100.37       230.64       264.30
64446    N blk inj, sciatic, cont inf          T             T         0206       5.4011       239.16       549.56       629.77
64447    N block inj fem, single               T             T         0204       2.2667       100.37       230.64       264.30
64448    N block inj fem, cont inf             T             T         0204       2.2667       100.37       230.64       264.30
64449    N block inj, lumbar plexus            T             T         0204       2.2667       100.37       230.64       264.30
64450    N block, other peripheral             T             T         0204       2.2667       100.37       230.64       264.30
64470    Inj paravertebral c/t                 T             T         0207       6.0140       266.30       611.92       701.23
64472    Inj paravertebral c/t add-on          T             T         0206       5.4011       239.16       549.56       629.77
64475    Inj paravertebral l/s                 T             T         0207       6.0140       266.30       611.92       701.23
64476    Inj paravertebral l/s add-on          T             T         0206       5.4011       239.16       549.56       629.77
64479    Inj foramen epidural c/t              T             T         0207       6.0140       266.30       611.92       701.23
64480    Inj foramen epidural add-on           T             T         0207       6.0140       266.30       611.92       701.23
64483    Inj foramen epidural l/s              T             T         0207       6.0140       266.30       611.92       701.23
64484    Inj foramen epidural add-on           T             T         0207       6.0140       266.30       611.92       701.23
64505    N block, spenopalatine gangl          T             T         0204       2.2667       100.37       230.64       264.30
64508    N block, carotid sinus s/p            T             T         0204       2.2667       100.37       230.64       264.30
64510    N block, stellate ganglion            T             T         0207       6.0140       266.30       611.92       701.23
64517    N block inj, hypogas plxs             T             T         0204       2.2667       100.37       230.64       264.30
64520    N block, lumbar/thoracic              T             T         0207       6.0140       266.30       611.92       701.23
64530    N block inj, celiac pelus             T             T         0207       6.0140       266.30       611.92       701.23
64550    Apply neurostimulator                 A             3         0000       0.0000         M01         M01          M01
64553    Implant neuroelectrodes               S             S         0225      250.8484     11,107.57   25,523.82    29,248.92
64555    Implant neuroelectrodes               S             S         0040      50.8322      2,250.85     5,172.18     5,927.03
64560    Implant neuroelectrodes               S             S         0040      50.8322      2,250.85     5,172.18     5,927.03
64561    Implant neuroelectrodes               S             S         0040      50.8322      2,250.85     5,172.18     5,927.03
64565    Implant neuroelectrodes               S             S         0040      50.8322      2,250.85     5,172.18     5,927.03
64573    Implant neuroelectrodes               S             S         0225      250.8484     11,107.57   25,523.82    29,248.92
64575    Implant neuroelectrodes               S             S         0061      93.4063      4,136.03     9,504.09    10,891.17
64577    Implant neuroelectrodes               S             S         0061      93.4063      4,136.03     9,504.09    10,891.17
64580    Implant neuroelectrodes               S             S         0061      93.4063      4,136.03     9,504.09    10,891.17
64581    Implant neuroelectrodes               S             S         0061      93.4063      4,136.03     9,504.09    10,891.17
64585    Revise/remove neuroelectrode          T             T         0687      19.1962       850.01      1,953.21     2,238.28


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  89 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

64590    Insrt/redo perph n generator          T             T         0222      192.4950     8,523.68    19,586.37    22,444.92
64595    Revise/remove neuroreceiver           T             T         0688      42.8588      1,897.79     4,360.88     4,997.34
64600    Injection treatment of nerve          T             T         0203      10.0965       447.07      1,027.32     1,177.25
64605    Injection treatment of nerve          T             T         0203      10.0965       447.07      1,027.32     1,177.25
64610    Injection treatment of nerve          T             T         0203      10.0965       447.07      1,027.32     1,177.25
64612    Destroy nerve, face muscle            T             T         0204       2.2667       100.37       230.64       264.30
64613    Destroy nerve, spine muscle           T             T         0204       2.2667       100.37       230.64       264.30
64614    Destroy nerve, extrem musc            T             T         0204       2.2667       100.37       230.64       264.30
64620    Injection treatment of nerve          T             T         0203      10.0965       447.07      1,027.32     1,177.25
64622    Destr paravertebrl nerve l/s          T             T         0203      10.0965       447.07      1,027.32     1,177.25
64623    Destr paravertebral n add-on          T             T         0207       6.0140       266.30       611.92       701.23
64626    Destr paravertebrl nerve c/t          T             T         0203      10.0965       447.07      1,027.32     1,177.25
64627    Destr paravertebral n add-on          T             T         0207       6.0140       266.30       611.92       701.23
64630    Injection treatment of nerve          T             T         0206       5.4011       239.16       549.56       629.77
64640    Injection treatment of nerve          T             T         0206       5.4011       239.16       549.56       629.77
64650    Chemodenerv eccrine glands            T             T         0204       2.2667       100.37       230.64       264.30
64653    Chemodenerv eccrine glands            T             T         0204       2.2667       100.37       230.64       264.30
64680    Injection treatment of nerve          T             T         0207       6.0140       266.30       611.92       701.23
64681    Injection treatment of nerve          T             T         0203      10.0965       447.07      1,027.32     1,177.25
64702    Revise finger/toe nerve               T             T         0220      17.3203       766.94      1,762.34     2,019.55
64704    Revise hand/foot nerve                T             T         0220      17.3203       766.94      1,762.34     2,019.55
64708    Revise arm/leg nerve                  T             T         0220      17.3203       766.94      1,762.34     2,019.55
64712    Revision of sciatic nerve             T             T         0220      17.3203       766.94      1,762.34     2,019.55
64713    Revision of arm nerve(s)              T             T         0220      17.3203       766.94      1,762.34     2,019.55
64714    Revise low back nerve(s)              T             T         0220      17.3203       766.94      1,762.34     2,019.55
64716    Revision of cranial nerve             T             T         0220      17.3203       766.94      1,762.34     2,019.55
64718    Revise ulnar nerve at elbow           T             T         0220      17.3203       766.94      1,762.34     2,019.55
64719    Revise ulnar nerve at wrist           T             T         0220      17.3203       766.94      1,762.34     2,019.55
64721    Carpal tunnel surgery                 T             T         0220      17.3203       766.94      1,762.34     2,019.55
64722    Relieve pressure on nerve(s)          T             T         0220      17.3203       766.94      1,762.34     2,019.55
64726    Release foot/toe nerve                T             T         0220      17.3203       766.94      1,762.34     2,019.55
64727    Internal nerve revision               T             T         0220      17.3203       766.94      1,762.34     2,019.55
64732    Incision of brow nerve                T             T         0220      17.3203       766.94      1,762.34     2,019.55
64734    Incision of cheek nerve               T             T         0220      17.3203       766.94      1,762.34     2,019.55
64736    Incision of chin nerve                T             T         0220      17.3203       766.94      1,762.34     2,019.55
64738    Incision of jaw nerve                 T             T         0220      17.3203       766.94      1,762.34     2,019.55
64740    Incision of tongue nerve              T             T         0220      17.3203       766.94      1,762.34     2,019.55
64742    Incision of facial nerve              T             T         0220      17.3203       766.94      1,762.34     2,019.55
64744    Incise nerve, back of head            T             T         0220      17.3203       766.94      1,762.34     2,019.55
64746    Incise diaphragm nerve                T             T         0220      17.3203       766.94      1,762.34     2,019.55
64752    Incision of vagus nerve               C             C         0000       0.0000        0.00         0.00         0.00
64755    Incision of stomach nerves            C             C         0000       0.0000        0.00         0.00         0.00
64760    Incision of vagus nerve               C             C         0000       0.0000        0.00         0.00         0.00
64761    Incision of pelvis nerve              T             T         0220      17.3203       766.94      1,762.34     2,019.55
64763    Incise hip/thigh nerve                T             T         0220      17.3203       766.94      1,762.34     2,019.55
64766    Incise hip/thigh nerve                T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64771    Sever cranial nerve                   T             T         0220      17.3203       766.94      1,762.34     2,019.55
64772    Incision of spinal nerve              T             T         0220      17.3203       766.94      1,762.34     2,019.55
64774    Remove skin nerve lesion              T             T         0220      17.3203       766.94      1,762.34     2,019.55
64776    Remove digit nerve lesion             T             T         0220      17.3203       766.94      1,762.34     2,019.55
64778    Digit nerve surgery add-on            T             T         0220      17.3203       766.94      1,762.34     2,019.55
64782    Remove limb nerve lesion              T             T         0220      17.3203       766.94      1,762.34     2,019.55
64783    Limb nerve surgery add-on             T             T         0220      17.3203       766.94      1,762.34     2,019.55
64784    Remove nerve lesion                   T             T         0220      17.3203       766.94      1,762.34     2,019.55
64786    Remove sciatic nerve lesion           T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64787    Implant nerve end                     T             T         0220      17.3203       766.94      1,762.34     2,019.55
64788    Remove skin nerve lesion              T             T         0220      17.3203       766.94      1,762.34     2,019.55
64790    Removal of nerve lesion               T             T         0220      17.3203       766.94      1,762.34     2,019.55


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  90 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

64792    Removal of nerve lesion               T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64795    Biopsy of nerve                       T             T         0220      17.3203       766.94      1,762.34     2,019.55
64802    Remove sympathetic nerves             T             T         0220      17.3203       766.94      1,762.34     2,019.55
64804    Remove sympathetic nerves             C             C         0000       0.0000        0.00         0.00         0.00
64809    Remove sympathetic nerves             C             C         0000       0.0000        0.00         0.00         0.00
64818    Remove sympathetic nerves             C             C         0000       0.0000        0.00         0.00         0.00
64820    Remove sympathetic nerves             T             T         0220      17.3203       766.94      1,762.34     2,019.55
64821    Remove sympathetic nerves             T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
64822    Remove sympathetic nerves             T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
64823    Remove sympathetic nerves             T             T         0054      25.1321      1,112.85     2,557.19     2,930.40
64831    Repair of digit nerve                 T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64832    Repair nerve add-on                   T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64834    Repair of hand or foot nerve          T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64835    Repair of hand or foot nerve          T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64836    Repair of hand or foot nerve          T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64837    Repair nerve add-on                   T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64840    Repair of leg nerve                   T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64856    Repair/transpose nerve                T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64857    Repair arm/leg nerve                  T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64858    Repair sciatic nerve                  T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64859    Nerve surgery                         T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64861    Repair of arm nerves                  T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64862    Repair of low back nerves             T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64864    Repair of facial nerve                T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64865    Repair of facial nerve                T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64866    Fusion of facial/other nerve          C             C         0000       0.0000        0.00         0.00         0.00
64868    Fusion of facial/other nerve          C             C         0000       0.0000        0.00         0.00         0.00
64870    Fusion of facial/other nerve          T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64872    Subsequent repair of nerve            T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64874    Repair & revise nerve add-on          T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64876    Repair nerve/shorten bone             T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64885    Nerve graft, head or neck             T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64886    Nerve graft, head or neck             T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64890    Nerve graft, hand or foot             T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64891    Nerve graft, hand or foot             T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64892    Nerve graft, arm or leg               T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64893    Nerve graft, arm or leg               T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64895    Nerve graft, hand or foot             T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64896    Nerve graft, hand or foot             T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64897    Nerve graft, arm or leg               T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64898    Nerve graft, arm or leg               T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64901    Nerve graft add-on                    T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64902    Nerve graft add-on                    T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64905    Nerve pedicle transfer                T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64907    Nerve pedicle transfer                T             T         0221      31.0536      1,375.05     3,159.70     3,620.85
64999    Nervous system surgery                T             1         0000       0.0000        0.00         0.00         0.00
65091    Revise eye                            T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
65093    Revise eye with implant               T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
65101    Removal of eye                        T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
65103    Remove eye/insert implant             T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
65105    Remove eye/attach implant             T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
65110    Removal of eye                        T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
65112    Remove eye/revise socket              T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
65114    Remove eye/revise socket              T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
65125    Revise ocular implant                 T             T         0240      18.0194       797.90      1,833.47     2,101.06
65130    Insert ocular implant                 T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
65135    Insert ocular implant                 T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
65140    Attach ocular implant                 T             T         0242      30.3478      1,343.80     3,087.89     3,538.55


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  91 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

