Table of Surgical Indemnity Benefits Schedule

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           Table of Surgical Indemnity Benefits Schedule
                                                                    Plan     Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                    CPT Codes
                                                                    1000     1500   2000   2500   3000   3500    4000           4500           5000
 Abdomen, Peritoneum, and
                                          49320-49329               148      222    296    370    444     518     592           666            740
 Omentum, Laparoscopy
 Ablation, Liver                          47380-47382               439      659    878    1098   1318   1538    1758           1978           2198
 Acne Surgery                                 10040                     37   56      74    93     112     131     150           169            188
 Adenoidectomy                            42830-42836                   89   134    178    223    268     313     358           403            448
 Adjacent Tissue Transfer or
                                          14000-14350               298      447    596    745    894    1043    1192           1341           1490
 Rearrangement
 Allograft/Autograft For Spine
                                          20930-20938                   85   128    170    213    256     299     342           385            428
 Surgery
 Aneurysm, Arteriovenous
 Malformation or Vascular                  61680-61711              972      1458   1944   2430   2916   3402    3888           4374           4860
 Disease, Surgery for
 Angioscopy                                   35400                     73   110    146    183    220     257     294           331            368
                                   65760, 65767-65770, 65850,
 Anterior Segment of the Eye,
                                   65900, 66160, 66170-66180,       476      714    952    1190   1428   1666    1904           2142           2380
 Surgery of the (Complex)
                                   66605, 66986, S0800, S0810
 Anterior Segment of the Eye,
                                              65765                 960      1440   1920   2400   2880   3360    3840          4320            4800
 Surgery of the (Complex)
                                   65400, 65420-65426, 65450-
                                   65600, 65771-65775, 65810-
 Anterior Segment of the Eye,
                                   65820, 65855-65880, 65920-
 Surgery of the (Moderate                                           186      279    372    465    558     651     744           837            930
                                   65930, 66130-66155, 66165,
 Complexity)
                                   66185-66220, 66250-66600,
                                      66625-66770, 66985
 Anterior Segment of the Eye,      65410, 65430-65436, 65800-
                                                                    105      158    210    263    316     369     422           475            528
 Surgery of the (Simple)           65805, 66020-66030, 66999
                                   46040-46045, 46060, 46200,
 Anus, Surgery of the
                                 46211, 46270-46288, 46700-46715,   164      246    328    410    492     574     656           738            820
 (Moderate Complexity)
                                           46753, 46938
                                   46030, 46050, 46070-46080,
                                   46210, 46220, 46320, 46754,
 Anus, Surgery of the (Simple)                                          96   144    192    240    288     336     384           432            480
                                   46900-46924, 46937, 46940-
                                          46942, 46999
 Anus, Diagnostic Endoscopy            46600-46606, S0601               23   35     46     58     70      82       94           106            118
 Anus, Repair of                           46716-46748              690      1035   1380   1725   2070   2415    2760           3105           3450
 Anus, Surgical Endoscopy                  46608-46615                  62   93     124    155    186     217     248           279            310
 Aortic Aneurysm, Repair of
                                          34820-34825               723      1085   1446   1808   2170   2532    2894          3256            3618
 (Highly Complex)
 Aortic Aneurysm, Repair of
                                       34808-34813, 34826           279      419    558    698    838     978     1118          1258           1398
 (Moderate Complexity)


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           Table of Surgical Indemnity Benefits Schedule
                                                                       Plan     Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                      CPT Codes
                                                                       1000     1500   2000   2500   3000   3500    4000           4500           5000
 Aortic Aneurysm, Repair of
                                      34800-34804, 34830-34832         121      182    242    303    364     425     486           547            608
 (Simple)
 Appendectomy                               44950, 44960               281      422    562    703    844     985    1126           1267           1408
 Appendectomy (Secondary
                                                44955                      38    57     76    95     114     133     152           171            190
 Procedure)
 Appendectomy, Laparoscopic                 44970, 56315               230      345    460    575    690     805     920           1035           1150
 Appendiceal Abscess,
                                             44900-44901               247      371    494    618    742     866     990           1114           1238
 Incision & Drainage
 Arm, Amputation of                          24900-24940               342      513    684    855    1026   1197    1368           1539           1710
 Arterial/Venous Aneurysm,         35001-35013, 35045, 35111-35112,
                                                                       509      764    1018   1273   1528   1783    2038          2293            2548
 Repair Of (Complex)                     35131, 35141-35161
 Arterial/Venous Aneurysm,         35021-35022, 35081-35103, 35121-
                                                                       755      1133   1510   1888   2266   2644    3022          3400            3778
 Repair Of (Highly Complex)              35122, 35132, 35162
 Arterial/Venous Fistula, Repair
                                         35180-35190, 35870            353      530    706    883    1060   1237    1414           1591           1768
 of
 Arteries and Veins, Ligation of      37565-37660, 37788-37799         241      362    482    603    724     845     966           1087           1208
                                   34001-34101, 34151-34401, 34451,
 Arteries/Veins, Surgery of the      34510-34530, 35693-35695,
                                                                       355      533    710    888    1066   1244    1422           1600           1778
 (Complex)                           35820, 35875-35876, 35879,
                                         35881, 35905-35907
 Arteries/Veins, Surgery of the
                                            34502, 35691               688      1032   1376   1720   2064   2408    2752          3096            3440
 (Highly Complex)
                                   34111, 34421, 34471-34501, 35701-
 Arteries/Veins, Surgery of the
                                      35800, 35840-35860, 35901-       245      368    490    613    736     859     982           1105           1228
 (Moderate Complexity)
                                             35903, G0159
 Arteries/Veins, Surgery of the
                                                35700                      75   113    150    188    226     264     302           340            378
 (Simple)
                                      35500-35571, 35601-35621,
 Artery Bypass Graft                                                   627      941    1254   1568   1882   2196    2510          2824            3138
                                            35626-35683
 Arthrocentesis                              20600-20610                   29   44     58     73     88      103     118           133            148
 Arthrodesis, Ankle Joint                    27870-27871               494      741    988    1235   1482   1729    1976          2223            2470
 Arthrodesis, Elbow                          24800-24802               413      620    826    1033   1240   1447    1654           1861           2068
 Arthrodesis, Foot or Toe                    28705-28760               389      584    778    973    1168   1363    1558           1753           1948
 Arthrodesis, Hand or Finger
                                         26820-26860, 26862            357      536    714    893    1072   1251    1430           1609           1788
 Joint
 Arthrodesis, Hand or Finger
                                            26861, 26863                   80   120    160    200    240     280     320           360            400
 Joint
 (Additional Procedures)                                                                              0       0       0             0              0




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           Table of Surgical Indemnity Benefits Schedule
                                                                     Plan     Plan   Plan   Plan   Plan   Plan     Plan           Plan           Plan
      Surgical Procedure                     CPT Codes
                                                                     1000     1500   2000   2500   3000   3500     4000           4500           5000
 Arthrodesis, Hip Joint                     27280-27286              489      734    978    1223   1468   1713     1958          2203            2448
 Arthrodesis, Knee                             27580                 645      968    1290   1613   1936   2259     2582          2905            3228
 Arthrodesis, Shoulder                      23800-23802              507      761    1014   1268   1522   1776     2030          2284            2538
 Arthrodesis, Wrist Joint                   25800-25830              367      551    734    918    1102   1286     1470           1654           1838
 Arthroplasty, Forearm/Wrist             25332, 25441-25449          389      584    778    973    1168   1363     1558           1753           1948
 Arthroplasty, Hand/Fingers                 26530-26536              401      602    802    1003   1204   1405     1606           1807           2008
 Arthroplasty, Hip                          27130-27138              693      1040   1386   1733   2080   2427     2774           3121           3468
 Arthroplasty, Knee Joint             27437-27447, 27486-27487       692      1038   1384   1730   2076   2422     2768           3114           3460
 Arthroplasty, Leg/Ankle Joint              27700-27703              308      462    616    770    924    1078     1232           1386           1540
 Arthroplasty, Shoulder                     23470-23472              628      942    1256   1570   1884   2198     2512          2826            3140
 Arthroplasty, Upper Arm/
                                            24360-24366              390      585    780    975    1170   1365     1560           1755           1950
 Elbow
 Arthroscopy, Knee –
                                               29870                 200      300    400    500    600     700     800            900            1000
 Diagnostic
 Arthroscopy,
                                            29900-29902              219      329    438    548    658     768     878            988            1098
 Metacarpophalangeal Joint
 Arthroscopy, Other                     29850-29856, 29909           317      476    634    793    952     1111    1270           1429           1588
 Arthroscopy, Shoulder                   29819-29826, S2300          341      512    682    853    1024   1195     1366           1537           1708
 Arthroscopy, Shoulder –
                                               29815                 226      339    452    565    678     791     904            1017           1130
 Diagnostic
 Arthroscopy,
                                               29804                 292      438    584    730    876    1022     1168           1314           1460
 Temporomandibular Joint
 Arthroscopy,
 Temporomandibular Joint –                     29800                 274      411    548    685    822     959     1096           1233           1370
 Diagnostic
 Arthroscopy, Wrist                         29843-29848              253      380    506    633    760     887     1014           1141           1268
 Arthroscopy, Wrist –
                                               29840                 244      366    488    610    732     854     976            1098           1220
 Diagnostic
 Arthrotomy, Forearm/Wrist            25040, 25100-25101, 25107      257      386    514    643    772     901     1030           1159           1288
 Arthrotomy, Hand/Fingers                   26070-26110              277      416    554    693    832     971     1110           1249           1388
 Arthrotomy, Pelvis/Hip Joint        27030-27033, 27050-27052        433      650    866    1083   1300   1517     1734           1951           2168
 Arthrotomy, Shoulder              23040-23044, 23100-23101, 23107   317      476    634    793    952     1111    1270           1429           1588
 Arthrotomy, Thigh/Knee Joint            27310, 27330-27331          304      456    608    760    912    1064     1216           1368           1520
 Arthrotomy, Upper Arm/Elbow          24000-24006, 24100-24101       246      369    492    615    738     861     984            1107           1230
 Artificial Insemination                    58321-58323                  36   54     72     90     108     126     144            162            180
 Benign Lesions, Excision of                11400-11471                  65   98     130    163    196     229     262            295            328