65150    Revise ocular implant                 T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
65155    Reinsert ocular implant               T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
65175    Removal of ocular implant             T             T         0240      18.0194       797.90      1,833.47     2,101.06
65205    Remove foreign body from eye          S             S         0698       1.2378        54.81       125.95       144.33
65210    Remove foreign body from eye          S             S         0698       1.2378        54.81       125.95       144.33
65220    Remove foreign body from eye          S             S         0698       1.2378        54.81       125.95       144.33
65222    Remove foreign body from eye          S             S         0698       1.2378        54.81       125.95       144.33
65235    Remove foreign body from eye          T             T         0233      14.6645       649.34      1,492.11     1,709.88
65260    Remove foreign body from eye          T             T         0236      16.9771       751.75      1,727.42     1,979.53
65265    Remove foreign body from eye          T             T         0237      28.7866      1,274.67     2,929.04     3,356.52
65270    Repair of eye wound                   T             T         0240      18.0194       797.90      1,833.47     2,101.06
65272    Repair of eye wound                   T             T         0234      22.0521       976.47      2,243.80     2,571.27
65273    Repair of eye wound                   C             C         0000       0.0000        0.00         0.00         0.00
65275    Repair of eye wound                   T             T         0234      22.0521       976.47      2,243.80     2,571.27
65280    Repair of eye wound                   T             T         0236      16.9771       751.75      1,727.42     1,979.53
65285    Repair of eye wound                   T             T         0672      36.8773      1,632.93     3,752.27     4,299.89
65286    Repair of eye wound                   T             T         0232       6.9204       306.44       704.15       806.92
65290    Repair of eye socket wound            T             T         0243      22.0338       975.66      2,241.94     2,569.14
65400    Removal of eye lesion                 T             T         0233      14.6645       649.34      1,492.11     1,709.88
65410    Biopsy of cornea                      T             T         0233      14.6645       649.34      1,492.11     1,709.88
65420    Removal of eye lesion                 T             T         0233      14.6645       649.34      1,492.11     1,709.88
65426    Removal of eye lesion                 T             T         0234      22.0521       976.47      2,243.80     2,571.27
65430    Corneal smear                         S             S         0698       1.2378        54.81       125.95       144.33
65435    Curette/treat cornea                  T             T         0239       7.0583       312.54       718.18       823.00
65436    Curette/treat cornea                  T             T         0233      14.6645       649.34      1,492.11     1,709.88
65450    Treatment of corneal lesion           S             S         0231       1.9167        84.87       195.02       223.49
65600    Revision of cornea                    T             T         0240      18.0194       797.90      1,833.47     2,101.06
65710    Corneal transplant                    T             T         0244      38.2309      1,692.86     3,889.99     4,457.72
65730    Corneal transplant                    T             T         0244      38.2309      1,692.86     3,889.99     4,457.72
65750    Corneal transplant                    T             T         0244      38.2309      1,692.86     3,889.99     4,457.72
65755    Corneal transplant                    T             T         0244      38.2309      1,692.86     3,889.99     4,457.72
65760    Revision of cornea                    E             1         0000       0.0000        0.00         0.00         0.00
65765    Revision of cornea                    E             1         0000       0.0000        0.00         0.00         0.00
65767    Corneal tissue transplant             E             1         0000       0.0000        0.00         0.00         0.00
65770    Revise cornea with implant            T             1         0000       0.0000        0.00         0.00         0.00
65771    Radial keratotomy                     E             1         0000       0.0000        0.00         0.00         0.00
65772    Correction of astigmatism             T             1         0000       0.0000        0.00         0.00         0.00
65775    Correction of astigmatism             T             1         0000       0.0000        0.00         0.00         0.00
65780    Ocular reconst, transplant            T             1         0000       0.0000        0.00         0.00         0.00
65781    Ocular reconst, transplant            T             1         0000       0.0000        0.00         0.00         0.00
65782    Ocular reconst, transplant            T             1         0000       0.0000        0.00         0.00         0.00
65800    Drainage of eye                       T             T         0233      14.6645       649.34      1,492.11     1,709.88
65805    Drainage of eye                       T             T         0233      14.6645       649.34      1,492.11     1,709.88
65810    Drainage of eye                       T             T         0234      22.0521       976.47      2,243.80     2,571.27
65815    Drainage of eye                       T             T         0234      22.0521       976.47      2,243.80     2,571.27
65820    Relieve inner eye pressure            T             T         0232       6.9204       306.44       704.15       806.92
65850    Incision of eye                       T             T         0234      22.0521       976.47      2,243.80     2,571.27
65855    Laser surgery of eye                  T             T         0247       5.0255       222.53       511.34       585.97
65860    Incise inner eye adhesions            T             T         0247       5.0255       222.53       511.34       585.97
65865    Incise inner eye adhesions            T             T         0233      14.6645       649.34      1,492.11     1,709.88
65870    Incise inner eye adhesions            T             T         0234      22.0521       976.47      2,243.80     2,571.27
65875    Incise inner eye adhesions            T             T         0234      22.0521       976.47      2,243.80     2,571.27
65880    Incise inner eye adhesions            T             T         0233      14.6645       649.34      1,492.11     1,709.88
65900    Remove eye lesion                     T             T         0233      14.6645       649.34      1,492.11     1,709.88
65920    Remove implant of eye                 T             T         0234      22.0521       976.47      2,243.80     2,571.27
65930    Remove blood clot from eye            T             T         0234      22.0521       976.47      2,243.80     2,571.27
66020    Injection treatment of eye            T             T         0233      14.6645       649.34      1,492.11     1,709.88
66030    Injection treatment of eye            T             T         0232       6.9204       306.44       704.15       806.92


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  92 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

66130    Remove eye lesion                     T             T         0234      22.0521       976.47      2,243.80     2,571.27
66150    Glaucoma surgery                      T             T         0234      22.0521       976.47      2,243.80     2,571.27
66155    Glaucoma surgery                      T             T         0234      22.0521       976.47      2,243.80     2,571.27
66160    Glaucoma surgery                      T             T         0234      22.0521       976.47      2,243.80     2,571.27
66165    Glaucoma surgery                      T             T         0234      22.0521       976.47      2,243.80     2,571.27
66170    Glaucoma surgery                      T             T         0234      22.0521       976.47      2,243.80     2,571.27
66172    Incision of eye                       T             T         0673      29.0835      1,287.82     2,959.25     3,391.14
66180    Implant eye shunt                     T             T         0673      29.0835      1,287.82     2,959.25     3,391.14
66185    Revise eye shunt                      T             T         0673      29.0835      1,287.82     2,959.25     3,391.14
66220    Repair eye lesion                     T             T         0672      36.8773      1,632.93     3,752.27     4,299.89
66225    Repair/graft eye lesion               T             T         0673      29.0835      1,287.82     2,959.25     3,391.14
66250    Follow-up surgery of eye              T             T         0233      14.6645       649.34      1,492.11     1,709.88
66500    Incision of iris                      T             T         0232       6.9204       306.44       704.15       806.92
66505    Incision of iris                      T             T         0232       6.9204       306.44       704.15       806.92
66600    Remove iris and lesion                T             T         0234      22.0521       976.47      2,243.80     2,571.27
66605    Removal of iris                       T             T         0234      22.0521       976.47      2,243.80     2,571.27
66625    Removal of iris                       T             T         0232       6.9204       306.44       704.15       806.92
66630    Removal of iris                       T             T         0234      22.0521       976.47      2,243.80     2,571.27
66635    Removal of iris                       T             T         0234      22.0521       976.47      2,243.80     2,571.27
66680    Repair iris & ciliary body            T             T         0234      22.0521       976.47      2,243.80     2,571.27
66682    Repair iris & ciliary body            T             T         0234      22.0521       976.47      2,243.80     2,571.27
66700    Destruction, ciliary body             T             T         0233      14.6645       649.34      1,492.11     1,709.88
66710    Ciliary transsleral therapy           T             T         0233      14.6645       649.34      1,492.11     1,709.88
66711    Ciliary endoscopic ablation           T             T         0233      14.6645       649.34      1,492.11     1,709.88
66720    Destruction, ciliary body             T             T         0233      14.6645       649.34      1,492.11     1,709.88
66740    Destruction, ciliary body             T             T         0234      22.0521       976.47      2,243.80     2,571.27
66761    Revision of iris                      T             T         0247       5.0255       222.53       511.34       585.97
66762    Revision of iris                      T             T         0247       5.0255       222.53       511.34       585.97
66770    Removal of inner eye lesion           T             T         0247       5.0255       222.53       511.34       585.97
66820    Incision, secondary cataract          T             T         0232       6.9204       306.44       704.15       806.92
66821    After cataract laser surgery          T             T         0247       5.0255       222.53       511.34       585.97
66825    Reposition intraocular lens           T             T         0234      22.0521       976.47      2,243.80     2,571.27
66830    Removal of lens lesion                T             T         0232       6.9204       306.44       704.15       806.92
66840    Removal of lens material              T             T         0245      13.0344       577.16      1,326.25     1,519.81
66850    Removal of lens material              T             T         0249      27.6388      1,223.85     2,812.25     3,222.68
66852    Removal of lens material              T             T         0249      27.6388      1,223.85     2,812.25     3,222.68
66920    Extraction of lens                    T             T         0249      27.6388      1,223.85     2,812.25     3,222.68
66930    Extraction of lens                    T             T         0249      27.6388      1,223.85     2,812.25     3,222.68
66940    Extraction of lens                    T             T         0245      13.0344       577.16      1,326.25     1,519.81
66982    Cataract surgery, complex             T             T         0246      23.3185      1,032.54     2,372.66     2,718.94
66983    Cataract surg w/iol, 1 stage          T             T         0246      23.3185      1,032.54     2,372.66     2,718.94
66984    Cataract surg w/iol, 1 stage          T             T         0246      23.3185      1,032.54     2,372.66     2,718.94
66985    Insert lens prosthesis                T             T         0246      23.3185      1,032.54     2,372.66     2,718.94
66986    Exchange lens prosthesis              T             T         0246      23.3185      1,032.54     2,372.66     2,718.94
66990    Ophthalmic endoscope add-on           N             N         0000       0.0000        0.00         0.00         0.00
66999    Eye surgery procedure                 T             1         0000       0.0000        0.00         0.00         0.00
67005    Partial removal of eye fluid          T             T         0237      28.7866      1,274.67     2,929.04     3,356.52
67010    Partial removal of eye fluid          T             T         0237      28.7866      1,274.67     2,929.04     3,356.52
67015    Release of eye fluid                  T             T         0237      28.7866      1,274.67     2,929.04     3,356.52
67025    Replace eye fluid                     T             T         0237      28.7866      1,274.67     2,929.04     3,356.52
67027    Implant eye drug system               T             T         0672      36.8773      1,632.93     3,752.27     4,299.89
67028    Injection eye drug                    T             T         0235       4.7925       212.21       487.64       558.81
67030    Incise inner eye strands              T             T         0236      16.9771       751.75      1,727.42     1,979.53
67031    Laser surgery, eye strands            T             T         0247       5.0255       222.53       511.34       585.97
67036    Removal of inner eye fluid            T             T         0672      36.8773      1,632.93     3,752.27     4,299.89
67038    Strip retinal membrane                T             T         0672      36.8773      1,632.93     3,752.27     4,299.89
67039    Laser treatment of retina             T             T         0672      36.8773      1,632.93     3,752.27     4,299.89
67040    Laser treatment of retina             T             T         0672      36.8773      1,632.93     3,752.27     4,299.89


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  93 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

67101    Repair detached retina                T             T         0236      16.9771       751.75      1,727.42     1,979.53
67105    Repair detached retina                T             T         0248       4.7199       209.00       480.25       550.34
67107    Repair detached retina                T             T         0672      36.8773      1,632.93     3,752.27     4,299.89
67108    Repair detached retina                T             T         0672      36.8773      1,632.93     3,752.27     4,299.89
67110    Repair detached retina                T             T         0236      16.9771       751.75      1,727.42     1,979.53
67112    Rerepair detached retina              T             T         0672      36.8773      1,632.93     3,752.27     4,299.89
67115    Release encircling material           T             T         0236      16.9771       751.75      1,727.42     1,979.53
67120    Remove eye implant material           T             T         0236      16.9771       751.75      1,727.42     1,979.53
67121    Remove eye implant material           T             T         0237      28.7866      1,274.67     2,929.04     3,356.52
67141    Treatment of retina                   T             T         0235       4.7925       212.21       487.64       558.81
67145    Treatment of retina                   T             T         0248       4.7199       209.00       480.25       550.34
67208    Treatment of retinal lesion           T             T         0236      16.9771       751.75      1,727.42     1,979.53
67210    Treatment of retinal lesion           T             T         0248       4.7199       209.00       480.25       550.34
67218    Treatment of retinal lesion           T             T         0236      16.9771       751.75      1,727.42     1,979.53
67220    Treatment of choroid lesion           T             T         0235       4.7925       212.21       487.64       558.81
67221    Ocular photodynamic ther              T             T         0235       4.7925       212.21       487.64       558.81
67225    Eye photodynamic ther add-on          T             T         0235       4.7925       212.21       487.64       558.81
67227    Treatment of retinal lesion           T             T         0236      16.9771       751.75      1,727.42     1,979.53
67228    Treatment of retinal lesion           T             T         0248       4.7199       209.00       480.25       550.34
67250    Reinforce eye wall                    T             T         0240      18.0194       797.90      1,833.47     2,101.06
67255    Reinforce/graft eye wall              T             T         0237      28.7866      1,274.67     2,929.04     3,356.52
67299    Eye surgery procedure                 T             1         0000       0.0000        0.00         0.00         0.00
67311    Revise eye muscle                     T             T         0243      22.0338       975.66      2,241.94     2,569.14
67312    Revise two eye muscles                T             T         0243      22.0338       975.66      2,241.94     2,569.14
67314    Revise eye muscle                     T             T         0243      22.0338       975.66      2,241.94     2,569.14
67316    Revise two eye muscles                T             T         0243      22.0338       975.66      2,241.94     2,569.14
67318    Revise eye muscle(s)                  T             T         0243      22.0338       975.66      2,241.94     2,569.14
67320    Revise eye muscle(s) add-on           T             T         0243      22.0338       975.66      2,241.94     2,569.14
67331    Eye surgery follow-up add-on          T             T         0243      22.0338       975.66      2,241.94     2,569.14
67332    Rerevise eye muscles add-on           T             T         0243      22.0338       975.66      2,241.94     2,569.14
67334    Revise eye muscle w/suture            T             T         0243      22.0338       975.66      2,241.94     2,569.14
67335    Eye suture during surgery             T             T         0243      22.0338       975.66      2,241.94     2,569.14
67340    Revise eye muscle add-on              T             T         0243      22.0338       975.66      2,241.94     2,569.14
67343    Release eye tissue                    T             T         0243      22.0338       975.66      2,241.94     2,569.14
67345    Destroy nerve of eye muscle           T             T         0238       2.6031       115.27       264.87       303.52
67350    Biopsy eye muscle                     T             T         0699       8.9556       396.55       911.23      1,044.22
67399    Eye muscle surgery procedure          T             1         0000       0.0000        0.00         0.00         0.00
67400    Explore/biopsy eye socket             T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
67405    Explore/drain eye socket              T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
67412    Explore/treat eye socket              T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
67413    Explore/treat eye socket              T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
67414    Explr/decompress eye socket           T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
67415    Aspiration, orbital contents          T             T         0240      18.0194       797.90      1,833.47     2,101.06
67420    Explore/treat eye socket              T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
67430    Explore/treat eye socket              T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
67440    Explore/drain eye socket              T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
67445    Explr/decompress eye socket           T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
67450    Explore/biopsy eye socket             T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
67500    Inject/treat eye socket               S             S         0231       1.9167        84.87       195.02       223.49
67505    Inject/treat eye socket               T             T         0238       2.6031       115.27       264.87       303.52
67515    Inject/treat eye socket               T             T         0238       2.6031       115.27       264.87       303.52
67550    Insert eye socket implant             T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
67560    Revise eye socket implant             T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
67570    Decompress optic nerve                T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
67599    Orbit surgery procedure               T             1         0000       0.0000        0.00         0.00         0.00
67700    Drainage of eyelid abscess            T             T         0238       2.6031       115.27       264.87       303.52
67710    Incision of eyelid                    T             T         0239       7.0583       312.54       718.18       823.00
67715    Incision of eyelid fold               T             T         0240      18.0194       797.90      1,833.47     2,101.06


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  94 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

67800    Remove eyelid lesion                  T             T         0238       2.6031       115.27       264.87       303.52
67801    Remove eyelid lesions                 T             T         0239       7.0583       312.54       718.18       823.00
67805    Remove eyelid lesions                 T             T         0238       2.6031       115.27       264.87       303.52
67808    Remove eyelid lesion(s)               T             T         0240      18.0194       797.90      1,833.47     2,101.06
67810    Biopsy of eyelid                      T             T         0238       2.6031       115.27       264.87       303.52
67820    Revise eyelashes                      S             S         0698       1.2378        54.81       125.95       144.33
67825    Revise eyelashes                      T             T         0238       2.6031       115.27       264.87       303.52
67830    Revise eyelashes                      T             T         0239       7.0583       312.54       718.18       823.00
67835    Revise eyelashes                      T             T         0240      18.0194       797.90      1,833.47     2,101.06
67840    Remove eyelid lesion                  T             T         0239       7.0583       312.54       718.18       823.00
67850    Treat eyelid lesion                   T             T         0239       7.0583       312.54       718.18       823.00
67875    Closure of eyelid by suture           T             T         0239       7.0583       312.54       718.18       823.00
67880    Revision of eyelid                    T             T         0233      14.6645       649.34      1,492.11     1,709.88
67882    Revision of eyelid                    T             T         0240      18.0194       797.90      1,833.47     2,101.06
67900    Repair brow defect                    T             T         0240      18.0194       797.90      1,833.47     2,101.06
67901    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67902    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67903    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67904    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67906    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67908    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67909    Revise eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67911    Revise eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67912    Correction eyelid w/implant           T             T         0240      18.0194       797.90      1,833.47     2,101.06
67914    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67915    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67916    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67917    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67921    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67922    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67923    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67924    Repair eyelid defect                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
67930    Repair eyelid wound                   T             T         0240      18.0194       797.90      1,833.47     2,101.06
67935    Repair eyelid wound                   T             T         0240      18.0194       797.90      1,833.47     2,101.06
67938    Remove eyelid foreign body            S             S         0698       1.2378        54.81       125.95       144.33
67950    Revision of eyelid                    T             T         0240      18.0194       797.90      1,833.47     2,101.06
67961    Revision of eyelid                    T             T         0240      18.0194       797.90      1,833.47     2,101.06
67966    Revision of eyelid                    T             T         0240      18.0194       797.90      1,833.47     2,101.06
67971    Reconstruction of eyelid              T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
67973    Reconstruction of eyelid              T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
67974    Reconstruction of eyelid              T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
67975    Reconstruction of eyelid              T             T         0240      18.0194       797.90      1,833.47     2,101.06
67999    Revision of eyelid                    T             1         0000       0.0000        0.00         0.00         0.00
68020    Incise/drain eyelid lining            T             T         0240      18.0194       797.90      1,833.47     2,101.06
68040    Treatment of eyelid lesions           S             S         0698       1.2378        54.81       125.95       144.33
68100    Biopsy of eyelid lining               T             T         0232       6.9204       306.44       704.15       806.92
68110    Remove eyelid lining lesion           T             T         0699       8.9556       396.55       911.23      1,044.22
68115    Remove eyelid lining lesion           T             T         0240      18.0194       797.90      1,833.47     2,101.06
68130    Remove eyelid lining lesion           T             T         0233      14.6645       649.34      1,492.11     1,709.88
68135    Remove eyelid lining lesion           T             T         0239       7.0583       312.54       718.18       823.00
68200    Treat eyelid by injection             S             S         0230       0.7902        34.99       80.40        92.14
68320    Revise/graft eyelid lining            T             T         0240      18.0194       797.90      1,833.47     2,101.06
68325    Revise/graft eyelid lining            T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
68326    Revise/graft eyelid lining            T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
68328    Revise/graft eyelid lining            T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
68330    Revise eyelid lining                  T             T         0234      22.0521       976.47      2,243.80     2,571.27
68335    Revise/graft eyelid lining            T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
68340    Separate eyelid adhesions             T             T         0240      18.0194       797.90      1,833.47     2,101.06


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  95 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

68360    Revise eyelid lining                  T             T         0234      22.0521       976.47      2,243.80     2,571.27
68362    Revise eyelid lining                  T             T         0234      22.0521       976.47      2,243.80     2,571.27
68371    Harvest eye tissue, alograft          T             1         0000       0.0000        0.00         0.00         0.00
68399    Eyelid lining surgery                 T             1         0000       0.0000        0.00         0.00         0.00
68400    Incise/drain tear gland               T             T         0238       2.6031       115.27       264.87       303.52
68420    Incise/drain tear sac                 T             T         0240      18.0194       797.90      1,833.47     2,101.06
68440    Incise tear duct opening              T             T         0238       2.6031       115.27       264.87       303.52
68500    Removal of tear gland                 T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
68505    Partial removal, tear gland           T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
68510    Biopsy of tear gland                  T             T         0240      18.0194       797.90      1,833.47     2,101.06
68520    Removal of tear sac                   T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
68525    Biopsy of tear sac                    T             T         0240      18.0194       797.90      1,833.47     2,101.06
68530    Clearance of tear duct                T             T         0240      18.0194       797.90      1,833.47     2,101.06
68540    Remove tear gland lesion              T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
68550    Remove tear gland lesion              T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
68700    Repair tear ducts                     T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
68705    Revise tear duct opening              T             T         0238       2.6031       115.27       264.87       303.52
68720    Create tear sac drain                 T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
68745    Create tear duct drain                T             T         0241      23.1681      1,025.88     2,357.35     2,701.40
68750    Create tear duct drain                T             T         0242      30.3478      1,343.80     3,087.89     3,538.55
68760    Close tear duct opening               S             S         0698       1.2378        54.81       125.95       144.33
68761    Close tear duct opening               S             S         0231       1.9167        84.87       195.02       223.49
68770    Close tear system fistula             T             T         0240      18.0194       797.90      1,833.47     2,101.06
68801    Dilate tear duct opening              S             S         0698       1.2378        54.81       125.95       144.33
68810    Probe nasolacrimal duct               S             S         0231       1.9167        84.87       195.02       223.49
68811    Probe nasolacrimal duct               T             T         0240      18.0194       797.90      1,833.47     2,101.06
68815    Probe nasolacrimal duct               T             T         0240      18.0194       797.90      1,833.47     2,101.06
68840    Explore/irrigate tear ducts           S             S         0231       1.9167        84.87       195.02       223.49
68850    Injection for tear sac x-ray          N             N         0000       0.0000        0.00         0.00         0.00
68899    Tear duct system surgery              S             1         0000       0.0000        0.00         0.00         0.00
69000    Drain external ear lesion             T             T         0006       1.5100        66.86       153.64       176.07
69005    Drain external ear lesion             T             T         0008      16.2953       721.56      1,658.05     1,900.03
69020    Drain outer ear canal lesion          T             T         0006       1.5100        66.86       153.64       176.07
69090    Pierce earlobes                       E             1         0000       0.0000        0.00         0.00         0.00
69100    Biopsy of external ear                T             T         0019       4.1481       183.68       422.07       483.67
69105    Biopsy of external ear canal          T             T         0253      16.0740       711.76      1,635.53     1,874.23
69110    Remove external ear, partial          T             T         0021      14.9984       664.13      1,526.09     1,748.81
69120    Removal of external ear               T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
69140    Remove ear canal lesion(s)            T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
69145    Remove ear canal lesion(s)            T             T         0021      14.9984       664.13      1,526.09     1,748.81
69150    Extensive ear canal surgery           T             T         0252       8.1033       358.81       824.51       944.84
69155    Extensive ear/neck surgery            C             C         0000       0.0000        0.00         0.00         0.00
69200    Clear outer ear canal                 X             X         0340       0.6137        27.17       62.44        71.56
69205    Clear outer ear canal                 T             T         0022      19.5716       866.63      1,991.41     2,282.05
69210    Remove impacted ear wax               X             X         0340       0.6137        27.17       62.44        71.56
69220    Clean out mastoid cavity              T             T         0012       0.8477        37.54       86.25        98.84
69222    Clean out mastoid cavity              T             T         0253      16.0740       711.76      1,635.53     1,874.23
69300    Revise external ear                   T             1         0000       0.0000        0.00         0.00         0.00
69310    Rebuild outer ear canal               T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69320    Rebuild outer ear canal               T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69399    Outer ear surgery procedure           T             1         0000       0.0000        0.00         0.00         0.00
69400    Inflate middle ear canal              T             T         0251       2.0789        92.05       211.53       242.40
69401    Inflate middle ear canal              T             T         0251       2.0789        92.05       211.53       242.40
69405    Catheterize middle ear canal          T             T         0252       8.1033       358.81       824.51       944.84
69420    Incision of eardrum                   T             T         0251       2.0789        92.05       211.53       242.40
69421    Incision of eardrum                   T             T         0253      16.0740       711.76      1,635.53     1,874.23
69424    Remove ventilating tube               T             T         0252       8.1033       358.81       824.51       944.84
69433    Create eardrum opening                T             T         0252       8.1033       358.81       824.51       944.84


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  96 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

69436    Create eardrum opening                T             T         0253      16.0740       711.76      1,635.53     1,874.23
69440    Exploration of middle ear             T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
69450    Eardrum revision                      T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69501    Mastoidectomy                         T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69502    Mastoidectomy                         T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
69505    Remove mastoid structures             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69511    Extensive mastoid surgery             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69530    Extensive mastoid surgery             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69535    Remove part of temporal bone          C             C         0000       0.0000        0.00         0.00         0.00
69540    Remove ear lesion                     T             T         0253      16.0740       711.76      1,635.53     1,874.23
69550    Remove ear lesion                     T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69552    Remove ear lesion                     T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69554    Remove ear lesion                     C             C         0000       0.0000        0.00         0.00         0.00
69601    Mastoid surgery revision              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69602    Mastoid surgery revision              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69603    Mastoid surgery revision              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69604    Mastoid surgery revision              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69605    Mastoid surgery revision              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69610    Repair of eardrum                     T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
69620    Repair of eardrum                     T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
69631    Repair eardrum structures             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69632    Rebuild eardrum structures            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69633    Rebuild eardrum structures            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69635    Repair eardrum structures             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69636    Rebuild eardrum structures            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69637    Rebuild eardrum structures            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69641    Revise middle ear & mastoid           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69642    Revise middle ear & mastoid           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69643    Revise middle ear & mastoid           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69644    Revise middle ear & mastoid           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69645    Revise middle ear & mastoid           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69646    Revise middle ear & mastoid           T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69650    Release middle ear bone               T             T         0254      23.3114      1,032.23     2,371.93     2,718.11
69660    Revise middle ear bone                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69661    Revise middle ear bone                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69662    Revise middle ear bone                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69666    Repair middle ear structures          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69667    Repair middle ear structures          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69670    Remove mastoid air cells              T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69676    Remove middle ear nerve               T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69700    Close mastoid fistula                 T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69710    Implant/replace hearing aid           E             3         0000       0.0000        M01          M01          M01
69711    Remove/repair hearing aid             T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69714    Implant temple bone w/stimul          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69715    Temple bne implnt w/stimulat          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69717    Temple bone implant revision          T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69718    Revise temple bone implant            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69720    Release facial nerve                  T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69725    Release facial nerve                  T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69740    Repair facial nerve                   T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69745    Repair facial nerve                   T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69799    Middle ear surgery procedure          T             1         0000       0.0000        0.00         0.00         0.00
69801    Incise inner ear                      T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69802    Incise inner ear                      T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69805    Explore inner ear                     T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69806    Explore inner ear                     T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69820    Establish inner ear window            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69840    Revise inner ear window               T             T         0256      37.0000      1,638.36     3,764.75     4,314.20


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  97 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

69905    Remove inner ear                      T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69910    Remove inner ear & mastoid            T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69915    Incise inner ear nerve                T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69930    Implant cochlear device               T             T         0259      393.7337     17,434.53   40,062.40    45,909.35
69949    Inner ear surgery procedure           T             1         0000       0.0000        0.00         0.00         0.00
69950    Incise inner ear nerve                C             C         0000       0.0000        0.00         0.00         0.00
69955    Release facial nerve                  T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69960    Release inner ear canal               T             T         0256      37.0000      1,638.36     3,764.75     4,314.20
69970    Remove inner ear lesion               C             C         0000       0.0000        0.00         0.00         0.00
69979    Temporal bone surgery                 T             1         0000       0.0000        0.00         0.00         0.00
69990    Microsurgery add-on                   N             N         0000       0.0000        0.00         0.00         0.00
70010    Contrast x-ray of brain               S             S         0274       2.9160       129.12       296.70       340.01
70015    Contrast x-ray of brain               S             S         0274       2.9160       129.12       296.70       340.01
70030    X-ray eye for foreign body            X             X         0260       0.7296        32.31       74.24        85.07
70100    X-ray exam of jaw                     X             X         0260       0.7296        32.31       74.24        85.07
70110    X-ray exam of jaw                     X             X         0260       0.7296        32.31       74.24        85.07
70120    X-ray exam of mastoids                X             X         0260       0.7296        32.31       74.24        85.07
70130    X-ray exam of mastoids                X             X         0260       0.7296        32.31       74.24        85.07
70134    X-ray exam of middle ear              X             X         0261       1.2416        54.98       126.33       144.77
70140    X-ray exam of facial bones            X             X         0260       0.7296        32.31       74.24        85.07
70150    X-ray exam of facial bones            X             X         0260       0.7296        32.31       74.24        85.07
70160    X-ray exam of nasal bones             X             X         0260       0.7296        32.31       74.24        85.07
70170    X-ray exam of tear duct               X             X         0264       3.4542       152.95       351.46       402.76
70190    X-ray exam of eye sockets             X             X         0260       0.7296        32.31       74.24        85.07
70200    X-ray exam of eye sockets             X             X         0260       0.7296        32.31       74.24        85.07
70210    X-ray exam of sinuses                 X             X         0260       0.7296        32.31       74.24        85.07
70220    X-ray exam of sinuses                 X             X         0260       0.7296        32.31       74.24        85.07
70240    X-ray exam, pituitary saddle          X             X         0260       0.7296        32.31       74.24        85.07
70250    X-ray exam of skull                   X             X         0260       0.7296        32.31       74.24        85.07
70260    X-ray exam of skull                   X             X         0261       1.2416        54.98       126.33       144.77
70300    X-ray exam of teeth                   X             X         0262       0.8019        35.51       81.59        93.50
70310    X-ray exam of teeth                   X             X         0262       0.8019        35.51       81.59        93.50
70320    Full mouth x-ray of teeth             X             X         0262       0.8019        35.51       81.59        93.50
70328    X-ray exam of jaw joint               X             X         0260       0.7296        32.31       74.24        85.07
70330    X-ray exam of jaw joints              X             X         0260       0.7296        32.31       74.24        85.07
70332    X-ray exam of jaw joint               S             S         0275       3.4927       154.66       355.38       407.25
70336    Magnetic image, jaw joint             S             S         0335       5.0997       225.81       518.89       594.63
70350    X-ray head for orthodontia            X             X         0260       0.7296        32.31       74.24        85.07
70355    Panoramic x-ray of jaws               X             X         0260       0.7296        32.31       74.24        85.07
70360    X-ray exam of neck                    X             X         0260       0.7296        32.31       74.24        85.07
70370    Throat x-ray & fluoroscopy            X             X         0272       1.3291        58.85       135.24       154.97
70371    Speech evaluation, complex            X             X         0272       1.3291        58.85       135.24       154.97
70373    Contrast x-ray of larynx              X             X         0263       1.6979        75.18       172.76       197.98
70380    X-ray exam of salivary gland          X             X         0260       0.7296        32.31       74.24        85.07
70390    X-ray exam of salivary duct           X             X         0263       1.6979        75.18       172.76       197.98
70450    Ct head/brain w/o dye                 S             S         0332       3.1608       139.96       321.61       368.55
70460    Ct head/brain w/dye                   S             S         0283       4.2921       190.05       436.72       500.46
70470    Ct head/brain w/o & w/dye             S             S         0333       5.1053       226.06       519.46       595.28
70480    Ct orbit/ear/fossa w/o dye            S             S         0332       3.1608       139.96       321.61       368.55
70481    Ct orbit/ear/fossa w/dye              S             S         0283       4.2921       190.05       436.72       500.46
70482    Ct orbit/ear/fossa w/o&w/dye          S             S         0333       5.1053       226.06       519.46       595.28
70486    Ct maxillofacial w/o dye              S             S         0332       3.1608       139.96       321.61       368.55
70487    Ct maxillofacial w/dye                S             S         0283       4.2921       190.05       436.72       500.46
70488    Ct maxillofacial w/o & w/dye          S             S         0333       5.1053       226.06       519.46       595.28
70490    Ct soft tissue neck w/o dye           S             S         0332       3.1608       139.96       321.61       368.55
70491    Ct soft tissue neck w/dye             S             S         0283       4.2921       190.05       436.72       500.46
70492    Ct sft tsue nck w/o & w/dye           S             S         0333       5.1053       226.06       519.46       595.28
70496    Ct angiography, head                  S             S         0662       4.9944       221.15       508.18       582.35