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           Table of Surgical Indemnity Benefits Schedule
                                                                       Plan     Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                       CPT Codes
                                                                       1000     1500   2000   2500   3000   3500    4000           4500           5000
                                      47400-47460, 47700-47711,
 Biliary Tract, Surgery of the
                                   47715-47716, 47741-47780, 47800,    614      921    1228   1535   1842   2149    2456           2763           3070
 (Complex)
                                            47802-47900
 Biliary Tract, Surgery of the
                                             47712, 47785              810      1215   1620   2025   2430   2835    3240          3645            4050
 (Highly Complex)
 Biliary Tract, Surgery of the     47480-47490, 47510-47530, 47630,
                                                                       244      366    488    610    732     854     976           1098           1220
 (Moderate Complexity)                          47801
 Biliary Tract, Surgery of the
                                             47500-47505                   57   86     114    143    172     201     230           259            288
 (Simple)
 Biliary Tract, Diagnostic
                                             47550-47553               120      180    240    300    360     420     480           540            600
 Endoscopy
 Biliary Tract, Surgical
                                             47554-47556               205      308    410    513    616     719     822           925            1028
 Endoscopy
 Biopsy, Eye Muscle                              67350                     83   125    166    208    250     292     334           376            418
 Biopsy, Prostate                            55700-55705               106      159    212    265    318     371     424           477            530
 Biopsy, Skin                                 11100-11101                  39   59     78     98     118     138     158           178            198
 Bladder, Surgery of the            51060, 51800-51841, 51860-51865,
                                                                       326      489    652    815    978    1141    1304           1467           1630
 (Complex)                                    51900-51925
 Bladder, Surgery of the
                                              51940-51960              642      963    1284   1605   1926   2247    2568          2889            3210
 (Highly Complex)
 Bladder, Surgery of the
                                    51050, 51080-51500, 51715, 51980   150      225    300    375    450     525     600           675            750
 (Moderate Complexity)
 Bladder, Surgery of the            51000-51010, 51600-51710, 51720-
                                                                           90   135    180    225    270     315     360           405            450
 (Simple)                                        51797
 Bladder Cystectomy                           51550-51596              834      1251   1668   2085   2502   2919    3336           3753           4170
                                   51020-51045, 51065, 51520-51535,
 Bladder Cystotomy                                                     229      344    458    573    688     803     918           1033           1148
                                                51880
 Blepharoplasty, Eyelids                     15820-15823               295      443    590    738    886    1034    1182           1330           1478
 Blood Vessel, Repair of                     35201-35286               423      635    846    1058   1270   1482    1694           1906           2118
 Bone Marrow Transplantation                 38230-38241                   49    74    98     123    148     173     198           223            248
 Brain Cavity Shunt                    62190-62192, 62220-62223        400      600    800    1000   1200   1400    1600           1800           2000
 Breast, Repair or
 Reconstruction of the (Highly                19361-19369              743      1115   1486   1858   2230   2602    2974          3346            3718
 Complex)
 Breast, Repair or
                                       19324-19340, 19350-19355,
 Reconstruction of the                                                 327      491    654    818    982    1146    1310           1474           1638
                                              19370-19380
 (Moderate Complexity)




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           Table of Surgical Indemnity Benefits Schedule
                                                                      Plan     Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                      CPT Codes
                                                                      1000     1500   2000   2500   3000   3500    4000           4500           5000
 Breast, Repair or
                                                19396                 158      237    316    395    474     553     632           711            790
 Reconstruction of the (Simple)
 Breast, Surgery of the
                                             19101-19125              185      278    370    463    556     649     742           835            928
 (Moderate Complexity)
                                   19000-19100, 19126, 19290-19291,
 Breast, Surgery of the (Simple)                                          43   65     86     108    130     152     174           196            218
                                                19499
 Breast Tumor, Removal of                   19260-19272               449      674    898    1123   1348   1573    1798          2023            2248
 Bunionectomy                               28290-28299               343      515    686    858    1030   1202    1374           1546           1718
 Burns, Local Treatment                     16000-16042                   41   62     82     103    124     145     166           187            208
 Bypass Graft, Not Vein                        35623                  602      903    1204   1505   1806   2107    2408          2709            3010
 Cardiac Assist                             33960-33978               295      443    590    738    886    1034    1182           1330           1478
 Cardiac Catheterization                 93501, 93508-93533           721      1082   1442   1803   2164   2525    2886           3247           3608
 Cardiac Valves Procedures                  33400-33496               900      1350   1800   2250   2700   3150    3600          4050            4500
 Carpal Tunnel Release                          64721                 191      287    382    478    574     670     766           862            958
 Casts, Application of               29000-29085, 29305-29450,
                                                                          36   54     72      90    108     126     144           162            180
                                           29700-29750
 Cataract Extraction                     66825, 66840-66984           308      462    616    770    924    1078    1232           1386           1540
 Cataract Extraction (Second
                                         66820-66821, 66830           107      161    214    268    322     376     430           484            538
 Cataract)
 Chemical Peel                              15788-15793               100      150    200    250    300     350     400           450            500
 Cholecystectomy                            47600-47620               385      578    770    963    1156   1349    1542           1735           1928
 Cholecystectomy,
                                      47562-47564, 56340-56342        296      444    592    740    888    1036    1184           1332           1480
 Laparoscopic
 Cholecystoenterostomy                      47720-47740               455      683    910    1138   1366   1594    1822          2050            2278
 Circumcision                                54150-54161              130      195    260    325    390     455     520           585            650
 Cleft Lip, Repair of                        40700-40761              442      663    884    1105   1326   1547    1768           1989           2210
 Cleft Palate, Repair of                    42200-42225               390      585    780    975    1170   1365    1560           1755           1950
 Colectomy (Partial)                         44140-44147              588      882    1176   1470   1764   2058    2352          2646            2940
 Colectomy (Total)                           44150-44160              605      908    1210   1513   1816   2119    2422          2725            3028
 Colonoscopy                                45355-45385               230      345    460    575    690     805     920           1035           1150
 Colostomy                           44320-44346, 44605, 45563,
                                                                      471      707    942    1178   1414   1650    1886           2122           2358
                                              45805
 Colposcopy                                  57452-57460                  56   84     112    140    168     196     224           252            280
 Complex Cardiac Anomalies,
                                            33600-33619               967      1451   1934   2418   2902   3386    3870          4354            4838
 Repair of




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           Table of Surgical Indemnity Benefits Schedule
                                                                    Plan     Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                    CPT Codes
                                                                    1000     1500   2000   2500   3000   3500    4000           4500           5000
 Conjunctiva, Surgery of the
                                          68505, 68550              364      546    728    910    1092   1274    1456           1638           1820
 (Complex)
 Conjunctiva, Surgery of the       68130, 68320-68362, 68500,
 (Moderate Complexity)             68510-68540, 68700, 68720-       287      431    574    718    862    1006    1150           1294           1438
                                          68750, 68770
 Conjunctiva, Surgery of the    68020-68115, 68135-68200, 68399-
 (Simple)                          68440, 68705, 68760-68761,           87   131    174    218    262     306     350           394            438
                                          68800-68899
 Control Of Nasal
                                          42970-42972               185      278    370    463    556     649     742           835            928
 Hemorrhage
 Control Of Throat Hemorrhage             42960-42962               178      267    356    445    534     623     712           801            890
 Corneal Transplant                       65710-65755               466      699    932    1165   1398   1631    1864          2097            2330
 Coronary Artery Anomalies,
                                          33500-33506               676      1014   1352   1690   2028   2366    2704          3042            3380
 Repair of
 Coronary Bypass/Grafts            33510-33516, 33533-33545,
                                   33702-33720, S2205, S2206,       860      1290   1720   2150   2580   3010    3440          3870            4300
                                          S2207, S2209
 Coronary Bypass/Grafts
                                   33517-33530, 33572, S2208        156      234    312    390    468     546     624           702            780
 (Additional)
 Coronary Transluminal
                                             92980                  364      546    728    910    1092   1274    1456           1638           1820
 Angioplasty
 Coronary Transluminal
                                              92981                 102      153    204    255    306     357     408           459            510
 Angioplasty (Additional)
 Craniectomy or Craniotomy                 61304-61576              823      1235   1646   2058   2470   2882    3294           3706           4118
 Cranioplasty                    62120, 62140-62141, 62145-62147    457      686    914    1143   1372   1601    1830          2059            2288
 Cryotherapy for Acne                         17340                     20   30     40      50     60     70      80            90             100
 Debridement                               11000-11044                  30   45     60      75     90     105     120           135            150
 Dentoalveolar Structures,
                                41820, 41823, 41827-41830, 41870,
 Surgery of the (Moderate                                           122      183    244    305    366     427     488           549            610
                                              41874
 Complexity)
 Dentoalveolar Structures,       41800-41806, 41821-41822, 41825-
                                                                        67   101    134    168    202     236     270           304            338
 Surgery of the (Simple)            41826, 41850, 41872, 41899
 Destruction By Neurolytic
                                          64600-64680                   89   134    178    223    268     313     358           403            448
 Agent
 Destruction of Lesion,
                                          67208-67228               327      491    654    818    982    1146    1310           1474           1638
 Retinopathy
 Destruction, Benign or             17000-17105, 17110-17250,
                                                                        30   45     60      75     90     105     120           135            150
 Premalignant Lesions                    G0051-G0053