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  98 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

70498    Ct angiography, neck                  S             S         0662       4.9944       221.15      508.18       582.35
70540    Mri orbit/face/neck w/o dye           S             S         0336       5.8678       259.83      597.05       684.19
70542    Mri orbit/face/neck w/dye             S             S         0284       6.2342       276.05      634.33       726.91
70543    Mri orbt/fac/nck w/o & w/dye          S             S         0337       8.5070       376.69      865.59       991.92
70544    Mr angiography head w/o dye           S             S         0336       5.8678       259.83      597.05       684.19
70545    Mr angiography head w/dye             S             S         0284       6.2342       276.05      634.33       726.91
70546    Mr angiograph head w/o&w/dye          S             S         0337       8.5070       376.69      865.59       991.92
70547    Mr angiography neck w/o dye           S             S         0336       5.8678       259.83      597.05       684.19
70548    Mr angiography neck w/dye             S             S         0284       6.2342       276.05      634.33       726.91
70549    Mr angiograph neck w/o&w/dye          S             S         0337       8.5070       376.69      865.59       991.92
70551    Mri brain w/o dye                     S             S         0336       5.8678       259.83      597.05       684.19
70552    Mri brain w/dye                       S             S         0284       6.2342       276.05      634.33       726.91
70553    Mri brain w/o & w/dye                 S             S         0337       8.5070       376.69      865.59       991.92
70557    Mri brain w/o dye                     S             S         0336       5.8678       259.83      597.05       684.19
70558    Mri brain w/dye                       S             S         0284       6.2342       276.05      634.33       726.91
70559    Mri brain w/o & w/dye                 S             S         0337       8.5070       376.69      865.59       991.92
71010    Chest x-ray                           X             X         0260       0.7296        32.31      74.24        85.07
71015    Chest x-ray                           X             X         0260       0.7296        32.31      74.24        85.07
71020    Chest x-ray                           X             X         0260       0.7296        32.31      74.24        85.07
71021    Chest x-ray                           X             X         0260       0.7296        32.31      74.24        85.07
71022    Chest x-ray                           X             X         0260       0.7296        32.31      74.24        85.07
71023    Chest x-ray and fluoroscopy           X             X         0272       1.3291        58.85      135.24       154.97
71030    Chest x-ray                           X             X         0260       0.7296        32.31      74.24        85.07
71034    Chest x-ray and fluoroscopy           X             X         0272       1.3291        58.85      135.24       154.97
71035    Chest x-ray                           X             X         0260       0.7296        32.31      74.24        85.07
71040    Contrast x-ray of bronchi             X             X         0263       1.6979        75.18      172.76       197.98
71060    Contrast x-ray of bronchi             X             X         0263       1.6979        75.18      172.76       197.98
71090    X-ray & pacemaker insertion           X             X         0272       1.3291        58.85      135.24       154.97
71100    X-ray exam of ribs                    X             X         0260       0.7296        32.31      74.24        85.07
71101    X-ray exam of ribs/chest              X             X         0260       0.7296        32.31      74.24        85.07
71110    X-ray exam of ribs                    X             X         0260       0.7296        32.31      74.24        85.07
71111    X-ray exam of ribs/chest              X             X         0261       1.2416        54.98      126.33       144.77
71120    X-ray exam of breastbone              X             X         0260       0.7296        32.31      74.24        85.07
71130    X-ray exam of breastbone              X             X         0260       0.7296        32.31      74.24        85.07
71250    Ct thorax w/o dye                     S             S         0332       3.1608       139.96      321.61       368.55
71260    Ct thorax w/dye                       S             S         0283       4.2921       190.05      436.72       500.46
71270    Ct thorax w/o & w/dye                 S             S         0333       5.1053       226.06      519.46       595.28
71275    Ct angiography, chest                 S             S         0662       4.9944       221.15      508.18       582.35
71550    Mri chest w/o dye                     S             S         0336       5.8678       259.83      597.05       684.19
71551    Mri chest w/dye                       S             S         0284       6.2342       276.05      634.33       726.91
71552    Mri chest w/o & w/dye                 S             S         0337       8.5070       376.69      865.59       991.92
71555    Mri angio chest w or w/o dye          B             1         0000       0.0000        0.00        0.00         0.00
72010    X-ray exam of spine                   X             X         0260       0.7296        32.31      74.24        85.07
72020    X-ray exam of spine                   X             X         0260       0.7296        32.31      74.24        85.07
72040    X-ray exam of neck spine              X             X         0260       0.7296        32.31      74.24        85.07
72050    X-ray exam of neck spine              X             X         0261       1.2416        54.98      126.33       144.77
72052    X-ray exam of neck spine              X             X         0261       1.2416        54.98      126.33       144.77
72069    X-ray exam of trunk spine             X             X         0260       0.7296        32.31      74.24        85.07
72070    X-ray exam of thoracic spine          X             X         0260       0.7296        32.31      74.24        85.07
72072    X-ray exam of thoracic spine          X             X         0260       0.7296        32.31      74.24        85.07
72074    X-ray exam of thoracic spine          X             X         0260       0.7296        32.31      74.24        85.07
72080    X-ray exam of trunk spine             X             X         0260       0.7296        32.31      74.24        85.07
72090    X-ray exam of trunk spine             X             X         0261       1.2416        54.98      126.33       144.77
72100    X-ray exam of lower spine             X             X         0260       0.7296        32.31      74.24        85.07
72110    X-ray exam of lower spine             X             X         0261       1.2416        54.98      126.33       144.77
72114    X-ray exam of lower spine             X             X         0261       1.2416        54.98      126.33       144.77
72120    X-ray exam of lower spine             X             X         0261       1.2416        54.98      126.33       144.77
72125    Ct neck spine w/o dye                 S             S         0332       3.1608       139.96      321.61       368.55


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  99 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

72126    Ct neck spine w/dye                   S             S         0283       4.2921       190.05       436.72       500.46
72127    Ct neck spine w/o & w/dye             S             S         0333       5.1053       226.06       519.46       595.28
72128    Ct chest spine w/o dye                S             S         0332       3.1608       139.96       321.61       368.55
72129    Ct chest spine w/dye                  S             S         0283       4.2921       190.05       436.72       500.46
72130    Ct chest spine w/o & w/dye            S             S         0333       5.1053       226.06       519.46       595.28
72131    Ct lumbar spine w/o dye               S             S         0332       3.1608       139.96       321.61       368.55
72132    Ct lumbar spine w/dye                 S             S         0283       4.2921       190.05       436.72       500.46
72133    Ct lumbar spine w/o & w/dye           S             S         0333       5.1053       226.06       519.46       595.28
72141    Mri neck spine w/o dye                S             S         0336       5.8678       259.83       597.05       684.19
72142    Mri neck spine w/dye                  S             S         0284       6.2342       276.05       634.33       726.91
72146    Mri chest spine w/o dye               S             S         0336       5.8678       259.83       597.05       684.19
72147    Mri chest spine w/dye                 S             S         0284       6.2342       276.05       634.33       726.91
72148    Mri lumbar spine w/o dye              S             S         0336       5.8678       259.83       597.05       684.19
72149    Mri lumbar spine w/dye                S             S         0284       6.2342       276.05       634.33       726.91
72156    Mri neck spine w/o & w/dye            S             S         0337       8.5070       376.69       865.59       991.92
72157    Mri chest spine w/o & w/dye           S             S         0337       8.5070       376.69       865.59       991.92
72158    Mri lumbar spine w/o & w/dye          S             S         0337       8.5070       376.69       865.59       991.92
72159    Mr angio spine w/o&w/dye              E             3         0000       0.0000         M01         M01          M01
72170    X-ray exam of pelvis                  X             X         0260       0.7296        32.31       74.24        85.07
72190    X-ray exam of pelvis                  X             X         0260       0.7296        32.31       74.24        85.07
72191    Ct angiograph pelv w/o&w/dye          S             S         0662       4.9944       221.15       508.18       582.35
72192    Ct pelvis w/o dye                     S             S         0332       3.1608       139.96       321.61       368.55
72193    Ct pelvis w/dye                       S             S         0283       4.2921       190.05       436.72       500.46
72194    Ct pelvis w/o & w/dye                 S             S         0333       5.1053       226.06       519.46       595.28
72195    Mri pelvis w/o dye                    S             S         0336       5.8678       259.83       597.05       684.19
72196    Mri pelvis w/dye                      S             S         0284       6.2342       276.05       634.33       726.91
72197    Mri pelvis w/o & w/dye                S             S         0337       8.5070       376.69       865.59       991.92
72198    Mr angio pelvis w/o & w/dye           B             1         0000       0.0000        0.00         0.00         0.00
72200    X-ray exam sacroiliac joints          X             X         0260       0.7296        32.31       74.24        85.07
72202    X-ray exam sacroiliac joints          X             X         0260       0.7296        32.31       74.24        85.07
72220    X-ray exam of tailbone                X             X         0260       0.7296        32.31       74.24        85.07
72240    Contrast x-ray of neck spine          S             S         0274       2.9160       129.12       296.70       340.01
72255    Contrast x-ray, thorax spine          S             S         0274       2.9160       129.12       296.70       340.01
72265    Contrast x-ray, lower spine           S             S         0274       2.9160       129.12       296.70       340.01
72270    Contrast x-ray, spine                 S             S         0274       2.9160       129.12       296.70       340.01
72275    Epidurography                         S             S         0274       2.9160       129.12       296.70       340.01
72285    X-ray c/t spine disk                  S             S         0388      12.1712       538.94      1,238.42     1,419.16
72295    X-ray of lower spine disk             S             S         0388      12.1712       538.94      1,238.42     1,419.16
73000    X-ray exam of collar bone             X             X         0260       0.7296        32.31       74.24        85.07
73010    X-ray exam of shoulder blade          X             X         0260       0.7296        32.31       74.24        85.07
73020    X-ray exam of shoulder                X             X         0260       0.7296        32.31       74.24        85.07
73030    X-ray exam of shoulder                X             X         0260       0.7296        32.31       74.24        85.07
73040    Contrast x-ray of shoulder            S             S         0275       3.4927       154.66       355.38       407.25
73050    X-ray exam of shoulders               X             X         0260       0.7296        32.31       74.24        85.07
73060    X-ray exam of humerus                 X             X         0260       0.7296        32.31       74.24        85.07
73070    X-ray exam of elbow                   X             X         0260       0.7296        32.31       74.24        85.07
73080    X-ray exam of elbow                   X             X         0260       0.7296        32.31       74.24        85.07
73085    Contrast x-ray of elbow               S             S         0275       3.4927       154.66       355.38       407.25
73090    X-ray exam of forearm                 X             X         0260       0.7296        32.31       74.24        85.07
73092    X-ray exam of arm, infant             X             X         0260       0.7296        32.31       74.24        85.07
73100    X-ray exam of wrist                   X             X         0260       0.7296        32.31       74.24        85.07
73110    X-ray exam of wrist                   X             X         0260       0.7296        32.31       74.24        85.07
73115    Contrast x-ray of wrist               S             S         0275       3.4927       154.66       355.38       407.25
73120    X-ray exam of hand                    X             X         0260       0.7296        32.31       74.24        85.07
73130    X-ray exam of hand                    X             X         0260       0.7296        32.31       74.24        85.07
73140    X-ray exam of finger(s)               X             X         0260       0.7296        32.31       74.24        85.07
73200    Ct upper extremity w/o dye            S             S         0332       3.1608       139.96       321.61       368.55
73201    Ct upper extremity w/dye              S             S         0283       4.2921       190.05       436.72       500.46


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                 100 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