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           Table of Surgical Indemnity Benefits Schedule
                                                                Plan      Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                   CPT Codes
                                                                1000      1500   2000   2500   3000   3500    4000           4500           5000
 Destruction, Benign or
                                          17106-17108           229       344    458    573    688     803     918           1033           1148
 Premalignant Vascular Lesions
 Destruction, Malignant Lesions,
                                          17260-17286               52    78     104    130    156     182     208           234            260
 Any Method
 Diagnostic Cystoscopy                    52000-52204               111   167    222    278    334     390     446           502            558
 Diagnostic Sigmoidoscopy          45300-45305, 45330-45331,
                                                                    49     74     98    123    148     173     198           223            248
                                   G0104-G0106, G0120-G0121
 Diaphragm, Repair of
                                             39503              1000      1500   2000   2500   3000   3500    4000          4500            5000
 (Neonatal)
 Diaphragm, Repair of              39501-39502, 39520-39561     426       639    852    1065   1278   1491    1704           1917           2130
 Dilatation and Curettage                57820, 58120           127       191    254    318    382     446     510           574            638
 Elective Esophagogastro-
 duodenoscopy
                                          43200-43258           149       224    298    373    448     523     598           673            748


 Embolization of Vertebral
                                          22520-22522           187       281    374    468    562     656     750           844            938
 Body
 Enterolysis                                 44005              417       626    834    1043   1252   1461    1670           1879           2088
 Enteroscopy                       44360-44361, 44376-44378         79    119    158    198    238     278     318           358            398
 Epidermal Introduction                11900-11980, S2190           27     41     54    68     82      96      110           124            138
 ERCP                                     43260-43272           175       263    350    438    526     614     702           790            878
 Esophagus, Surgery of the         43045, 43101, 43130-43135,
 (Complex)                         43300-43305, 43320-43352,    528       792    1056   1320   1584   1848     2112          2376           2640
                                      43400-43415, 43425
 Esophagus, Surgery of the
                                   43020-43030, 43100, 43420    283       425    566    708    850     992    1134           1276           1418
 (Moderate Complexity)
 Esophagus, Dilation of the               43450-43460               49     74     98    123    148     173     198           223            248
 Esophagus, Laparoscopy                   43280-43289           457       686    914    1143   1372   1601    1830          2059            2288
 Exenteration Pelvic Complete                51597              982       1473   1964   2455   2946   3437    3928           4419           4910
 External Ear, Surgery of the
                                    69150-69155, 69310-69320    399       599    798    998    1198   1398    1598           1798           1998
 (Complex)
 External Ear, Surgery of the
                                      69110, 69140, 69300       157       236    314    393    472     551     630           709            788
 (Moderate Complexity)
 External Ear, Surgery of the      69000-69105, 69120, 69145,
                                                                    59    89     118    148    178     208     238           268            298
 (Simple)                                   69399
 Extracranial, Peripheral, and
 Autonomic Nerves, Surgery of                64876                  85    128    170    213    256     299     342           385            428
 the (Moderate Complexity)




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           Table of Surgical Indemnity Benefits Schedule
                                                                     Plan     Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                     CPT Codes
                                                                     1000     1500   2000   2500   3000   3500    4000           4500           5000
 Eyeball, Surgery of the
                                            65110-65114              509      764    1018   1273   1528   1783    2038          2293            2548
 (Complex)
 Eyeball, Surgery of the
                                        65091-65105, 65290           338      507    676    845    1014   1183    1352           1521           1690
 (Moderate Complexity)
 Fallopian Tubes, Ligation of                  58611                     36   54     72     90     108     126     144           162            180
 Fasciectomy                         26121-26125, 28060-28062        354      531    708    885    1062   1239    1416           1593           1770
 Female Genital, Surgery of the   56805, 57106-57107, 57109-57112,
 (Complex)                          57265, 57270-57280, 57284-
                                    57289, 57292, 57305-57307,
                                                                     350      525    700    875    1050   1225    1400           1575           1750
                                    57330-57335, 57540, 57555,
                                    58140, 58540, 58720, 58750-
                                    58752, 58770, 58950, 58960
 Female Genital, Surgery of the
                                        57531, 58951-58952           645      968    1290   1613   1936   2259    2582          2905            3228
 (Highly Complex)
 Female Genital, Surgery of the     56440, 56740-56800, 56810,
 (Moderate Complexity)              57010, 57065, 57108, 57120,
                                    57200-57260, 57268, 57282,
                                    57291, 57300, 57308-57320,
                                                                     171      257    342    428    514     600     686           772            858
                                    57520-57530, 57545-57550,
                                    57556-57720, 58145, 58345,
                                    58400-58520, 58615, 58700,
                                    58740, 58760, 58800-58925
 Female Genital, Surgery of the      56405-56420, 56441-56606,
 (Simple)                           56700-56720, 57000, 57020-
                                  57061, 57100-57105, 57130-57180,
                                                                         74   111    148    185    222     259     296           333            370
                                  57400-57415, 57500-57513, 57800,
                                     58100, 58300-58301, 58340,
                                            58350, 58999
 Finger, Amputation of                     26910-26952               324      486    648    810    972    1134    1296           1458           1620
 Flaps (Graft - Myocutaneous)               15732-15738              518      777    1036   1295   1554   1813    2072           2331           2590
 Flaps (Graft - Pedicle)                   15570-15650               223      335    446    558    670     782     894           1006           1118
 Foot & Toes, Surgery of the
                                     28114, 28262-28264, 28360       515      773    1030   1288   1546   1804    2062          2320            2578
 (Complex)
 Foot & Toes, Surgery of the        28002-28035, 28045-28054,
 (Moderate Complexity)            28070-28113, 28116-28175, 28192-
                                    28230, 28236-28261, 28270-       238      357    476    595    714     833     952           1071           1190
                                    28280, 28286-28289, 28313-
                                               28345
 Foot & Toes, Surgery of the        28001, 28043, 28190, 28232-
                                                                     158      237    316    395    474     553     632           711            790
 (Simple)                                  28234, 28899




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          Table of Surgical Indemnity Benefits Schedule
                                                                      Plan     Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                      CPT Codes
                                                                      1000     1500   2000   2500   3000   3500    4000           4500           5000
 Foot or Toe - Closed Treatment,     28400-28405, 28430-28435,
 Fracture and/or Dislocation of      28470-28475, 28490-28495,
                                     28510-28515, 28530, 28540-
                                                                      101      152    202    253    304     355     406           457            508
                                     28545, 28570-28575, 28600-
                                     28605, 28630-28635, 28660-
                                               28665
 Foot or Toe - Percutaneous          28406, 28436, 28456, 28476,
 Skeletal Fixation, Fracture         28496, 28546, 28576, 28606,      236      354    472    590    708     826     944           1062           1180
 and/or Dislocation of                      28636, 28666
 Foot or Toe - Treatment Of
 Tarsal Bone Fracture, Fracture             28450-28455               124      186    248    310    372     434     496           558            620
 and/or Dislocation of
 Foot or Toe, Amputation of                 28800-28825               255      383    510    638    766     894    1022           1150           1278
 Foot or Toe, Osteotomy                     28300-28312               271      407    542    678    814     950    1086           1222           1358
 Forearm or Wrist - Closed           25500-25505, 25520, 25530-
 Treatment, Fracture and/or          25535, 25560-25565, 25600-
 Dislocation of                      25605, 25622-25624, 25630-       161      242    322    403    484     565     646           727            808
                                     25635, 25650-25660, 25675,
                                            25680, 25690
 Forearm or Wrist - Open             25515, 25525-25526, 25545,
 Treatment, Fracture and/or          25574-25575, 25620, 25628,
                                                                      338      507    676    845    1014   1183    1352           1521           1690
 Dislocation of                      25645, 25670, 25676, 25685,
                                               25695
 Forearm or Wrist –
 Percutaneous Skeletal Fixation,                25611                 315      473    630    788    946    1104    1262           1420           1578
 Fracture and/or Dislocation of
 Forearm, Amputation of                     25900-25931               382      573    764    955    1146   1337    1528           1719           1910
 Forearm/Wrist, Surgery of the        25077, 25170, 25315-25331,
 (Complex)                            25335-25337, 25390-25440,       456      684    912    1140   1368   1596    1824          2052            2280
                                             25455-25492
 Forearm/Wrist, Surgery of the       25000-25028, 25035, 25066-
 (Moderate Complexity)                25076, 25085, 25105, 25110-
                                                                      230      345    460    575    690     805     920           1035           1150
                                   25151, 25210-25240, 25248-25312,
                                                25450
 Forearm/Wrist, Surgery of the
                                     25031, 25065, 25246, 25999       181      272    362    453    544     635     726           817            908
 (Simple)
 Forearm/Wrist, Osteotomy                   25350-25375               451      677    902    1128   1354   1580    1806          2032            2258
 Foreign Body From Ear,
                                            69200-69222                   23   35     46     58     70      82       94           106            118
 Removal of
 Foreign Body From Eyeball,
                                            65205-65265                   49    74    98     123    148     173     198           223            248
 Removal of