73202    Ct uppr extremity w/o&w/dye           S             S         0333       5.1053       226.06      519.46       595.28
73206    Ct angio upr extrm w/o&w/dye          S             S         0662       4.9944       221.15      508.18       582.35
73218    Mri upper extremity w/o dye           S             S         0336       5.8678       259.83      597.05       684.19
73219    Mri upper extremity w/dye             S             S         0284       6.2342       276.05      634.33       726.91
73220    Mri uppr extremity w/o&w/dye          S             S         0337       8.5070       376.69      865.59       991.92
73221    Mri joint upr extrem w/o dye          S             S         0336       5.8678       259.83      597.05       684.19
73222    Mri joint upr extrem w/dye            S             S         0284       6.2342       276.05      634.33       726.91
73223    Mri joint upr extr w/o&w/dye          S             S         0337       8.5070       376.69      865.59       991.92
73225    Mr angio upr extr w/o&w/dye           E             3         0000       0.0000         M01        M01          M01
73500    X-ray exam of hip                     X             X         0260       0.7296        32.31      74.24        85.07
73510    X-ray exam of hip                     X             X         0260       0.7296        32.31      74.24        85.07
73520    X-ray exam of hips                    X             X         0261       1.2416        54.98      126.33       144.77
73525    Contrast x-ray of hip                 S             S         0275       3.4927       154.66      355.38       407.25
73530    X-ray exam of hip                     X             X         0261       1.2416        54.98      126.33       144.77
73540    X-ray exam of pelvis & hips           X             X         0260       0.7296        32.31      74.24        85.07
73542    X-ray exam, sacroiliac joint          S             S         0275       3.4927       154.66      355.38       407.25
73550    X-ray exam of thigh                   X             X         0260       0.7296        32.31      74.24        85.07
73560    X-ray exam of knee, 1 or 2            X             X         0260       0.7296        32.31      74.24        85.07
73562    X-ray exam of knee, 3                 X             X         0260       0.7296        32.31      74.24        85.07
73564    X-ray exam, knee, 4 or more           X             X         0260       0.7296        32.31      74.24        85.07
73565    X-ray exam of knees                   X             X         0260       0.7296        32.31      74.24        85.07
73580    Contrast x-ray of knee joint          S             S         0275       3.4927       154.66      355.38       407.25
73590    X-ray exam of lower leg               X             X         0260       0.7296        32.31      74.24        85.07
73592    X-ray exam of leg, infant             X             X         0260       0.7296        32.31      74.24        85.07
73600    X-ray exam of ankle                   X             X         0260       0.7296        32.31      74.24        85.07
73610    X-ray exam of ankle                   X             X         0260       0.7296        32.31      74.24        85.07
73615    Contrast x-ray of ankle               S             S         0275       3.4927       154.66      355.38       407.25
73620    X-ray exam of foot                    X             X         0260       0.7296        32.31      74.24        85.07
73630    X-ray exam of foot                    X             X         0260       0.7296        32.31      74.24        85.07
73650    X-ray exam of heel                    X             X         0260       0.7296        32.31      74.24        85.07
73660    X-ray exam of toe(s)                  X             X         0260       0.7296        32.31      74.24        85.07
73700    Ct lower extremity w/o dye            S             S         0332       3.1608       139.96      321.61       368.55
73701    Ct lower extremity w/dye              S             S         0283       4.2921       190.05      436.72       500.46
73702    Ct lwr extremity w/o&w/dye            S             S         0333       5.1053       226.06      519.46       595.28
73706    Ct angio lwr extr w/o&w/dye           S             S         0662       4.9944       221.15      508.18       582.35
73718    Mri lower extremity w/o dye           S             S         0336       5.8678       259.83      597.05       684.19
73719    Mri lower extremity w/dye             S             S         0284       6.2342       276.05      634.33       726.91
73720    Mri lwr extremity w/o&w/dye           S             S         0337       8.5070       376.69      865.59       991.92
73721    Mri jnt of lwr extre w/o dye          S             S         0336       5.8678       259.83      597.05       684.19
73722    Mri joint of lwr extr w/dye           S             S         0284       6.2342       276.05      634.33       726.91
73723    Mri joint lwr extr w/o&w/dye          S             S         0337       8.5070       376.69      865.59       991.92
73725    Mr ang lwr ext w or w/o dye           B             1         0000       0.0000        0.00        0.00         0.00
74000    X-ray exam of abdomen                 X             X         0260       0.7296        32.31      74.24        85.07
74010    X-ray exam of abdomen                 X             X         0260       0.7296        32.31      74.24        85.07
74020    X-ray exam of abdomen                 X             X         0260       0.7296        32.31      74.24        85.07
74022    X-ray exam series, abdomen            X             X         0261       1.2416        54.98      126.33       144.77
74150    Ct abdomen w/o dye                    S             S         0332       3.1608       139.96      321.61       368.55
74160    Ct abdomen w/dye                      S             S         0283       4.2921       190.05      436.72       500.46
74170    Ct abdomen w/o & w/dye                S             S         0333       5.1053       226.06      519.46       595.28
74175    Ct angio abdom w/o & w/dye            S             S         0662       4.9944       221.15      508.18       582.35
74181    Mri abdomen w/o dye                   S             S         0336       5.8678       259.83      597.05       684.19
74182    Mri abdomen w/dye                     S             S         0284       6.2342       276.05      634.33       726.91
74183    Mri abdomen w/o & w/dye               S             S         0337       8.5070       376.69      865.59       991.92
74185    Mri angio, abdom w orw/o dye          B             1         0000       0.0000        0.00        0.00         0.00
74190    X-ray exam of peritoneum              X             X         0264       3.4542       152.95      351.46       402.76
74210    Contrst x-ray exam of throat          S             S         0276       1.4693        65.06      149.50       171.32
74220    Contrast x-ray, esophagus             S             S         0276       1.4693        65.06      149.50       171.32
74230    Cine/vid x-ray, throat/esoph          S             S         0276       1.4693        65.06      149.50       171.32


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                 101 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

74235    Remove esophagus obstruction          S             S         0296       2.2684       100.44       230.81       264.50
74240    X-ray exam, upper gi tract            S             S         0276       1.4693        65.06       149.50       171.32
74241    X-ray exam, upper gi tract            S             S         0276       1.4693        65.06       149.50       171.32
74245    X-ray exam, upper gi tract            S             S         0277       2.2951       101.63       233.53       267.61
74246    Contrst x-ray uppr gi tract           S             S         0276       1.4693        65.06       149.50       171.32
74247    Contrst x-ray uppr gi tract           S             S         0276       1.4693        65.06       149.50       171.32
74249    Contrst x-ray uppr gi tract           S             S         0277       2.2951       101.63       233.53       267.61
74250    X-ray exam of small bowel             S             S         0276       1.4693        65.06       149.50       171.32
74251    X-ray exam of small bowel             S             S         0277       2.2951       101.63       233.53       267.61
74260    X-ray exam of small bowel             S             S         0277       2.2951       101.63       233.53       267.61
74270    Contrast x-ray exam of colon          S             S         0276       1.4693        65.06       149.50       171.32
74280    Contrast x-ray exam of colon          S             S         0277       2.2951       101.63       233.53       267.61
74283    Contrast x-ray exam of colon          S             S         0276       1.4693        65.06       149.50       171.32
74290    Contrast x-ray, gallbladder           S             S         0276       1.4693        65.06       149.50       171.32
74291    Contrast x-rays, gallbladder          S             S         0276       1.4693        65.06       149.50       171.32
74300    X-ray bile ducts/pancreas             X             X         0263       1.6979        75.18       172.76       197.98
74301    X-rays at surgery add-on              X             X         0263       1.6979        75.18       172.76       197.98
74305    X-ray bile ducts/pancreas             X             X         0263       1.6979        75.18       172.76       197.98
74320    Contrast x-ray of bile ducts          X             X         0264       3.4542       152.95       351.46       402.76
74327    X-ray bile stone removal              S             S         0296       2.2684       100.44       230.81       264.50
74328    X-ray bile duct endoscopy             N             N         0000       0.0000        0.00         0.00         0.00
74329    X-ray for pancreas endoscopy          N             N         0000       0.0000        0.00         0.00         0.00
74330    X-ray bile/panc endoscopy             N             N         0000       0.0000        0.00         0.00         0.00
74340    X-ray guide for GI tube               X             X         0272       1.3291        58.85       135.24       154.97
74350    X-ray guide, stomach tube             X             X         0263       1.6979        75.18       172.76       197.98
74355    X-ray guide, intestinal tube          X             X         0263       1.6979        75.18       172.76       197.98
74360    X-ray guide, GI dilation              S             S         0296       2.2684       100.44       230.81       264.50
74363    X-ray, bile duct dilation             S             S         0297       5.0977       225.73       518.69       594.39
74400    Contrst x-ray, urinary tract          S             S         0278       2.5559       113.18       260.06       298.02
74410    Contrst x-ray, urinary tract          S             S         0278       2.5559       113.18       260.06       298.02
74415    Contrst x-ray, urinary tract          S             S         0278       2.5559       113.18       260.06       298.02
74420    Contrst x-ray, urinary tract          S             S         0278       2.5559       113.18       260.06       298.02
74425    Contrst x-ray, urinary tract          S             S         0278       2.5559       113.18       260.06       298.02
74430    Contrast x-ray, bladder               S             S         0278       2.5559       113.18       260.06       298.02
74440    X-ray, male genital tract             S             S         0278       2.5559       113.18       260.06       298.02
74445    X-ray exam of penis                   S             S         0278       2.5559       113.18       260.06       298.02
74450    X-ray, urethra/bladder                S             S         0278       2.5559       113.18       260.06       298.02
74455    X-ray, urethra/bladder                S             S         0278       2.5559       113.18       260.06       298.02
74470    X-ray exam of kidney lesion           X             X         0263       1.6979        75.18       172.76       197.98
74475    X-ray control, cath insert            S             S         0297       5.0977       225.73       518.69       594.39
74480    X-ray control, cath insert            S             S         0296       2.2684       100.44       230.81       264.50
74485    X-ray guide, GU dilation              S             S         0296       2.2684       100.44       230.81       264.50
74710    X-ray measurement of pelvis           X             X         0261       1.2416        54.98       126.33       144.77
74740    X-ray, female genital tract           X             X         0264       3.4542       152.95       351.46       402.76
74742    X-ray, fallopian tube                 X             X         0264       3.4542       152.95       351.46       402.76
74775    X-ray exam of perineum                S             S         0278       2.5559       113.18       260.06       298.02
75552    Heart mri for morph w/o dye           S             S         0336       5.8678       259.83       597.05       684.19
75553    Heart mri for morph w/dye             S             S         0284       6.2342       276.05       634.33       726.91
75554    Cardiac MRI/function                  S             S         0336       5.8678       259.83       597.05       684.19
75555    Cardiac MRI/limited study             S             S         0336       5.8678       259.83       597.05       684.19
75556    Cardiac MRI/flow mapping              E             3         0000       0.0000         M01         M01          M01
75600    Contrast x-ray exam of aorta          S             S         0280      20.4187       904.14      2,077.60     2,380.82
75605    Contrast x-ray exam of aorta          S             S         0280      20.4187       904.14      2,077.60     2,380.82
75625    Contrast x-ray exam of aorta          S             S         0280      20.4187       904.14      2,077.60     2,380.82
75630    X-ray aorta, leg arteries             S             S         0280      20.4187       904.14      2,077.60     2,380.82
75635    Ct angio abdominal arteries           S             S         0662       4.9944       221.15       508.18       582.35
75650    Artery x-rays, head & neck            S             S         0280      20.4187       904.14      2,077.60     2,380.82
75658    Artery x-rays, arm                    S             S         0279       8.6988       385.18       885.10      1,014.28


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                 102 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

75660    Artery x-rays, head & neck            S             S         0668       6.3104       279.42       642.08       735.79
75662    Artery x-rays, head & neck            S             S         0280      20.4187       904.14      2,077.60     2,380.82
75665    Artery x-rays, head & neck            S             S         0280      20.4187       904.14      2,077.60     2,380.82
75671    Artery x-rays, head & neck            S             S         0280      20.4187       904.14      2,077.60     2,380.82
75676    Artery x-rays, neck                   S             S         0280      20.4187       904.14      2,077.60     2,380.82
75680    Artery x-rays, neck                   S             S         0280      20.4187       904.14      2,077.60     2,380.82
75685    Artery x-rays, spine                  S             S         0280      20.4187       904.14      2,077.60     2,380.82
75705    Artery x-rays, spine                  S             S         0668       6.3104       279.42       642.08       735.79
75710    Artery x-rays, arm/leg                S             S         0280      20.4187       904.14      2,077.60     2,380.82
75716    Artery x-rays, arms/legs              S             S         0280      20.4187       904.14      2,077.60     2,380.82
75722    Artery x-rays, kidney                 S             S         0280      20.4187       904.14      2,077.60     2,380.82
75724    Artery x-rays, kidneys                S             S         0280      20.4187       904.14      2,077.60     2,380.82
75726    Artery x-rays, abdomen                S             S         0280      20.4187       904.14      2,077.60     2,380.82
75731    Artery x-rays, adrenal gland          S             S         0280      20.4187       904.14      2,077.60     2,380.82
75733    Artery x-rays, adrenals               S             S         0668       6.3104       279.42       642.08       735.79
75736    Artery x-rays, pelvis                 S             S         0280      20.4187       904.14      2,077.60     2,380.82
75741    Artery x-rays, lung                   S             S         0279       8.6988       385.18       885.10      1,014.28
75743    Artery x-rays, lungs                  S             S         0280      20.4187       904.14      2,077.60     2,380.82
75746    Artery x-rays, lung                   S             S         0279       8.6988       385.18       885.10      1,014.28
75756    Artery x-rays, chest                  S             S         0279       8.6988       385.18       885.10      1,014.28
75774    Artery x-ray, each vessel             S             S         0279       8.6988       385.18       885.10      1,014.28
75790    Visualize A-V shunt                   S             S         0279       8.6988       385.18       885.10      1,014.28
75801    Lymph vessel x-ray, arm/leg           X             X         0264       3.4542       152.95       351.46       402.76
75803    Lymph vessel x-ray,arms/legs          X             X         0264       3.4542       152.95       351.46       402.76
75805    Lymph vessel x-ray, trunk             X             X         0264       3.4542       152.95       351.46       402.76
75807    Lymph vessel x-ray, trunk             X             X         0264       3.4542       152.95       351.46       402.76
75809    Nonvascular shunt, x-ray              X             X         0263       1.6979        75.18       172.76       197.98
75810    Vein x-ray, spleen/liver              S             S         0279       8.6988       385.18       885.10      1,014.28
75820    Vein x-ray, arm/leg                   S             S         0668       6.3104       279.42       642.08       735.79
75822    Vein x-ray, arms/legs                 S             S         0668       6.3104       279.42       642.08       735.79
75825    Vein x-ray, trunk                     S             S         0279       8.6988       385.18       885.10      1,014.28
75827    Vein x-ray, chest                     S             S         0279       8.6988       385.18       885.10      1,014.28
75831    Vein x-ray, kidney                    S             S         0279       8.6988       385.18       885.10      1,014.28
75833    Vein x-ray, kidneys                   S             S         0279       8.6988       385.18       885.10      1,014.28
75840    Vein x-ray, adrenal gland             S             S         0280      20.4187       904.14      2,077.60     2,380.82
75842    Vein x-ray, adrenal glands            S             S         0280      20.4187       904.14      2,077.60     2,380.82
75860    Vein x-ray, neck                      S             S         0668       6.3104       279.42       642.08       735.79
75870    Vein x-ray, skull                     S             S         0668       6.3104       279.42       642.08       735.79
75872    Vein x-ray, skull                     S             S         0279       8.6988       385.18       885.10      1,014.28
75880    Vein x-ray, eye socket                S             S         0668       6.3104       279.42       642.08       735.79
75885    Vein x-ray, liver                     S             S         0280      20.4187       904.14      2,077.60     2,380.82
75887    Vein x-ray, liver                     S             S         0279       8.6988       385.18       885.10      1,014.28
75889    Vein x-ray, liver                     S             S         0280      20.4187       904.14      2,077.60     2,380.82
75891    Vein x-ray, liver                     S             S         0279       8.6988       385.18       885.10      1,014.28
75893    Venous sampling by catheter           N             N         0000       0.0000        0.00         0.00         0.00
75894    X-rays, transcath therapy             S             S         0297       5.0977       225.73       518.69       594.39
75896    X-rays, transcath therapy             S             S         0297       5.0977       225.73       518.69       594.39
75898    Follow-up angiography                 X             X         0263       1.6979        75.18       172.76       197.98
75900    Arterial catheter exchange            C             C         0000       0.0000        0.00         0.00         0.00
75901    Remove cva device obstruct            X             X         0263       1.6979        75.18       172.76       197.98
75902    Remove cva lumen obstruct             X             X         0263       1.6979        75.18       172.76       197.98
75940    X-ray placement, vein filter          S             S         0297       5.0977       225.73       518.69       594.39
75945    Intravascular us                      S             S         0267       2.5543       113.10       259.90       297.83
75946    Intravascular us add-on               S             S         0266       1.5883        70.33       161.61       185.20
75952    Endovasc repair abdom aorta           C             C         0000       0.0000        0.00         0.00         0.00
75953    Abdom aneurysm endovas rpr            C             C         0000       0.0000        0.00         0.00         0.00
75954    Iliac aneurysm endovas rpr            C             C         0000       0.0000        0.00         0.00         0.00
75956    Xray, endovasc thor ao repr           C             C         0000       0.0000        0.00         0.00         0.00