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          Table of Surgical Indemnity Benefits Schedule
                                                                        Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                      CPT Codes
                                                                        1000   1500   2000   2500   3000   3500    4000           4500           5000
 Free Skin Grafts                     15000-15100, 15120, 15200,
                                     15220, 15240, 15260, 15350-         288   432    576    720    864    1008    1152           1296           1440
                                         15401, G0169-G0171
 Free Skin Grafts (Additional      15101, 15121, 15201, 15221, 15241,
                                                                         59    89     118    148    178     208     238           268            298
 Procedure)                                      15261
 Gastrectomy                             43620-43634, 43639              616   924    1232   1540   1848   2156    2464          2772            3080
 Gastric Surgery for Morbid
                                             43846-43848                 687   1031   1374   1718   2062   2406    2750           3094           3438
 Obesity
 General Pacemaker or                33237-33238, 33243, 33245,
 Defibrillator Procedures            33247-33250, 33260, 33282-          399   599    798    998    1198   1398    1598           1798           1998
 (Complex)                                    33284
 General Pacemaker or
 Defibrillator Procedures             33246, 33251-33253, 33261          674   1011   1348   1685   2022   2359    2696          3033            3370
 (Highly Complex)
 General Pacemaker or
                                      33210-33236, 33240-33242,
 Defibrillator Procedures                                                180   270    360    450    540     630     720           810            900
                                               33244
 (Moderate Complexity)
 Grafts of Bone, Cartilage,
                                         20900-20926, S2109              265   398    530    663    796     929    1062           1195           1328
 Tendon
 Great Vessels, Surgery of the
                                             33800, 33915                508   762    1016   1270   1524   1778    2032          2286            2540
 (Complex)
 Great Vessels, Surgery of the       33735-33737, 33788, 33802-
 (Highly Complex)                    33814, 33822-33851, 33860-          895   1343   1790   2238   2686   3134    3582          4030            4478
                                        33875, 33910, 33916
 Great Vessels, Surgery of the
                                                33924                    138   207    276    345    414     483     552           621            690
 (Moderate Complexity)
 Great Vessels, Repair of            33730-33732, 33770-33786,
                                     33820, 33852-33853, 33877,          668   1002   1336   1670   2004   2338    2672          3006            3340
                                            33917-33920
 Hair Transplant                             15775-15776                 125   188    250    313    376     439     502           565            628
 Hammertoe Operation                            28285                    234   351    468    585    702     819     936           1053           1170
 Hand or Finger - Closed              26600-26607, 26641-26645,
 Treatment, Fracture and/or           26670-26675, 26700-26705,
                                                                         109   164    218    273    328     383     438           493            548
 Dislocation of                       26720-26725, 26740-26742,
                                      26750-26755, 26770-26775
 Hand or Finger - Open               26615, 26665, 26685-26686,
 Treatment, Fracture and/or          26715, 26735, 26746, 26765,         245   368    490    613    736     859     982           1105           1228
 Dislocation of                                26785
 Hand or Finger - Percutaneous
                                     26608, 26650, 26676, 26706,
 Skeletal Fixation, Fracture                                             248   372    496    620    744     868     992           1116           1240
                                        26727, 26756, 26776
 and/or Dislocation of




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          Table of Surgical Indemnity Benefits Schedule
                                                                     Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                     CPT Codes
                                                                     1000   1500   2000   2500   3000   3500    4000           4500           5000
 Hand/Fingers, Surgery of the       26255, 26392, 26492, 26496,
 (Complex)                          26498, 26555, 26561-26562,        510   765    1020   1275   1530   1785    2040          2295            2550
                                       26580-26585, 26590
 Hand/Fingers, Surgery of the
                                        26550-26554, 26556            981   1472   1962   2453   2944   3435    3926           4417           4908
 (Highly Complex)
 Hand/Fingers, Surgery of the     26025-26055, 26117, 26130-26145,
 (Moderate Complexity)              26185, 26250, 26260-26320,
                                    26416, 26437-26455, 26471-
                                    26490, 26494, 26497, 26499-       271   407    542    678    814     950    1086           1222           1358
                                    26525, 26540-26548, 26557-
                                    26560, 26565-26568, 26587,
                                        26591-26593, 26597
 Hand/Fingers, Surgery of the        26010-26011, 26060, 26460,
                                                                      135   203    270    338    406     474     542           610            678
 (Simple)                                      26989
 Hand/Fingers, Repair of          26350-26373, 26410-26412, 26418-
                                                                      399   599    798    998    1198   1398    1598           1798           1998
                                               26434
 Heart & Pericardium, Surgery       33020-33025, 33031-33050,
 of the (Complex)                   33130, 33300, 33310-33320,        382   573    764    955    1146   1337    1528           1719           1910
                                              33330
 Heart & Pericardium, Surgery       33030, 33120, 33140, 33305,
 of the (Highly Complex)            33321-33322, 33332-33350,         633   950    1266   1583   1900   2217    2534           2851           3168
                                           33722, S2204
 Heart & Pericardium, Surgery
                                               33015                  198   297    396    495    594     693     792           891            990
 of the (Moderate Complexity)
 Heart & Pericardium, Surgery
                                        33010-33011, 33999            56    84     112    140    168     196     224           252            280
 of the (Simple)
 Heart/Lung Transplantation                33935, 33945              1000   1500   2000   2500   3000   3500    4000          4500            5000
 Heart/Lung Transplantation –
                                           33930, 33940               461   692    922    1153   1384   1615    1846          2077            2308
 Donor
 Hemorrhoid Surgery                 46083, 46500, 46934-46936,
                                                                      119   179    238    298    358     418     478           538            598
                                           46945-46946
 Hemorrhoidectomy                          46221-46262                143   215    286    358    430     502     574           646            718
 Hernia Repair                              49495-49611               228   342    456    570    684     798     912           1026           1140
 Hernia, Laparoscopy                       49650-49659                177   266    354    443    532     621     710           799            888
 Hypospadias, Repair of                    54308-54352                453   680    906    1133   1360   1587    1814           2041           2268
 Hysterectomy                              58150-58285                413   620    826    1033   1240   1447    1654           1861           2068
 Hysterectomy, Following
                                               59525                  227   341    454    568    682     796     910           1024           1138
 Cesarean Section
 Injection of Nerve Block Agent            64400-64530                63    95     126    158    190     222     254           286            318
 Inner Ear, Surgery of the           69801-69820, 69905-69910,
                                                                      373   560    746    933    1120   1307    1494           1681           1868
 (Complex)                                    69930


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            Table of Surgical Indemnity Benefits Schedule
                                                                     Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                     CPT Codes
                                                                     1000   1500   2000   2500   3000   3500    4000           4500           5000
 Inner Ear, Surgery of the
                                               69915                  644   966    1288   1610   1932   2254    2576          2898            3220
 (Highly Complex)
 Inner Ear, Surgery of the
                                               69840                  332   498    664    830    996    1162    1328           1494           1660
 (Moderate Complexity)
 Intestine, Laparoscopy                    44200-44209                415   623    830    1038   1246   1454    1662           1870           2078
 Intestines Except Rectum,        44020-44055, 44111-44120, 44125-
 Surgery of the (Complex)           44130, 44310, 44316, 44602-       443   665    886    1108   1330   1552    1774           1996           2218
                                    44604, 44615, 44625-44700
 Intestines Except Rectum,          44010-44015, 44110, 44121,
 Surgery of the (Moderate           44300, 44312-44314, 44620,        280   420    560    700    840     980    1120           1260           1400
 Complexity)                               44800-44850
 Intestines Except Rectum,          44100, 44139, 44500, 44799,
                                                                      16    24     32     40     48      56      64            72              80
 Surgery of the (Simple)                      44899
 Intestines, Diagnostic
                                           44380-44389                120   180    240    300    360     420     480           540            600
 Endoscopy
 Intestines, Surgical Endoscopy      44363-44373, 44390-44394         129   194    258    323    388     453     518           583            648
 Intravascular Ultrasound
                                            37250-37251               51    77     102    128    154     180     206           232            258
 Services
 Introduction of Needle or        36000-36012, 36100-36160, 36245-
                                                                      75    113    150    188    226     264     302           340            378
 Intracatheter                          36410, 36420-36680
 Intubation                                    31500                  53    80     106    133    160     187     214           241            268
 Kidney, Surgery of the             50010-50020, 50100, 50280-
                                                                      494   741    988    1235   1482   1729    1976          2223            2470
                                    50290, 50400, 50500-50540
 (Complex)                                                                                        0       0       0             0              0
 Kidney, Surgery of the                        50405                  620   930    1240   1550   1860   2170    2480          2790            3100
 (Highly Complex)                                                                                 0       0       0             0              0
 Kidney, Surgery of the             50021, 50205, 50392-50393,
                                                                      105   158    210    263    316     369     422           475            528
                                              50395
 (Moderate Complexity)                                                                            0       0       0             0              0
 Kidney, Surgery of the             50200, 50390, 50394, 50396-
                                                                      58    87     116    145    174     203     232           261            290
                                              50398
 (Simple)                                                                                         0       0       0             0              0
 Kidney, Diagnostic Endoscopy           50551-50555, 50574            258   387    516    645    774     903    1032           1161           1290
 Kidney, Surgical Endoscopy          50557-50572, 50575-50580         334   501    668    835    1002   1169    1336           1503           1670
 Knee Reconstruction                        27427-27429               458   687    916    1145   1374   1603    1832           2061           2290
 Laceration of Eyeball, Repair
                                           65270-65286                308   462    616    770    924    1078    1232           1386           1540
 of
 Laminectomy                         63001-63030, 63040-63047,
                                                                      454   681    908    1135   1362   1589    1816          2043            2270
                                            63170-63290
 Laminectomy                               63035, 63048               92    138    184    230    276     322     368           414            460

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            Table of Surgical Indemnity Benefits Schedule
                                                                      Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                      CPT Codes
                                                                      1000   1500   2000   2500   3000   3500    4000           4500           5000
 (Additional Procedure)                                                                            0       0       0             0              0
 Laparotomy                              49000-49002, 49220            316   474    632    790    948    1106    1264           1422           1580
 Laryngectomy                                31360-31382               724   1086   1448   1810   2172   2534    2896          3258            3620
 Laryngoplasty                        31580-31584, 31587-31588         552   828    1104   1380   1656   1932    2208          2484            2760
 Larynx, Surgery of the                         31300                  546   819    1092   1365   1638   1911    2184           2457           2730
 (Complex)                                                                                         0       0       0             0              0
 Larynx, Surgery of the                      31390-31395               973   1460   1946   2433   2920   3407    3894           4381           4868
 (Highly Complex)                                                                                  0       0       0             0              0
 Larynx, Surgery of the            31320, 31400-31420, 31585-31586,
                                                                       395   593    790    988    1186   1384    1582           1780           1978
                                             31590-31595
 (Moderate Complexity)                                                                             0       0       0             0              0
 Larynx, Surgery of the                     31502, 31599               44    66     88     110    132     154     176           198            220
 (Simple)                                                                                          0       0       0             0              0
 Larynx, Diagnostic Endoscopy                31505-31513               43    65     86     108    130     152     174           196            218
 Larynx, Surgical Endoscopy                  31515-31579               61    92     122    153    184     215     246           277            308
 Leg or Ankle Joint – Closed          27750-27752, 27760-27762,
 Treatment, Fracture and/or           27780-27781, 27786-27788,
 Dislocation of                    27808-27810, 27816-27818, 27824-    160   240    320    400    480     560     640           720            800
                                     27825, 27830-27831, 27840-
                                                27842
 Leg or Ankle Joint – Open           27758-27759, 27766, 27784,
 Treatment, Fracture and/or          27792, 27814, 27822-27823,
                                                                       384   576    768    960    1152   1344    1536           1728           1920
 Dislocation of                      27826-27829, 27832, 27846-
                                               27848
 Leg or Ankle Joint –
 Percutaneous Skeletal Fixation,                27756                  309   464    618    773    928    1083    1238           1393           1548
 Fracture and/or Dislocation of
 Leg or Ankle Joint, Amputation
                                            27880-27889                409   614    818    1023   1228   1433    1638           1843           2048
 of
 Leg/Ankle Joint, Surgery of the    27615, 27626, 27637-27640,
 (Complex)                       27645-27647, 27650-27654, 27698,      379   569    758    948    1138   1328    1518           1708           1898
                                    27715-27720, 27742-27745
 Leg/Ankle Joint, Surgery of the   27600-27603, 27606-27612, 27614,
 (Moderate Complexity)             27618-27625, 27630-27635, 27641,
                                                                       313   470    626    783    940    1097    1254           1411           1568
                                   27680-27691, 27695-27696, 27704,
                                      27730-27740, 27892-27894
 Leg/Ankle Joint, Surgery of the      27604-27605, 27613, 27648,
                                                                       148   222    296    370    444     518     592           666            740
 (Simple)                                27692, 27860, 27899
 Leg/Ankle Joint, Osteotomy                 27705-27712                374   561    748    935    1122   1309    1496           1683           1870
 Leg/Ankle Joint, Repair of           27656-27676, 27722-27727         403   605    806    1008   1210   1412    1614           1816           2018


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           Table of Surgical Indemnity Benefits Schedule
                                                                      Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                      CPT Codes
                                                                      1000   1500   2000   2500   3000   3500    4000           4500           5000
 Lesions on Hand/Fingers,          26020, 26115-26116, 26160-26180,
 Excision of                         26200-26236, 26390, 26415,        246   369    492    615    738     861     984           1107           1230
                                                26596
 Lipectomy                            15831-15839, 15876-15879         346   519    692    865    1038   1211    1384           1557           1730
 Lips, Surgery of the (Complex)                40527                   326   489    652    815    978    1141    1304           1467           1630
 Lips, Surgery of the (Moderate
                                     40500-40525, 40530-40654          199   299    398    498    598     698     798           898            998
 Complexity)
 Lips, Surgery of the (Simple)              40490, 40799               49     74     98    123    148     173     198           223            248
 Lithotripsy                                   50590                   340   510    680    850    1020   1190    1360           1530           1700
 Liver - Transplant (Donor)                 47133-47134                975   1463   1950   2438   2926   3414    3902          4390            4878
 Liver - Transplant, Surgery of
                                            47135-47136               1000   1500   2000   2500   3000   3500    4000          4500            5000
 the (Highly Complex)
 Liver, Surgery of the (Complex)     47120, 47350-47360, S2210         771   1157   1542   1928   2314   2700    3086           3472           3858
 Liver, Surgery of the (Highly
                                         47122-47130, 47361           1000   1500   2000   2500   3000   3500    4000          4500            5000
 Complex)
 Liver, Surgery of the
                                     47010-47100, 47300, 47362         338   507    676    845    1014   1183    1352           1521           1690
 (Moderate Complexity)
 Liver, Surgery of the (Simple)          47000-47001, 47399            168   252    336    420    504     588     672           756            840
 Liver, Laparoscopy                         47370-47379                281   422    562    703    844     985    1126           1267           1408
 Lung Transplant                            32851-32854               1000   1500   2000   2500   3000   3500    4000          4500            5000
 Lung Transplant (Donor)                       32850                   528   792    1056   1320   1584   1848     2112          2376           2640
 Lungs/Pleura, Surgery of the         32100-32200, 32215-32310,
 (Complex)                           32320, 32440-32445, 32480,
                                     32482-32484, 32485, 32486-
                                     32488, 32491-32500, 32520-        597   896    1194   1493   1792   2091    2390          2689            2988
                                     32525, 32540, 32800-32810,
                                     32815-32820, 32900-32905,
                                            32940, G0061
 Lungs/Pleura, Surgery of the
                                               32906                   737   1106   1474   1843   2212   2581    2950           3319           3688
 (Highly Complex)
 Lungs/Pleura, Surgery of the        32000-32005, 32095, 32201,
                                                                       81    122    162    203    244     285     326           367            408
 (Moderate Complexity)                     32402, 32501
 Lungs/Pleura, Surgery of the        32400, 32405-32420, 32960-
                                                                       71    107    142    178    214     250     286           322            358
 (Simple)                                      32999
 Lungs/Pleura, Diagnostic
                                            32601-32606                177   266    354    443    532     621     710           799            888
 Endoscopy
 Lungs/Pleura, Surgical
                                            32650-32665                395   593    790    988    1186   1384    1582           1780           1978
 Endoscopy
 Lymph Nodes and Lymphatic
 Channels, Surgery of the                   38381, 38555               416   624    832    1040   1248   1456    1664           1872           2080
 (Complex)

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          Table of Surgical Indemnity Benefits Schedule
                                                                     Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                     CPT Codes
                                                                     1000   1500   2000   2500   3000   3500    4000           4500           5000
 Lymph Nodes and Lymphatic
                                    38305-38380, 38382, 38510-
 Channels, Surgery of the                                             201   302    402    503    604     705     806           907            1008
                                          38550, 38794
 (Moderate Complexity)
 Lymph Nodes and Lymphatic
                                    38300, 38500-38505, 38790,
 Channels, Surgery of the                                             113   170    226    283    340     397     454           511            568
                                           38792, 38999
 (Simple)
 Lymphadenectomy                     38562-38564, 38700-38745,
                                                                      399   599    798    998    1198   1398    1598           1798           1998
                                           38760-38780
 Lymphadenectomy (Additional
                                            38746-38747               119   179    238    298    358     418     478           538            598
 Procedure)
 Lymphadenectomy,
                                     38571-38572, 56312-56313         366   549    732    915    1098   1281    1464           1647           1830
 Laparoscopic
 Major Vessel Shunt                     33750-33767, 33922            623   935    1246   1558   1870   2182    2494          2806            3118
 Male Genital, Surgery of the     54111-54112, 54125-54130, 54304,
 (Complex)                          54360-54401, 54405-54420,
                                                                      371   557    742    928    1114   1300    1486           1672           1858
                                    54650, 54680, 54900-54901,
                                               55650
 Male Genital, Surgery of the
                                               54135                  710   1065   1420   1775   2130   2485    2840           3195           3550
 (Highly Complex)
 Male Genital, Surgery of the       54115-54120, 54205, 54300,
 (Moderate Complexity)              54402, 54430-54435, 54510,
                                    54550-54640, 54660-54670,
                                                                      182   273    364    455    546     637     728           819            910
                                    54820-54861, 55040-55060,
                                    55110-55200, 55300-55540,
                                       55600-55605, 55680
 Male Genital, Surgery of the     54000-54001, 54015, 54050-54105,
 (Simple)                            54110, 54200, 54220-54250,
                                                                      73    110    146    183    220     257     294           331            368
                                     54440-54505, 54700-54800,
                                     55000, 55100, 55870-55980
 Malignant Lesions, Excision of             11600-11646               91    137    182    228    274     320     366           412            458
 Mastectomy                                 19140-19240               348   522    696    870    1044   1218    1392           1566           1740
 Mediastinum, Surgery of the
                                           39010-39220                411   617    822    1028   1234   1440    1646           1852           2058
 (Complex)
 Mediastinum, Surgery of the
                                               39000                  237   356    474    593    712     831     950           1069           1188
 (Moderate Complexity)
 Middle Ear, Surgery of the         69501-69502, 69505-69530,
 (Complex)                          69550-69552, 69601-69605,         401   602    802    1003   1204   1405    1606           1807           2008
                                  69650-69670, 69720, 69740-69745
 Middle Ear, Surgery of the
                                        69535, 69554, 69725           927   1391   1854   2318   2782   3246    3710           4174           4638
 (Highly Complex)
 Middle Ear, Surgery of the
                                  69440-69450, 69620, 69676-69711     228   342    456    570    684     798     912           1026           1140
 (Moderate Complexity)


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           Table of Surgical Indemnity Benefits Schedule
                                                                     Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                     CPT Codes
                                                                     1000   1500   2000   2500   3000   3500    4000           4500           5000
 Middle Ear, Surgery of the         69400-69424, 69540, 69610,
                                                                      86    129    172    215    258     301     344           387            430
 (Simple)                                    69799
 Miscellaneous Cardiac              93503-93505, 93536, 93561-
                                                                      86    129    172    215    258     301     344           387            430
 Procedure                                   93572
 MOHS’ Micrographic Surgery                17304-17310                260   390    520    650    780     910    1040           1170           1300
 Mouth Lesion, Incision &
                                     41000-41009, 41015-41018         116   174    232    290    348     406     464           522            580
 Drainage
 Musculoskeletal System,
                                           20150, 21935               553   830    1106   1383   1660   1937    2214           2491           2768
 Surgery of the (Complex)
 Musculoskeletal System,
 Surgery of the (Highly                    20955-20973               1000   1500   2000   2500   3000   3500    4000          4500            5000
 Complex)
 Musculoskeletal System,         20100, 20102-20103, 20245-20251,
 Surgery of the (Moderate          20525, 20661-20664, 20680-
                                                                      164   246    328    410    492     574     656           738            820
 Complexity)                        20694, 20975, 21925-21930,
                                              22900
 Musculoskeletal System,            20000-20005, 20101, 20200-
 Surgery of the (Simple)            20240, 20500-20520, 20550,
                                     20615-20660, 20665-20670,        35    53      70     88    106     124     142           160            178
                                    20950, 20974, 20979, 20999,
                                           21920, 22999
 Nails, Incision, Excision of           11700-11765, G0127            42    63      84    105    126     147     168           189            210
 Neck or Thorax – Closed
 Treatment, Fracture and/or                21800, 21820               56    84     112    140    168     196     224           252            280
 Dislocation of
 Neck or Thorax - Open
 Treatment, Fracture and/or                21805, 21825               303   455    606    758    910    1062    1214           1366           1518
 Dislocation of
 Neck/Thorax, Surgery of the
                                  21610-21616, 21630-21632, 21740     451   677    902    1128   1354   1580    1806          2032            2258
 (Complex)
 Neck/Thorax, Surgery of the      21501-21510, 21555-21600, 21620-
                                                                      191   287    382    478    574     670     766           862            958
 (Moderate Complexity)               21627, 21700-21725, 21750
 Neck/Thorax, Surgery of the
                                           21550, 21899               75    113    150    188    226     264     302           340            378
 (Simple)
 Nephrectomy                               50220-50240                555   833    1110   1388   1666   1944    2222          2500            2778
 Nephrostomy/
 Nephrolithotomy/                          50040-50081                518   777    1036   1295   1554   1813    2072           2331           2590
 Nephrostolithotomy
 Nerve Graft                               64885-64898                495   743    990    1238   1486   1734    1982          2230            2478
 Nerve Graft (Additional
                                           64901-64902                302   453    604    755    906    1057    1208           1359           1510
 Procedures)