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                 103 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

75957    Xray, endovasc thor ao repr           C             C         0000       0.0000        0.00        0.00          0.00
75958    Xray, place prox ext thor ao          C             C         0000       0.0000        0.00        0.00          0.00
75959    Xray, place dist ext thor ao          C             C         0000       0.0000        0.00        0.00          0.00
75960    Transcath iv stent rs&i               S             S         0668       6.3104       279.42      642.08        735.79
75961    Retrieval, broken catheter            S             S         0668       6.3104       279.42      642.08        735.79
75962    Repair arterial blockage              S             S         0668       6.3104       279.42      642.08        735.79
75964    Repair artery blockage, each          S             S         0668       6.3104       279.42      642.08        735.79
75966    Repair arterial blockage              S             S         0668       6.3104       279.42      642.08        735.79
75968    Repair artery blockage, each          S             S         0668       6.3104       279.42      642.08        735.79
75970    Vascular biopsy                       S             S         0668       6.3104       279.42      642.08        735.79
75978    Repair venous blockage                S             S         0668       6.3104       279.42      642.08        735.79
75980    Contrast xray exam bile duct          S             S         0297       5.0977       225.73      518.69        594.39
75982    Contrast xray exam bile duct          S             S         0297       5.0977       225.73      518.69        594.39
75984    Xray control catheter change          X             X         0263       1.6979        75.18      172.76        197.98
75989    Abscess drainage under x-ray          N             N         0000       0.0000        0.00        0.00          0.00
75992    Atherectomy, x-ray exam               S             S         0279       8.6988       385.18      885.10       1,014.28
75993    Atherectomy, x-ray exam               S             S         0279       8.6988       385.18      885.10       1,014.28
75994    Atherectomy, x-ray exam               S             S         0279       8.6988       385.18      885.10       1,014.28
75995    Atherectomy, x-ray exam               S             S         0279       8.6988       385.18      885.10       1,014.28
75996    Atherectomy, x-ray exam               S             S         0279       8.6988       385.18      885.10       1,014.28
75998    Fluoroguide for vein device           N             N         0000       0.0000        0.00        0.00          0.00
76000    Fluoroscope examination               X             X         0272       1.3291        58.85      135.24        154.97
76001    Fluoroscope exam, extensive           N             N         0000       0.0000        0.00        0.00          0.00
76003    Needle localization by x-ray          N             N         0000       0.0000        0.00        0.00          0.00
76005    Fluoroguide for spine inject          N             N         0000       0.0000        0.00        0.00          0.00
76006    X-ray stress view                     X             X         0260       0.7296        32.31      74.24         85.07
76010    X-ray, nose to rectum                 X             X         0260       0.7296        32.31      74.24         85.07
76012    Percut vertebroplasty fluor           S             S         0274       2.9160       129.12      296.70        340.01
76013    Percut vertebroplasty, ct             S             S         0274       2.9160       129.12      296.70        340.01
76020    X-rays for bone age                   X             X         0260       0.7296        32.31      74.24         85.07
76040    X-rays, bone evaluation               X             X         0261       1.2416        54.98      126.33        144.77
76061    X-rays, bone survey                   X             X         0261       1.2416        54.98      126.33        144.77
76062    X-rays, bone survey                   X             X         0261       1.2416        54.98      126.33        144.77
76065    X-rays, bone evaluation               X             X         0261       1.2416        54.98      126.33        144.77
76066    Joint survey, single view             X             X         0260       0.7296        32.31      74.24         85.07
76070    Ct bone density, axial                S             S         0288       1.2216        54.09      124.30        142.44
76071    Ct bone density, peripheral           S             S         0282       1.5934        70.56      162.13        185.79
76075    Dxa bone density, axial               S             S         0288       1.2216        54.09      124.30        142.44
76076    Dxa bone density/peripheral           S             S         0665       0.6381        28.26      64.93         74.40
76077    Dxa bone density/v-fracture           X             X         0260       0.7296        32.31      74.24         85.07
76078    Radiographic absorptiometry           X             X         0260       0.7296        32.31      74.24         85.07
76080    X-ray exam of fistula                 X             X         0263       1.6979        75.18      172.76        197.98
76082    Computer mammogram add-on             A             3         0000       0.0000         M01        M01           M01
76083    Computer mammogram add-on             A             3         0000       0.0000         M01        M01           M01
76086    X-ray of mammary duct                 X             X         0263       1.6979        75.18      172.76        197.98
76088    X-ray of mammary ducts                X             X         0263       1.6979        75.18      172.76        197.98
76090    Mammogram, one breast                 A             3         0000       0.0000         M01        M01           M01
76091    Mammogram, both breasts               A             3         0000       0.0000         M01        M01           M01
76092    Mammogram, screening                  A             3         0000       0.0000         M01        M01           M01
76093    Magnetic image, breast                E             1         0000       0.0000        0.00        0.00          0.00
76094    Magnetic image, both breasts          E             1         0000       0.0000        0.00        0.00          0.00
76095    Stereotactic breast biopsy            X             X         0264       3.4542       152.95      351.46        402.76
76096    X-ray of needle wire, breast          X             X         0263       1.6979        75.18      172.76        197.98
76098    X-ray exam, breast specimen           X             X         0260       0.7296        32.31      74.24         85.07
76100    X-ray exam of body section            X             X         0261       1.2416        54.98      126.33        144.77
76101    Complex body section x-ray            X             X         0263       1.6979        75.18      172.76        197.98
76102    Complex body section x-rays           X             X         0264       3.4542       152.95      351.46        402.76
76120    Cine/video x-rays                     X             X         0272       1.3291        58.85      135.24        154.97


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                 104 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

76125    Cine/video x-rays add-on              X             X         0260       0.7296        32.31      74.24        85.07
76140    X-ray consultation                    E             1         0000       0.0000        0.00        0.00         0.00
76150    X-ray exam, dry process               X             X         0260       0.7296        32.31      74.24        85.07
76350    Special x-ray contrast study          N             N         0000       0.0000        0.00        0.00         0.00
76355    Ct scan for localization              S             S         0283       4.2921       190.05      436.72       500.46
76360    Ct scan for needle biopsy             S             S         0283       4.2921       190.05      436.72       500.46
76362    Ct guide for tissue ablation          S             S         0333       5.1053       226.06      519.46       595.28
76370    Ct scan for therapy guide             S             S         0282       1.5934        70.56      162.13       185.79
76376    3d render w/o postprocess             X             X         0340       0.6137        27.17      62.44        71.56
76377    3d rendering w/postprocess            S             S         0282       1.5934        70.56      162.13       185.79           X
76380    CAT scan follow-up study              S             S         0282       1.5934        70.56      162.13       185.79
76390    Mr spectroscopy                       E             3         0000       0.0000         M01        M01          M01
76393    Mr guidance for needle place          S             S         0335       5.0997       225.81      518.89       594.63
76394    Mri for tissue ablation               S             S         0335       5.0997       225.81      518.89       594.63
76400    Magnetic image, bone marrow           S             S         0335       5.0997       225.81      518.89       594.63
76496    Fluoroscopic procedure                X             1         0000       0.0000        0.00        0.00         0.00
76497    Ct procedure                          S             1         0000       0.0000        0.00        0.00         0.00
76498    Mri procedure                         S             1         0000       0.0000        0.00        0.00         0.00
76499    Radiographic procedure                X             1         0000       0.0000        0.00        0.00         0.00
76506    Echo exam of head                     S             S         0265       0.9930        43.97      101.04       115.78
76510    Ophth us, b & quant a                 S             S         0266       1.5883        70.33      161.61       185.20
76511    Ophth us, quant a only                S             S         0266       1.5883        70.33      161.61       185.20
76512    Ophth us, b w/non-quant a             S             S         0266       1.5883        70.33      161.61       185.20
76513    Echo exam of eye, water bath          S             S         0266       1.5883        70.33      161.61       185.20
76514    Echo exam of eye, thickness           X             X         0340       0.6137        27.17      62.44        71.56
76516    Echo exam of eye                      S             S         0265       0.9930        43.97      101.04       115.78
76519    Echo exam of eye                      S             S         0266       1.5883        70.33      161.61       185.20
76529    Echo exam of eye                      S             S         0265       0.9930        43.97      101.04       115.78
76536    Us exam of head and neck              S             S         0266       1.5883        70.33      161.61       185.20
76604    Us exam, chest, b-scan                S             S         0266       1.5883        70.33      161.61       185.20
76645    Us exam, breast(s)                    S             S         0265       0.9930        43.97      101.04       115.78
76700    Us exam, abdom, complete              S             S         0266       1.5883        70.33      161.61       185.20
76705    Echo exam of abdomen                  S             S         0266       1.5883        70.33      161.61       185.20
76770    Us exam abdo back wall, comp          S             S         0266       1.5883        70.33      161.61       185.20
76775    Us exam abdo back wall, lim           S             S         0266       1.5883        70.33      161.61       185.20
76778    Us exam kidney transplant             S             S         0266       1.5883        70.33      161.61       185.20
76800    Us exam, spinal canal                 S             S         0266       1.5883        70.33      161.61       185.20
76801    Ob us < 14 wks, single fetus          S             S         0266       1.5883        70.33      161.61       185.20
76802    Ob us < 14 wks, add’l fetus           S             S         0265       0.9930        43.97      101.04       115.78
76805    Ob us >/= 14 wks, sngl fetus          S             S         0266       1.5883        70.33      161.61       185.20
76810    Ob us >/= 14 wks, addl fetus          S             S         0266       1.5883        70.33      161.61       185.20
76811    Ob us, detailed, sngl fetus           S             S         0267       2.5543       113.10      259.90       297.83
76812    Ob us, detailed, addl fetus           S             S         0266       1.5883        70.33      161.61       185.20
76815    Ob us, limited, fetus(s)              S             S         0265       0.9930        43.97      101.04       115.78
76816    Ob us, follow-up, per fetus           S             S         0265       0.9930        43.97      101.04       115.78
76817    Transvaginal us, obstetric            S             S         0266       1.5883        70.33      161.61       185.20
76818    Fetal biophys profile w/nst           S             S         0266       1.5883        70.33      161.61       185.20
76819    Fetal biophys profil w/o nst          S             S         0266       1.5883        70.33      161.61       185.20
76820    Umbilical artery echo                 S             S         0096       1.6020        70.94      163.00       186.79
76821    Middle cerebral artery echo           S             S         0096       1.6020        70.94      163.00       186.79
76825    Echo exam of fetal heart              S             S         0671       1.6763        74.23      170.56       195.46
76826    Echo exam of fetal heart              S             S         0697       1.5121        66.96      153.86       176.31
76827    Echo exam of fetal heart              S             S         0671       1.6763        74.23      170.56       195.46
76828    Echo exam of fetal heart              S             S         0697       1.5121        66.96      153.86       176.31
76830    Transvaginal us, non-ob               S             S         0266       1.5883        70.33      161.61       185.20
76831    Echo exam, uterus                     S             S         0267       2.5543       113.10      259.90       297.83
76856    Us exam, pelvic, complete             S             S         0266       1.5883        70.33      161.61       185.20
76857    Us exam, pelvic, limited              S             S         0265       0.9930        43.97      101.04       115.78


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                 105 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

76870    Us exam, scrotum                      S             S         0266       1.5883        70.33       161.61       185.20
76872    Us, transrectal                       S             S         0266       1.5883        70.33       161.61       185.20
76873    Echograp trans r, pros study          S             S         0266       1.5883        70.33       161.61       185.20
76880    Us exam, extremity                    S             S         0266       1.5883        70.33       161.61       185.20
76885    Us exam infant hips, dynamic          S             S         0265       0.9930        43.97       101.04       115.78
76886    Us exam infant hips, static           S             S         0266       1.5883        70.33       161.61       185.20
76930    Echo guide, cardiocentesis            S             S         0268       1.0460        46.32       106.43       121.96
76932    Echo guide for heart biopsy           S             S         0268       1.0460        46.32       106.43       121.96
76936    Echo guide for artery repair          S             S         0268       1.0460        46.32       106.43       121.96
76937    Us guide, vascular access             N             N         0000       0.0000        0.00         0.00         0.00
76940    Us guide, tissue ablation             S             S         0268       1.0460        46.32       106.43       121.96
76941    Echo guide for transfusion            S             S         0268       1.0460        46.32       106.43       121.96
76942    Echo guide for biopsy                 S             S         0268       1.0460        46.32       106.43       121.96
76945    Echo guide, villus sampling           S             S         0268       1.0460        46.32       106.43       121.96
76946    Echo guide for amniocentesis          S             S         0268       1.0460        46.32       106.43       121.96
76948    Echo guide, ova aspiration            S             S         0268       1.0460        46.32       106.43       121.96
76950    Echo guidance radiotherapy            S             S         0268       1.0460        46.32       106.43       121.96
76965    Echo guidance radiotherapy            S             S         0268       1.0460        46.32       106.43       121.96
76970    Ultrasound exam follow-up             S             S         0265       0.9930        43.97       101.04       115.78
76975    GI endoscopic ultrasound              S             S         0266       1.5883        70.33       161.61       185.20
76977    Us bone density measure               X             X         0340       0.6137        27.17       62.44        71.56
76986    Ultrasound guide intraoper            S             S         0266       1.5883        70.33       161.61       185.20
76999    Echo examination procedure            S             1         0000       0.0000        0.00         0.00         0.00
77261    Radiation therapy planning            B             1         0000       0.0000        0.00         0.00         0.00
77262    Radiation therapy planning            B             1         0000       0.0000        0.00         0.00         0.00
77263    Radiation therapy planning            B             1         0000       0.0000        0.00         0.00         0.00
77280    Set radiation therapy field           X             X         0304       1.7323        76.71       176.26       201.99
77285    Set radiation therapy field           X             X         0305       3.9335       174.18       400.23       458.65
77290    Set radiation therapy field           X             X         0305       3.9335       174.18       400.23       458.65
77295    Set radiation therapy field           X             X         0310      13.8818       614.69      1,412.47     1,618.62
77299    Radiation therapy planning            X             1         0000       0.0000        0.00         0.00         0.00
77300    Radiation therapy dose plan           X             X         0304       1.7323        76.71       176.26       201.99
77301    Radiotherapy dose plan, imrt          X             X         0310      13.8818       614.69      1,412.47     1,618.62
77305    Teletx isodose plan simple            X             X         0304       1.7323        76.71       176.26       201.99
77310    Teletx isodose plan intermed          X             X         0305       3.9335       174.18       400.23       458.65
77315    Teletx isodose plan complex           X             X         0305       3.9335       174.18       400.23       458.65
77321    Special teletx port plan              X             X         0305       3.9335       174.18       400.23       458.65
77326    Brachytx isodose calc simp            X             X         0304       1.7323        76.71       176.26       201.99
77327    Brachytx isodose calc interm          X             X         0305       3.9335       174.18       400.23       458.65
77328    Brachytx isodose plan compl           X             X         0305       3.9335       174.18       400.23       458.65
77331    Special radiation dosimetry           X             X         0304       1.7323        76.71       176.26       201.99
77332    Radiation treatment aid(s)            X             X         0303       2.8241       125.05       287.35       329.29
77333    Radiation treatment aid(s)            X             X         0303       2.8241       125.05       287.35       329.29
77334    Radiation treatment aid(s)            X             X         0303       2.8241       125.05       287.35       329.29
77336    Radiation physics consult             X             X         0304       1.7323        76.71       176.26       201.99
77370    Radiation physics consult             X             X         0304       1.7323        76.71       176.26       201.99
77399    External radiation dosimetry          X             1         0000       0.0000        0.00         0.00         0.00
77401    Radiation treatment delivery          S             S         0300       1.4660        64.91       149.17       170.94
77402    Radiation treatment delivery          S             S         0300       1.4660        64.91       149.17       170.94
77403    Radiation treatment delivery          S             S         0300       1.4660        64.91       149.17       170.94
77404    Radiation treatment delivery          S             S         0300       1.4660        64.91       149.17       170.94
77406    Radiation treatment delivery          S             S         0300       1.4660        64.91       149.17       170.94
77407    Radiation treatment delivery          S             S         0300       1.4660        64.91       149.17       170.94
77408    Radiation treatment delivery          S             S         0300       1.4660        64.91       149.17       170.94
77409    Radiation treatment delivery          S             S         0300       1.4660        64.91       149.17       170.94
77411    Radiation treatment delivery          S             S         0301       2.2056        97.66       224.42       257.17
77412    Radiation treatment delivery          S             S         0301       2.2056        97.66       224.42       257.17
77413    Radiation treatment delivery          S             S         0301       2.2056        97.66       224.42       257.17