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          Table of Surgical Indemnity Benefits Schedule
                                                                     Plan   Plan    Plan    Plan    Plan    Plan    Plan           Plan           Plan
      Surgical Procedure                     CPT Codes
                                                                     1000   1500    2000    2500    3000    3500    4000           4500           5000
 Nervous System, Surgery of         64755, 64786, 64790-64792,
 the (Complex)                      64804-64818, 64866-64870,         369   554     738     923     1108    1293    1478           1663           1848
                                           64905-64907
 Nervous System, Surgery of         64732-64752, 64760-64784,
                                                                      200   300     400     500     600     700     800            900            1000
 the (Moderate Complexity)          64787-64788, 64802, 64820
 Nervous System, Surgery of
                                           64795, 64830               87    131     174     218     262     306     350            394            438
 the (Simple)
 Neuroplasty                         64702-64719, 64722-64727         192   288     384     480     576     672     768            864            960
 Neurorrhaphy                       64831, 64834-64858, 64861-
                                                                      328   492     656     820     984     1148    1312           1476           1640
                                              64865
 Neurorrhaphy (Additional
                                    64832, 64859, 64872-64874         158   237     316     395     474     553     632            711            790
 Procedure)
 Neurostimulators (Complex)       61850-61860, 61870-61875, 63655     323   485     646     808     970     1132    1294           1456           1618
 Neurostimulators (Highly
                                           61862, 61865               591   887     1182    1478    1774    2070    2366          2662            2958
 Complex)
 Neurostimulators (Moderate         61880-61888, 63650, 63660-
                                                                      188   282     376     470     564     658     752            846            940
 Complexity)                           63688, 64573-64580
 Neurostimulators (Simple)          63690-63691, 64550-64565,
                                                                      14     21      28      35      42      49      56            63              70
                                          64585-64595
 Nose/Nasal Passages,
                                       30160, 30545, 30920            319   479     638     798     958     1118    1278           1438           1598
 Surgery of the (Complex)
 Nose/Nasal Passages,
 Surgery of the (Highly                     31225-31230               608   912     1216    1520    1824    2128    2432          2736            3040
 Complex)
 Nose/Nasal Passages,             30115-30120, 30125, 30140-30150,
 Surgery of the (Moderate           30320, 30540, 30580-30600,        162   243     324     405     486     567     648            729            810
 Complexity)                         30630, 30915, 31200-31205
 Nose/Nasal Passages,               30000-30110, 30124, 30130,
 Surgery of the (Simple)            30200-30310, 30560, 30801-        62     93     124     155     186     217     248            279            310
                                    30906, 30930-31002, 31299
 Nose/Nasal Passages,
                                            31231-31235               55     83     110     138     166     194     222            250            278
 Diagnostic Endoscopy
 Nose/Nasal Passages,
                                            31237-31294               150   225     300     375     450     525     600            675            750
 Surgical Endoscopy
 Obstetric Care, Antepartum
                                               59400                  710   1,065 1,420 1,775       2,130   2,485 2,840           3,195 3,550
 Vaginal Delivery, Postpartum
 Obstetric Care, Antepartum
                                               59510                  809   1,213   1,618   2,022   2,427   2,831 3,236 3,640 4,045
 Cesearian Delivery, Postpartum
 Ocular Adnexa, Surgery of the
                               67414, 67550, 67570, 67971-67974       424   636     848     1060    1272    1484    1696           1908           2120
 (Complex)




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           Table of Surgical Indemnity Benefits Schedule
                                                                    Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                    CPT Codes
                                                                    1000   1500   2000   2500   3000   3500    4000           4500           5000
 Ocular Adnexa, Surgery of the      67343, 67560, 67808, 67880-
 (Moderate Complexity)              67882, 67909, 67935, 67950-      260   390    520    650    780     910    1040           1170           1300
                                           67966, 67975
 Ocular Adnexa, Surgery of the      67345, 67399, 67415, 67500-
 (Simple)                           67515, 67599-67805, 67810,
                                                                     104   156    208    260    312     364     416           468            520
                                    67840-67875, 67930, 67938,
                                              67999
 Ocular Adnexa, Repair of           67820-67835, 67900-67908,
                                                                     160   240    320    400    480     560     640           720            800
                                           67911-67924
 Ocular Implant                            65125-65175               290   435    580    725    870    1015    1160           1305           1450
 Oophorectomy                              58940-58943               242   363    484    605    726     847     968           1089           1210
 Orbitotomy                          67400-67413, 67420-67450        460   690    920    1150   1380   1610    1840          2070            2300
 Orchiectomy                        54520-54535, 54690, 56318        208   312    416    520    624     728     832           936            1040
 Other Biliary Tract,
                                     47560-47561, 47570-47579        121   182    242    303    364     425     486           547            608
 Laparoscopy
 Other Bodily Systems,
                                           39400, 43259              176   264    352    440    528     616     704           792            880
 Diagnostic Endoscopy
 Other Flaps and Grafts                    15740-15770               589   884    1178   1473   1768   2063    2358          2653            2948
 Other Lymphatic System,
                                           38570, 38589              246   369    492    615    738     861     984           1107           1230
 Laparoscopy
 Other Prostate Surgery             52647-52648, 55859-55865,
                                                                     390   585    780    975    1170   1365    1560           1755           1950
                                             G0160
 Other Testis, Laparoscopy                 54692-54699               327   491    654    818    982    1146    1310           1474           1638
 Other Uterus, Laparoscopy/
                                           58551-58579               156   234    312    390    468     546     624           702            780
 Hysteroscopy
 Oviduct/Ovary, Laparoscopy                58660-58679               249   374    498    623    748     873     998           1123           1248
 Pacemaker Insertion,
                                           33200-33208               248   372    496    620    744     868     992           1116           1240
 Permanent
 Palate/Uvula, Surgery of the
                                  42107-42120, 42145, 42226-42227    269   404    538    673    808     943    1078           1213           1348
 (Moderate Complexity)
 Palate/Uvula, Surgery of the       42000-42106, 42140, 42160,
                                                                     73    110    146    183    220     257     294           331            368
 (Simple)                                 42280-42299
 Palate/Uvula, Repair of             42180-42182, 42235-42260        181   272    362    453    544     635     726           817            908
 Pancreas, Surgery of the           48000-48020, 48120, 48148,
                                                                     661   992    1322   1653   1984   2315    2646          2977            3308
 (Complex)                       48180, 48500-48510, 48520-48547
 Pancreas, Surgery of the
                                        48100-48102, 48511           226   339    452    565    678     791     904           1017           1130
 (Moderate Complexity)
 Pancreas, Surgery of the
                                           48400, 48999              46    69     92     115    138     161     184           207            230
 (Simple)




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           Table of Surgical Indemnity Benefits Schedule
                                                                  Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                    CPT Codes
                                                                  1000   1500   2000   2500   3000   3500    4000           4500           5000
 Pancreas Transplant                   48160, 48554-48556          432   648    864    1080   1296   1512    1728           1944           2160
 Pancreas Transplant (Donor)                  48550                904   1356   1808   2260   2712   3164    3616          4068            4520
 Pancreatectomy                      48140-48146, 48150-48155      862   1293   1724   2155   2586   3017    3448           3879           4310
 Parathyroid, Thymus, Adrenal
 Glands, and Carotid Body,          60500-60505, 60520-60605       458   687    916    1145   1374   1603    1832           2061           2290
 Surgery of the (Complex)
 Parathyroid, Thymus, Adrenal
 Glands, and Carotid Body,
                                              60512                110   165    220    275    330     385     440           495            550
 Surgery of the (Moderate
 Complexity)
 Paring or Curettement                     11050-11057             19    29     38      48     58     68      78            88              98
 Pelvis, Surgery of the
                                     27170, 27176-27181, 27187     439   659    878    1098   1318   1538    1758           1978           2198
 (Complex)
 Pelvis, Surgery of the
 (Moderate Complexity)                     27175, 27185            342   513    684    855    1026   1197    1368           1539           1710

 Pelvis or Hip Joint -
 Percutaneous Skeletal Fixation,           27216, 27235            432   648    864    1080   1296   1512    1728           1944           2160
 Fracture and/or Dislocation of
 Pelvis or Hip Joint, Osteotomy            27140-27165             589   884    1178   1473   1768   2063    2358          2653            2948
 Pelvis or Hip, Amputation of              27290-27295             660   990    1320   1650   1980   2310    2640           2970           3300
 Pelvis/Hip Joint, Surgery of the   26992, 27035-27036, 27049,
 (Complex)                          27054, 27067, 27071-27075,
                                                                   528   792    1056   1320   1584   1848     2112          2376           2640
                                    27078-27079, 27090, 27100,
                                            27110-27125
 Pelvis/Hip Joint, Surgery of the
                                        27076-27077, 27091         691   1037   1382   1728   2074   2420    2766           3112           3458
 (Highly Complex)
 Pelvis/Hip Joint, Surgery of the   26990-26991, 27000-27025,
 (Moderate Complexity)              27041-27048, 27060-27066,
                                                                   331   497    662    828    994    1160    1326           1492           1658
                                    27070, 27080, 27087, 27097-
                                           27098, 27105
 Pelvis/Hip Joint, Surgery of the   27040, 27086, 27093-27096,
                                                                   227   341    454    568    682     796     910           1024           1138
 (Simple)                                  27275, 27299
 Percutaneous Transluminal
                                              92982                269   404    538    673    808     943    1078           1213           1348
 Balloon Angioplasty
 Percutaneous Transluminal
 Balloon Angioplasty                          92984                73    110    146    183    220     257     294           331            368
 (Additional Procedure)
 Peritoneum and Omentum,            49010-49020, 49062, 49200-
                                                                   461   692    922    1153   1384   1615    1846           2077           2308
 Surgery of the (Complex)                  49215, 49425




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           Table of Surgical Indemnity Benefits Schedule
                                                                      Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                      CPT Codes
                                                                      1000   1500   2000   2500   3000   3500    4000           4500           5000
 Pharynx, Adenoids, and
 Tonsils, Surgery of the                  42844, 42890-42892           437   656    874    1093   1312   1531    1750           1969           2188
 (Complex)
 Pharynx, Adenoids, and
 Tonsils, Surgery of the (Highly             42845, 42894              716   1074   1432   1790   2148   2506    2864          3222            3580
 Complex)
 Pharynx, Adenoids, and               42720-42725, 42810-42815,
 Tonsils, Surgery of the              42842, 42870-42880, 42900-       214   321    428    535    642     749     856           963            1070
 (Moderate Complexity)                          42955
 Pharynx, Adenoids, and               42700, 42800-42809, 42860,
                                                                       87    131    174    218    262     306     350           394            438
 Tonsils, Surgery of the (Simple)               42999
 Portal Decompression
                                             37140-37181               587   881    1174   1468   1762   2056    2350          2644            2938
 Procedures
 Posterior Segment of the Eye,
                                                67121                  393   590    786    983    1180   1377    1574           1771           1968
 Surgery of the (Complex)
 Posterior Segment of the Eye,
                                       67115-67120, 67141-67145,
 Surgery of the (Moderate                                              202   303    404    505    606     707     808           909            1010
                                             67250-67255
 Complexity)
 Pressure Ulcers                             15920-15999               468   702    936    1170   1404   1638    1872           2106           2340
 Proctectomy                           45110-45112, 45114-45116,
                                                                       696   1044   1392   1740   2088   2436    2784           3132           3480
                                             45120-45126
 Prostate Abscess, Drainage of            52700, 55720-55725           228   342    456    570    684     798     912           1026           1140
 Prostatectomy                               55801-55845               725   1088   1450   1813   2176   2539    2902          3265            3628
 Pyelotomy/Pyelostomy/
                                             50120-50135               473   710    946    1183   1420   1657    1894           2131           2368
 Pyelolithotomy
 Rectum, Surgery of the                  45130-45135, 45160,
 (Complex)                            45540-45550, 45562, 45800,       435   653    870    1088   1306   1524    1742           1960           2178
                                             45820-45825
 Rectum, Surgery of the (Highly
                                             45113, 45119              769   1154   1538   1923   2308   2693    3078          3463            3848
 Complex)
 Rectum, Surgery of the                45000, 45020-45108, 45150,
                                                                       227   341    454    568    682     796     910           1024           1138
 (Moderate Complexity)              45170-45190, 45500-45505, 45560
 Rectum, Surgery of the
                                      45005, 45520, 45900-45999        212   318    424    530    636     742     848           954            1060
 (Simple)
 Renal Transplantation                       50340-50380               820   1230   1640   2050   2460   2870    3280          3690            4100
 Renal Transplantation (Donor)               50300-50320               583   875    1166   1458   1750   2042    2334          2626            2918
 Renal, Laparoscopy                          50541-50549               491   737    982    1228   1474   1720    1966           2212           2458
 Repair/Closure of Wounds –
                                             13100-13300               166   249    332    415    498     581     664           747            830
 Complex




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          Table of Surgical Indemnity Benefits Schedule
                                                                      Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                      CPT Codes
                                                                      1000   1500   2000   2500   3000   3500    4000           4500           5000
 Repair/Closure of Wounds –
                                             12031-12057               91    137    182    228    274     320     366           412            458
 Intermediate
 Repair/Closure of Wounds –
                                             12001-12021               69    104    138    173    208     243     278           313            348
 Simple
 Replantation Of Limbs and
                                            20802-20840               1000   1500   2000   2500   3000   3500    4000          4500            5000
 Appendages
 Retina, Repair of                           67101-67112               528   792    1056   1320   1584   1848     2112          2376           2640
 Rhinoplasty                                30400-30462                464   696    928    1160   1392   1624    1856          2088            2320
 Rhytidectomy                               15824-15829                705   1058   1410   1763   2116   2469    2822           3175           3528
 Salivary Glands & Ducts,
                                         42415-42425, 42509            536   804    1072   1340   1608   1876    2144           2412           2680
 Surgery of the (Complex)
 Salivary Glands & Ducts,
 Surgery of the (Highly                        42426                   638   957    1276   1595   1914   2233    2552           2871           3190
 Complex)
 Salivary Glands & Ducts,            42305, 42326, 42335-42340,
 Surgery of the (Moderate            42408-42410, 42440-42508,         210   315    420    525    630     735     840           945            1050
 Complexity)                                42510, 42600
 Septal and Intranasal
                                               30620                   219   329    438    548    658     768     878           988            1098
 Dermatoplasty
 Septal Defect, Repair of                   33641-33698                753   1130   1506   1883   2260   2637    3014           3391           3768
 Septoplasty                                   30520                   201   302    402    503    604     705     806           907            1008
 Shaving of Epidermal or
                                             11300-11313               33    50      66     83    100     117     134           151            168
 Dermal Lesions
 Shoulder – Closed Treatment,        23500-23505, 23520-23525,
 Fracture and/or Dislocation of      23540-23545, 23570-23575,
                                                                       130   195    260    325    390     455     520           585            650
                                     23600-23605, 23620-23625,
                                     23650-23655, 23665, 23675
 Shoulder – Open Treatment,          23515, 23530-23532, 23550-
 Fracture and/or Dislocation of      23552, 23585, 23615-23616,        320   480    640    800    960    1120    1280           1440           1600
                                     23630, 23660, 23670, 23680
 Shoulder, Surgery of the         23077, 23155, 23184, 23195-23221,
 (Complex)                          23332, 23395-23400, 23406-
                                                                       486   729    972    1215   1458   1701    1944           2187           2430
                                    23412, 23420, 23450-23466,
                                            23485-23491
 Shoulder, Surgery of the
                                               23222                   799   1199   1598   1998   2398   2798    3198          3598            3998
 (Highly Complex)
 Shoulder, Surgery of the            23000-23030, 23035, 23076,
 (Moderate Complexity)             23105-23106, 23120-23150, 23156-
                                                                       314   471    628    785    942    1099    1256           1413           1570
                                     23182, 23190, 23331, 23405,
                                      23415, 23430-23440, 23480




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          Table of Surgical Indemnity Benefits Schedule
                                                                      Plan   Plan   Plan   Plan   Plan   Plan     Plan           Plan           Plan
      Surgical Procedure                     CPT Codes
                                                                      1000   1500   2000   2500   3000   3500     4000           4500           5000
 Shoulder, Surgery of the           23031, 23065-23075, 23330,
                                                                       138   207    276    345    414     483     552            621            690
 (Simple)                                  23350, 23929
 Shoulder, Amputation of                    23900-23921                642   963    1284   1605   1926   2247     2568          2889            3210
 Shoulder, Manipulation of the                 23700                   106   159    212    265    318     371     424            477            530
 Sinusotomy (Complex)                       31075-31090                325   488    650    813    976    1139     1302           1465           1628
 Sinusotomy (Moderate
                                            31020-31070                196   294    392    490    588     686     784            882            980
 Complexity)
 Skin, Incision & Drainage                  10060-10180                50    75     100    125    150     175     200            225            250
 Skin, Subcutaneous, etc..,
                                           15840, 15845                396   594    792    990    1188   1386     1584           1782           1980
 Surgery of the (Complex)
 Skin, Subcutaneous, etc..,
 Surgery of the (Highly                     15841-15842                838   1257   1676   2095   2514   2933     3352           3771           4190
 Complex)
 Skin, Subcutaneous, etc..,
                                  11771-11772, 15780-15781, 15783,
 Surgery of the (Moderate                                              213   320    426    533    640     747     854            961            1068
                                            15810-15819
 Complexity)
 Skin, Subcutaneous, etc..,       11770, 15782, 15786-15787, 15850-
                                                                       51    77     102    128    154     180     206            232            258
 Surgery of the (Simple)                 15860, 17360-17999
 Skull Fracture and/or               21300-21320, 21337, 21345,
 Dislocation - Closed Treatment   21400-21401, 21421, 21431, 21440,
                                                                       117   176    234    293    352     411     470            529            588
                                  21450-21451, 21453, 21480-21485,
                                            21493-21494
 Skull Fracture and/or            21325-21336, 21338-21339, 21343-
 Dislocation - Open Treatment     21344, 21346-21348, 21356-21395,
                                  21406-21408, 21422-21423, 21432-     317   476    634    793    952     1111    1270           1429           1588
                                  21436, 21445, 21454-21470, 21490,
                                         21495-21497, 66225
 Skull Fracture and/or
                                     21340, 21355, 21452, 21499        196   294    392    490    588     686     784            882            980
 Dislocation - Other
 Skull, Meninges, and Brain,       61108, 61140-61150, 61154-61156,
 Surgery of the (Complex)         61250-61253, 61618-61626, 62005,
                                                                       418   627    836    1045   1254   1463     1672           1881           2090
                                  62115, 62142-62143, 62180, 62200-
                                         62201, 62230, 62258
 Skull, Meninges, and Brain,
                                  61580-61608, 61610, 61612-61616,
 Surgery of the (Highly                                                850   1275   1700   2125   2550   2975     3400          3825            4250
                                  62010-62100, 62116-62117, 62121
 Complex)
 Skull, Meninges, and Brain,       61105-61107, 61120-61130, 61151,
 Surgery of the (Moderate         61210-61215, 61609, 61611, 62000,    192   288    384    480    576     672     768            864            960
 Complexity)                            62194, 62225, 62256