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                 106 of 223
State of Wyoming Oupatient Prospective Payment System                                                         Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                     Critical
                                                                                              General      Children's                 Change
                                               2006      WY 2006                                                         Access
 CPT/                                                                           APC Relative Hospital       Hospital                   from
                 Description (short)          Status       Status       APC                                              Hospital
HCPCS                                                                             Weight     Outpatient    Outpatient                 4-14-06
                                            Indicator    Indicator                                                      Outpatient
                                                                                                Fee           Fee                    Schedule
                                           (FYI Only)                                                                      Fee

77414    Radiation treatment delivery          S             S         0301       2.2056           97.66     224.42       257.17
77416    Radiation treatment delivery          S             S         0301       2.2056           97.66     224.42       257.17
77417    Radiology port film(s)                X             X         0260       0.7296           32.31     74.24        85.07
77418    Radiation tx delivery, imrt           S             S         0412       5.3573          237.22     545.11       624.66
77421    Stereoscopic x-ray guidance           S             S         1502       1.2603      *    55.81     128.24       146.95
77422    Neutron beam tx, simple               S             S         0301       2.2056           97.66     224.42       257.17
77423    Neutron beam tx, complex              S             S         0301       2.2056           97.66     224.42       257.17
77427    Radiation tx management, x5           B             1         0000       0.0000           0.00       0.00         0.00
77431    Radiation therapy management          B             1         0000       0.0000           0.00       0.00         0.00
77432    Stereotactic radiation trmt           B             1         0000       0.0000           0.00       0.00         0.00
77470    Special radiation treatment           S             S         0299       5.7678          255.40     586.87       672.53
77499    Radiation therapy management          B             1         0000       0.0000           0.00       0.00         0.00
77520    Proton trmt, simple w/o comp          S             S         0664      15.9286          705.32    1,620.74     1,857.27
77522    Proton trmt, simple w/comp            S             S         0664      15.9286          705.32    1,620.74     1,857.27
77523    Proton trmt, intermediate             S             S         0667      19.0566          843.83    1,939.01     2,222.00
77525    Proton treatment, complex             S             S         0667      19.0566          843.83    1,939.01     2,222.00
77600    Hyperthermia treatment                S             S         0314       5.5840          247.26     568.17       651.09
77605    Hyperthermia treatment                S             S         0314       5.5840          247.26     568.17       651.09
77610    Hyperthermia treatment                S             S         0314       5.5840          247.26     568.17       651.09
77615    Hyperthermia treatment                S             S         0314       5.5840          247.26     568.17       651.09
77620    Hyperthermia treatment                S             S         0314       5.5840          247.26     568.17       651.09
77750    Infuse radioactive materials          S             S         0301       2.2056           97.66     224.42       257.17
77761    Apply intrcav radiat simple           S             S         0312       5.5674          246.52     566.48       649.16
77762    Apply intrcav radiat interm           S             S         0312       5.5674          246.52     566.48       649.16
77763    Apply intrcav radiat compl            S             S         0312       5.5674          246.52     566.48       649.16
77776    Apply interstit radiat simpl          S             S         0312       5.5674          246.52     566.48       649.16
77777    Apply interstit radiat inter          S             S         0312       5.5674          246.52     566.48       649.16
77778    Apply interstit radiat compl          S             S         0651      11.1948          495.71    1,139.07     1,305.31
77781    High intensity brachytherapy          S             S         0313      13.0202          576.53    1,324.81     1,518.16
77782    High intensity brachytherapy          S             S         0313      13.0202          576.53    1,324.81     1,518.16
77783    High intensity brachytherapy          S             S         0313      13.0202          576.53    1,324.81     1,518.16
77784    High intensity brachytherapy          S             S         0313      13.0202          576.53    1,324.81     1,518.16
77789    Apply surface radiation               S             S         0300       1.4660           64.91     149.17       170.94
77790    Radiation handling                    N             N         0000       0.0000           0.00       0.00         0.00
77799    Radium/radioisotope therapy           S             1         0000       0.0000           0.00       0.00         0.00
78000    Thyroid, single uptake                S             S         0389       1.4276           63.21     145.26       166.46
78001    Thyroid, multiple uptakes             S             S         0389       1.4276           63.21     145.26       166.46
78003    Thyroid suppress/stimul               S             S         0392       3.5231          156.00     358.48       410.79
78006    Thyroid imaging with uptake           S             S         0390       2.4663          109.21     250.95       287.57
78007    Thyroid image, mult uptakes           S             S         0391       2.7803          123.11     282.90       324.18
78010    Thyroid imaging                       S             S         0390       2.4663          109.21     250.95       287.57
78011    Thyroid imaging with flow             S             S         0390       2.4663          109.21     250.95       287.57
78015    Thyroid met imaging                   S             S         0406       4.1397          183.31     421.21       482.69
78016    Thyroid met imaging/studies           S             S         0406       4.1397          183.31     421.21       482.69
78018    Thyroid met imaging, body             S             S         0406       4.1397          183.31     421.21       482.69
78020    Thyroid met uptake                    S             S         0399       1.5039           66.59     153.02       175.35
78070    Parathyroid nuclear imaging           S             S         0391       2.7803          123.11     282.90       324.18
78075    Adrenal nuclear imaging               S             S         0391       2.7803          123.11     282.90       324.18
78099    Endocrine nuclear procedure           S             1         0000       0.0000           0.00       0.00         0.00
78102    Bone marrow imaging, ltd              S             S         0400       3.9160          173.40     398.45       456.61
78103    Bone marrow imaging, mult             S             S         0400       3.9160          173.40     398.45       456.61
78104    Bone marrow imaging, body             S             S         0400       3.9160          173.40     398.45       456.61
78110    Plasma volume, single                 S             S         0393       3.4467          152.62     350.70       401.89
78111    Plasma volume, multiple               S             S         0393       3.4467          152.62     350.70       401.89
78120    Red cell mass, single                 S             S         0393       3.4467          152.62     350.70       401.89
78121    Red cell mass, multiple               S             S         0393       3.4467          152.62     350.70       401.89
78122    Blood volume                          S             S         0393       3.4467          152.62     350.70       401.89
78130    Red cell survival study               S             S         0393       3.4467          152.62     350.70       401.89


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  107 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

78135    Red cell survival kinetics            S             S         0393       3.4467       152.62       350.70       401.89
78140    Red cell sequestration                S             S         0393       3.4467       152.62       350.70       401.89
78185    Spleen imaging                        S             S         0400       3.9160       173.40       398.45       456.61
78190    Platelet survival, kinetics           S             S         0392       3.5231       156.00       358.48       410.79
78191    Platelet survival                     S             S         0392       3.5231       156.00       358.48       410.79
78195    Lymph system imaging                  S             S         0400       3.9160       173.40       398.45       456.61
78199    Blood/lymph nuclear exam              S             1         0000       0.0000        0.00         0.00         0.00
78201    Liver imaging                         S             S         0394       4.3107       190.88       438.61       502.63
78202    Liver imaging with flow               S             S         0394       4.3107       190.88       438.61       502.63
78205    Liver imaging (3D)                    S             S         0394       4.3107       190.88       438.61       502.63
78206    Liver image (3d) with flow            S             S         0394       4.3107       190.88       438.61       502.63
78215    Liver and spleen imaging              S             S         0394       4.3107       190.88       438.61       502.63
78216    Liver & spleen image/flow             S             S         0394       4.3107       190.88       438.61       502.63
78220    Liver function study                  S             S         0394       4.3107       190.88       438.61       502.63
78223    Hepatobiliary imaging                 S             S         0394       4.3107       190.88       438.61       502.63
78230    Salivary gland imaging                S             S         0395       3.7696       166.92       383.56       439.54
78231    Serial salivary imaging               S             S         0395       3.7696       166.92       383.56       439.54
78232    Salivary gland function exam          S             S         0395       3.7696       166.92       383.56       439.54
78258    Esophageal motility study             S             S         0395       3.7696       166.92       383.56       439.54
78261    Gastric mucosa imaging                S             S         0395       3.7696       166.92       383.56       439.54
78262    Gastroesophageal reflux exam          S             S         0395       3.7696       166.92       383.56       439.54
78264    Gastric emptying study                S             S         0395       3.7696       166.92       383.56       439.54
78267    Breath tst attain/anal c-14           A             3         0000       0.0000         M01         M01          M01
78268    Breath test analysis, c-14            A             3         0000       0.0000         M01         M01          M01
78270    Vit B-12 absorption exam              S             S         0392       3.5231       156.00       358.48       410.79
78271    Vit b-12 absrp exam, int fac          S             S         0392       3.5231       156.00       358.48       410.79
78272    Vit B-12 absorp, combined             S             S         0392       3.5231       156.00       358.48       410.79
78278    Acute GI blood loss imaging           S             S         0395       3.7696       166.92       383.56       439.54
78282    GI protein loss exam                  S             S         0395       3.7696       166.92       383.56       439.54
78290    Meckel’s divert exam                  S             S         0395       3.7696       166.92       383.56       439.54
78291    Leveen/shunt patency exam             S             S         0395       3.7696       166.92       383.56       439.54
78299    GI nuclear procedure                  S             1         0000       0.0000        0.00         0.00         0.00
78300    Bone imaging, limited area            S             S         0396       3.9921       176.77       406.20       465.48
78305    Bone imaging, multiple areas          S             S         0396       3.9921       176.77       406.20       465.48
78306    Bone imaging, whole body              S             S         0396       3.9921       176.77       406.20       465.48
78315    Bone imaging, 3 phase                 S             S         0396       3.9921       176.77       406.20       465.48
78320    Bone imaging (3D)                     S             S         0396       3.9921       176.77       406.20       465.48
78350    Bone mineral, single photon           X             X         0260       0.7296        32.31       74.24        85.07
78351    Bone mineral, dual photon             E             3         0000       0.0000         M01         M01          M01
78399    Musculoskeletal nuclear exam          S             1         0000       0.0000        0.00         0.00         0.00
78414    Non-imaging heart function            S             S         0398       4.2038       186.14       427.74       490.16
78428    Cardiac shunt imaging                 S             S         0398       4.2038       186.14       427.74       490.16
78445    Vascular flow imaging                 S             S         0397       2.0829        92.23       211.94       242.87
78456    Acute venous thrombus image           S             S         0397       2.0829        92.23       211.94       242.87
78457    Venous thrombosis imaging             S             S         0397       2.0829        92.23       211.94       242.87
78458    Ven thrombosis images, bilat          S             S         0397       2.0829        92.23       211.94       242.87
78459    Heart muscle imaging (PET)            S             S         0306      13.4521       595.66      1,368.75     1,568.51
78460    Heart muscle blood, single            S             S         0398       4.2038       186.14       427.74       490.16
78461    Heart muscle blood, multiple          S             S         0377       6.6729       295.48       678.97       778.06
78464    Heart image (3d), single              S             S         0398       4.2038       186.14       427.74       490.16
78465    Heart image (3d), multiple            S             S         0377       6.6729       295.48       678.97       778.06
78466    Heart infarct image                   S             S         0398       4.2038       186.14       427.74       490.16
78468    Heart infarct image (ef)              S             S         0398       4.2038       186.14       427.74       490.16
78469    Heart infarct image (3D)              S             S         0398       4.2038       186.14       427.74       490.16
78472    Gated heart, planar, single           S             S         0398       4.2038       186.14       427.74       490.16
78473    Gated heart, multiple                 S             S         0376       5.0315       222.79       511.96       586.67
78478    Heart wall motion add-on              S             S         0399       1.5039        66.59       153.02       175.35
78480    Heart function add-on                 S             S         0399       1.5039        66.59       153.02       175.35


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                 108 of 223
State of Wyoming Oupatient Prospective Payment System                                                           Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                       Critical
                                                                                              General        Children's                 Change
                                               2006      WY 2006                                                           Access
 CPT/                                                                           APC Relative Hospital         Hospital                   from
                 Description (short)          Status       Status       APC                                                Hospital
HCPCS                                                                             Weight     Outpatient      Outpatient                 4-14-06
                                            Indicator    Indicator                                                        Outpatient
                                                                                                Fee             Fee                    Schedule
                                           (FYI Only)                                                                        Fee

78481    Heart first pass, single              S             S         0398       4.2038           186.14      427.74       490.16
78483    Heart first pass, multiple            S             S         0376       5.0315           222.79      511.96       586.67
78491    Heart image (pet), single             S             S         0306      13.4521           595.66     1,368.75     1,568.51
78492    Heart image (pet), multiple           S             S         0307      41.7549          1,848.91    4,248.56     4,868.62
78494    Heart image, spect                    S             S         0398       4.2038           186.14      427.74       490.16
78496    Heart first pass add-on               S             S         0399       1.5039            66.59      153.02       175.35
78499    Cardiovascular nuclear exam           S             1         0000       0.0000            0.00        0.00         0.00
78580    Lung perfusion imaging                S             S         0401       3.3166           146.86      337.46       386.72
78584    Lung V/Q image single breath          S             S         0378       5.4064           239.40      550.10       630.39
78585    Lung V/Q imaging                      S             S         0378       5.4064           239.40      550.10       630.39
78586    Aerosol lung image, single            S             S         0401       3.3166           146.86      337.46       386.72
78587    Aerosol lung image, multiple          S             S         0401       3.3166           146.86      337.46       386.72
78588    Perfusion lung image                  S             S         0378       5.4064           239.40      550.10       630.39
78591    Vent image, 1 breath, 1 proj          S             S         0401       3.3166           146.86      337.46       386.72
78593    Vent image, 1 proj, gas               S             S         0401       3.3166           146.86      337.46       386.72
78594    Vent image, mult proj, gas            S             S         0401       3.3166           146.86      337.46       386.72
78596    Lung differential function            S             S         0378       5.4064           239.40      550.10       630.39
78599    Respiratory nuclear exam              S             1         0000       0.0000            0.00        0.00         0.00
78600    Brain imaging, ltd static             S             S         0402       5.1709           228.97      526.14       602.93
78601    Brain imaging, ltd w/flow             S             S         0402       5.1709           228.97      526.14       602.93
78605    Brain imaging, complete               S             S         0402       5.1709           228.97      526.14       602.93
78606    Brain imaging, compl w/flow           S             S         0402       5.1709           228.97      526.14       602.93
78607    Brain imaging (3D)                    S             S         0402       5.1709           228.97      526.14       602.93
78608    Brain imaging (PET)                   S             S         1513      19.3242      *    855.68     1,966.24     2,253.20
78609    Brain imaging (PET)                   E             1         0000       0.0000            0.00        0.00         0.00
78610    Brain flow imaging only               S             S         0402       5.1709           228.97      526.14       602.93
78615    Cerebral vascular flow image          S             S         0402       5.1709           228.97      526.14       602.93
78630    Cerebrospinal fluid scan              S             S         0403       3.5015           155.05      356.28       408.27
78635    CSF ventriculography                  S             S         0403       3.5015           155.05      356.28       408.27
78645    CSF shunt evaluation                  S             S         0403       3.5015           155.05      356.28       408.27
78647    Cerebrospinal fluid scan              S             S         0403       3.5015           155.05      356.28       408.27
78650    CSF leakage imaging                   S             S         0403       3.5015           155.05      356.28       408.27
78660    Nuclear exam of tear flow             S             S         0403       3.5015           155.05      356.28       408.27
78699    Nervous system nuclear exam           S             1         0000       0.0000            0.00        0.00         0.00
78700    Kidney imaging, static                S             S         0404       3.6558           161.88      371.98       426.27
78701    Kidney imaging with flow              S             S         0404       3.6558           161.88      371.98       426.27
78704    Imaging renogram                      S             S         0404       3.6558           161.88      371.98       426.27
78707    Kidney flow/function image            S             S         0404       3.6558           161.88      371.98       426.27
78708    Kidney flow/function image            S             S         0405       4.1493           183.73      422.19       483.81
78709    Kidney flow/function image            S             S         0405       4.1493           183.73      422.19       483.81
78710    Kidney imaging (3D)                   S             S         0404       3.6558           161.88      371.98       426.27
78715    Renal vascular flow exam              S             S         0404       3.6558           161.88      371.98       426.27
78725    Kidney function study                 S             S         0389       1.4276            63.21      145.26       166.46
78730    Urinary bladder retention             X             X         0340       0.6137            27.17      62.44        71.56
78740    Ureteral reflux study                 S             S         0404       3.6558           161.88      371.98       426.27
78760    Testicular imaging                    S             S         0404       3.6558           161.88      371.98       426.27
78761    Testicular imaging/flow               S             S         0404       3.6558           161.88      371.98       426.27
78799    Genitourinary nuclear exam            S             1         0000       0.0000            0.00        0.00         0.00
78800    Tumor imaging, limited area           S             S         0406       4.1397           183.31      421.21       482.69
78801    Tumor imaging, mult areas             S             S         0406       4.1397           183.31      421.21       482.69
78802    Tumor imaging, whole body             S             S         0406       4.1397           183.31      421.21       482.69
78803    Tumor imaging (3D)                    S             S         0406       4.1397           183.31      421.21       482.69
78804    Tumor imaging, whole body             S             S         1508      10.9224      *    483.64     1,111.35     1,273.55
78805    Abscess imaging, ltd area             S             S         0406       4.1397           183.31      421.21       482.69
78806    Abscess imaging, whole body           S             S         0406       4.1397           183.31      421.21       482.69
78807    Nuclear localization/abscess          S             S         0406       4.1397           183.31      421.21       482.69
78811    Tumor imaging (pet), limited          S             S         1513      19.3242      *    855.68     1,966.24     2,253.20
78812    Tumor image (pet)/skul-thigh          S             S         1513      19.3242      *    855.68     1,966.24     2,253.20


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                    109 of 223
State of Wyoming Oupatient Prospective Payment System                                                         Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                     Critical
                                                                                              General      Children's                 Change
                                               2006      WY 2006                                                         Access
 CPT/                                                                           APC Relative Hospital       Hospital                   from
                 Description (short)          Status       Status       APC                                              Hospital
HCPCS                                                                             Weight     Outpatient    Outpatient                 4-14-06
                                            Indicator    Indicator                                                      Outpatient
                                                                                                Fee           Fee                    Schedule
                                           (FYI Only)                                                                      Fee

78813    Tumor image (pet) full body           S             S         1513      19.3242      *   855.68    1,966.24     2,253.20
78814    Tumor image pet/ct, limited           S             S         1514      21.0045      *   930.08    2,137.21     2,449.12
78815    Tumorimage pet/ct skul-thigh          S             S         1514      21.0045      *   930.08    2,137.21     2,449.12
78816    Tumor image pet/ct full body          S             S         1514      21.0045      *   930.08    2,137.21     2,449.12
78890    Nuclear medicine data proc            N             N         0000       0.0000           0.00       0.00         0.00
78891    Nuclear med data proc                 N             N         0000       0.0000           0.00       0.00         0.00
78999    Nuclear diagnostic exam               S             1         0000       0.0000           0.00       0.00         0.00
79005    Nuclear rx, oral admin                S             S         0407       3.8758          171.62     394.36       451.92
79101    Nuclear rx, iv admin                  S             S         0407       3.8758          171.62     394.36       451.92
79200    Nuclear rx, intracav admin            S             S         0407       3.8758          171.62     394.36       451.92
79300    Nuclr rx, interstit colloid           S             S         0407       3.8758          171.62     394.36       451.92
79403    Hematopoietic nuclear tx              S             1         0000       0.0000      *    0.00       0.00         0.00
79440    Nuclear rx, intra-articular           S             S         0407       3.8758          171.62     394.36       451.92
79445    Nuclear rx, intra-arterial            S             S         0407       3.8758          171.62     394.36       451.92
79999    Nuclear medicine therapy              S             1         0000       0.0000           0.00       0.00         0.00
80048    Basic metabolic panel                 A             3         0000       0.0000           M01        M01          M01
80050    General health panel                  E             3         0000       0.0000           M01        M01          M01
80051    Electrolyte panel                     A             3         0000       0.0000           M01        M01          M01
80053    Comprehen metabolic panel             A             3         0000       0.0000           M01        M01          M01
80055    Obstetric panel                       E             3         0000       0.0000           M01        M01          M01
80061    Lipid panel                           A             3         0000       0.0000           M01        M01          M01
80069    Renal function panel                  A             3         0000       0.0000           M01        M01          M01
80074    Acute hepatitis panel                 A             3         0000       0.0000           M01        M01          M01
80076    Hepatic function panel                A             3         0000       0.0000           M01        M01          M01
80100    Drug screen, qualitate/multi          A             3         0000       0.0000           M01        M01          M01
80101    Drug screen, single                   A             3         0000       0.0000           M01        M01          M01
80102    Drug confirmation                     A             3         0000       0.0000           M01        M01          M01
80103    Drug analysis, tissue prep            N             N         0000       0.0000           0.00       0.00         0.00
80150    Assay of amikacin                     A             3         0000       0.0000           M01        M01          M01
80152    Assay of amitriptyline                A             3         0000       0.0000           M01        M01          M01
80154    Assay of benzodiazepines              A             3         0000       0.0000           M01        M01          M01
80156    Assay, carbamazepine, total           A             3         0000       0.0000           M01        M01          M01
80157    Assay, carbamazepine, free            A             3         0000       0.0000           M01        M01          M01
80158    Assay of cyclosporine                 A             3         0000       0.0000           M01        M01          M01
80160    Assay of desipramine                  A             3         0000       0.0000           M01        M01          M01
80162    Assay of digoxin                      A             3         0000       0.0000           M01        M01          M01
80164    Assay, dipropylacetic acid            A             3         0000       0.0000           M01        M01          M01
80166    Assay of doxepin                      A             3         0000       0.0000           M01        M01          M01
80168    Assay of ethosuximide                 A             3         0000       0.0000           M01        M01          M01
80170    Assay of gentamicin                   A             3         0000       0.0000           M01        M01          M01
80172    Assay of gold                         A             3         0000       0.0000           M01        M01          M01
80173    Assay of haloperidol                  A             3         0000       0.0000           M01        M01          M01
80174    Assay of imipramine                   A             3         0000       0.0000           M01        M01          M01
80176    Assay of lidocaine                    A             3         0000       0.0000           M01        M01          M01
80178    Assay of lithium                      A             3         0000       0.0000           M01        M01          M01
80182    Assay of nortriptyline                A             3         0000       0.0000           M01        M01          M01
80184    Assay of phenobarbital                A             3         0000       0.0000           M01        M01          M01
80185    Assay of phenytoin, total             A             3         0000       0.0000           M01        M01          M01
80186    Assay of phenytoin, free              A             3         0000       0.0000           M01        M01          M01
80188    Assay of primidone                    A             3         0000       0.0000           M01        M01          M01
80190    Assay of procainamide                 A             3         0000       0.0000           M01        M01          M01
80192    Assay of procainamide                 A             3         0000       0.0000           M01        M01          M01
80194    Assay of quinidine                    A             3         0000       0.0000           M01        M01          M01
80195    Assay of sirolimus                    A             3         0000       0.0000           M01        M01          M01
80196    Assay of salicylate                   A             3         0000       0.0000           M01        M01          M01
80197    Assay of tacrolimus                   A             3         0000       0.0000           M01        M01          M01
80198    Assay of theophylline                 A             3         0000       0.0000           M01        M01          M01
80200    Assay of tobramycin                   A             3         0000       0.0000           M01        M01          M01


                                                   e9fbefe1-8c03-48c9-80f2-f502869a4fea.xls                                  110 of 223
State of Wyoming Oupatient Prospective Payment System                                                        Updated    6/19/06
Procedure Code List
Effective Date: 2006

Conversion Factors:
  $44.28 General Acute Care Hospitals
 $101.75 Children's Hospitals
 $116.60 Critical Access Hospitals


                                            Medicare                                                                    Critical
                                                                                              General     Children's                 Change
                                               2006      WY 2006                                                        Access
 CPT/                                                                           APC Relative Hospital      Hospital                   from
                 Description (short)          Status       Status       APC                                             Hospital
HCPCS                                                                             Weight     Outpatient   Outpatient                 4-14-06
                                            Indicator    Indicator                                                     Outpatient
                                                                                                Fee          Fee                    Schedule
                                           (FYI Only)                                                                     Fee

80201    Assay of topiramate                   A             3         0000       0.0000        M01          M01          M01
80202    Assay of vancomycin                   A             3         0000       0.0000        M01          M01          M01
80299    Quantitative assay, drug              A             1         0000       0.0000       0.00          0.00         0.00
80400    Acth stimulation panel                A             3         0000       0.0000        M01          M01          M01
80402    Acth stimulation panel                A             3         0000       0.0000        M01          M01          M01
80406    Acth stimulation panel                A             3         0000       0.0000        M01          M01          M01
80408    Aldosterone suppression eval          A             3         0000       0.0000        M01          M01          M01
80410    Calcitonin stimul panel               A             3         0000       0.0000        M01          M01          M01
80412    CRH stimulation panel                 A             3         0000       0.0000        M01          M01          M01
80414    Testosterone response                 A             3         0000       0.0000        M01          M01          M01
80415    Estradiol response panel              A             3         0000       0.0000        M01          M01          M01
80416    Renin stimulation panel               A             3         0000       0.0000        M01          M01          M01
80417    Renin stimulation panel               A             3         0000       0.0000        M01          M01          M01
80418    Pituitary evaluation panel            A             3         0000       0.0000        M01          M01          M01
80420    Dexamethasone panel                   A             3         0000       0.0000        M01          M01          M01
80422    Glucagon tolerance panel              A             3         0000       0.0000        M01          M01          M01
80424    Glucagon tolerance panel              A             3         0000       0.0000        M01          M01          M01
80426    Gonadotropin hormone panel            A             3         0000       0.0000        M01          M01          M01
80428    Growth hormone panel                  A             3         0000       0.0000        M01          M01          M01
80430    Growth hormone panel                  A             3         0000       0.0000        M01          M01          M01
80432    Insulin suppression panel             A             3         0000       0.0000        M01          M01          M01
80434    Insulin tolerance panel               A             3         0000       0.0000        M01          M01          M01
80435    Insulin tolerance panel               A             3         0000       0.0000        M01          M01          M01
80436    Metyrapone panel                      A             3         0000       0.0000        M01          M01          M01
80438    TRH stimulation panel                 A             3         0000       0.0000        M01          M01          M01
80439    TRH stimulation panel                 A             3         0000       0.0000        M01          M01          M01
80440    TRH stimulation panel                 A             3         0000       0.0000        M01          M01          M01
80500    Lab pathology consultation            X             X         0433       0.2493       11.04        25.37        29.07
80502    Lab pathology consultation            X             X         0342       0.1450       6.42         14.75        16.91
81000    Urinalysis, nonauto w/scope           A             3         0000       0.0000        M01          M01          M01
81001    Urinalysis, auto w/scope              A             3         0000       0.0000        M01          M01          M01
81002    Urinalysis nonauto w/o scope          A             3         0000       0.0000        M01          M01          M01
81003    Urinalysis, auto, w/o scope           A             3         0000       0.0000        M01          M01          M01
81005    Urinalysis                            A             3         0000       0.0000        M01          M01          M01
81007    Urine screen for bacteria             A             3         0000       0.0000        M01          M01          M01
81015    Microscopic exam of urine             A             3         0000       0.0000        M01          M01          M01
81020    Urinalysis, glass test                A             3         0000       0.0000        M01          M01          M01
81025    Urine pregnancy test                  A             3         0000       0.0000        M01          M01          M01
81050    Urinalysis, volume measure            A             3         0000       0.0000        M01          M01          M01
81099    Urinalysis test procedure             A             1         0000       0.0000       0.00          0.00         0.00
82000    Assay of blood acetaldehyde           A             3         0000       0.0000        M01          M01          M01
82003    Assay of acetaminophen                A             3         0000       0.0000        M01          M01          M01
82009    Test for acetone/ketones              A             3         0000       0.0000        M01          M01          M01
82010    Acetone assay                         A             3         0000       0.0000        M01          M01          M01
82013    Acetylcholinesterase assay            A             3         0000       0.0000        M01          M01          M01
82016    Acylcarnitines, qual                  A             3         0000       0.0000        M01          M01          M01
82017    Acylcarnitines, quant                 A             3         0000       0