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          Table of Surgical Indemnity Benefits Schedule
                                                                       Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                     CPT Codes
                                                                       1000   1500   2000   2500   3000   3500    4000           4500           5000
 Skull, Meninges, and Brain,
                                            61000-61070                 85    128    170    213    256     299     342           385            428
 Surgery of the (Simple)
 Skull/Face/Jaw, Surgery of       21010, 21034, 21044-21060, 21076,
 the (Complex)                     21085, 21123, 21127, 21138-21143,
                                   21145-21147, 21193-21208, 21210-     411   617    822    1028   1234   1440    1646           1852           2058
                                  21230, 21240-21246, 21248, 21255-
                                      21260, 21267, 21270-21275
 Skull/Face/Jaw, Surgery of       21077-21084, 21086-21087, 21144,
 the (Highly Complex)              21150-21180, 21182-21188, 21247,     768   1152   1536   1920   2304   2688    3072          3456            3840
                                      21249, 21261-21263, 21268
 Skull/Face/Jaw, Surgery of       21015-21032, 21041, 21070, 21088,
 the (Moderate Complexity)         21110, 21120-21122, 21125, 21137,
                                                                        219   329    438    548    658     768     878           988            1098
                                  21181, 21209, 21235, 21280-21282,
                                                21296
 Skull/Face/Jaw, Surgery of       21040, 21089-21100, 21116, 21295,
                                                                        132   198    264    330    396     462     528           594            660
 the (Simple)                                  21299
 Spermatic Cord, Laparoscopy                55550-55559                 89    134    178    223    268     313     358           403            448
 Sphincteroplasty                    46750-46751, 46760-46762           289   434    578    723    868    1013    1158           1303           1448
 Spinal Arthrodesis                  22548-22558, 22590-22612,
                                                                        654   981    1308   1635   1962   2289    2616           2943           3270
                                              22630
 Spinal Arthrodesis (Additional
                                        22585, 22614, 22632             182   273    364    455    546     637     728           819            910
 Procedure)
 Spinal Catheter Implantation               62350-62355                 191   287    382    478    574     670     766           862            958
 Spinal Herniation/Leakage,
                                            63700-63709                 433   650    866    1083   1300   1517    1734           1951           2168
 Repair of
 Spinal Instrumentation                     22840-22855                 392   588    784    980    1176   1372    1568           1764           1960
 Spinal Puncture for Purpose of
                                            62263-62319                 101   152    202    253    304     355     406           457            508
 Injection, etc..
 Spinal Reservoir/Pump
                                            62360-62368                 40    60     80     100    120     140     160           180            200
 Implantation
 Spine - Closed Treatment,
 Fracture and/or Dislocation of             22305-22315                 131   197    262    328    394     460     526           592            658
 (Vertical Column)
 Spine - Open Treatment,
 Fracture and/or Dislocation of             22318-22328                 624   936    1248   1560   1872   2184    2496          2808            3120
 (Vertical Column)
 Spine & Spinal Cord, Surgery
                                         63710-63741, 63750             296   444    592    740    888    1036    1184           1332           1480
 of the (Complex)
 Spine & Spinal Cord, Surgery       63055-63056, 63064, 63075,
                                                                        618   927    1236   1545   1854   2163    2472           2781           3090
 of the (Highly Complex)               63077, S2350, S2351




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           Table of Surgical Indemnity Benefits Schedule
                                                                             Plan    Plan     Plan     Plan     Plan    Plan     Plan           Plan           Plan
      Surgical Procedure                         CPT Codes
                                                                             1000    1500     2000     2500     3000    3500     4000           4500           5000
 Spine & Spinal Cord, Surgery         63057, 63066, 63076, 63078,
                                                                             194      291      388     485      582      679      776           873            970
 of the (Moderate Complexity)            63744-63746, 63780
 Spine, Surgery of the              22110-22114, 22145, 22150-22151,
                                                                             631      947     1262     1578     1894     2210    2526          2842            3158
 (Complex)                             22212-22214, 22222-22224
 Spine, Surgery of the (Highly
                                    22140-22142, 22152-22210, 22220          677     1016     1354     1693    2032     2371     2710          3049            3388
 Complex)
 Spine, Surgery of the              22100-22102, 22105-22107, 22148,
                                                                             336      504      672     840      1008     1176    1344           1512           1680
 (Moderate Complexity)                    22216, 22226-22230
 Spine, Surgery of the (Simple)            22103, 22116, 22899                66       99      132     165      198      231      264           297            330
 Spine Requiring Anesthesia,
                                                   22505                     112      168      224     280      336      392      448           504            560
 Manipulation of the
 Spleen, Surgery of the
                                            38100-38101, 38115               378      567      756     945      1134    1323     1512           1701           1890
 (Complex)
 Spleen, Surgery of the
                                                   38102                     117      176      234     293      352      411      470           529            588
 (Moderate Complexity)
 Spleen, Surgery of the
                                                   38200                      62       93      124     155      186      217      248           279            310
 (Simple)
 Spleen, Laparoscopy                            38120-38129                  439      659      878     1098     1318    1538     1758           1978           2198
 Splints, Application of                29105-29131, 29505-29515              26       39      52       65       78       91      104           117            130
 Stamey, Raz Procedure                             51845                     288      432      576     720      864     1008     1152           1296           1440
 Stereotaxis                            61720-61795, 63600-63615             525      788     1050     1313     1576    1839     2102          2365            2628
 Stomach, Surgery of the           43501-43502, 43610-43611, 43638,
 (Complex)                            43640-43641, 43810-43825,
                                                                             479      719      958     1198     1438    1678     1918           2158           2398
                                     43832, 43842-43843, 43850-
                                            43865, 43880
 Stomach, Surgery of the               43500, 43510-43520, 43605,
 (Moderate Complexity)                 43750, 43800, 43830-43831,            226      339      452     565      678      791      904           1017           1130
                                                 43870
 Stomach, Surgery of the               43600, 43635, 43760-43761,
                                                                              44       66      88      110      132      154      176           198            220
 (Simple)                                       43999
 Stomach, Laparoscopy                          43651-43659                   240      360      480     600      720      840      960           1080           1200
 Strabismus Surgery                        67311-67334, 67340                240      360      480     600      720      840      960           1080           1200
 Strabismus Surgery (Additional
                                                   67335                      63       95      126     158      190      222      254           286            318
 Procedure)
 Strapping, Application of             29200-29280, 29520-29590,
                                                                              17       26      34       43       52       61      70            79              88
                                                29799
 Stress Incontinence,
                                                51990-51992                  341      512      682     853      1024     1195    1366           1537           1708
 Laparoscopy



               This brochure is intended for illustrative purposes - please refer to the approved Surgical Schedule for complete information.

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           Table of Surgical Indemnity Benefits Schedule
                                                                     Plan   Plan   Plan   Plan   Plan    Plan    Plan          Plan            Plan
      Surgical Procedure                     CPT Codes
                                                                     1000   1500   2000   2500   3000    3500    4000          4500            5000
 Surgical Use of Operating
                                               69990                  98    147    196    245    294      343     392           441            490
 Microscope
 Therapeutic Cystoscopy                     52214-52340               243   365    486    608    730      852     974          1096            1218
 Therapeutic Invasive
                                        92986-92995, 92997            350   525    700    875    1050    1225    1400          1575            1750
 Cardiovascular
 Therapeutic Invasive
 Cardiovascular (Additional                92996, 92998               110   165    220    275    330      385     440           495            550
 Procedure)
 Therapeutic Sigmoidoscopy           45307-45321, 45332-45339         97    146    194    243    292      341     390           439            488
 Thigh or Knee Joint - Closed       27500-27503, 27508, 27510,
 Treatment, Fracture and/or       27516-27517, 27520, 27530-27532,
                                                                      222   333    444    555    666      777     888           999            1110
 Dislocation of                     27538, 27550-27552, 27560-
                                                27562
 Thigh or Knee Joint - Open       27506-27507, 27511-27514, 27519,
 Treatment, Fracture and/or         27524, 27535-27536, 27540,        485   728    970    1213   1456    1699    1942          2185         2428
 Dislocation of                         27556-27558, 27566
 Thigh or Knee Joint -
 Percutaneous Skeletal Fixation
                                               27509                  304   456    608    760     912    1064    1216          1368            1520
 Of Femoral Fracture, Fracture
 and/or Dislocation of
 Thigh or Knee Joint,
                                           27590-27598                415   623    830    1038   1246    1454    1662          1870         2078
 Amputation of
 Thigh, Osteotomy                           27448-27468               463   695    926    1158   1390    1622    1854          2086            2318
 Thigh/Knee Joint, Surgery of       27329, 27334-27335, 27357,
 the (Complex)                      27360-27365, 27381, 27386,
                                    27395, 27397, 27405-27424,        409   614    818    1023   1228    1433    1638          1843         2048
                                    27430, 27470, 27477-27479,
                                       27488-27495, S9085
 Thigh/Knee Joint, Surgery of
                                               27472                  620   930    1240   1550   1860    2170    2480          2790            3100
 the (Highly Complex)
 Thigh/Knee Joint, Surgery of     27301-27307, 27315-27320, 27324-
 the (Moderate Complexity)          27328, 27332-27333, 27340-
                                    27356, 27358, 27372-27380,
                                                                      251   377    502    628    754      880    1006           1132           1258
                                    27385, 27390-27394, 27396,
                                     27400-27403, 27425, 27435,
                                     27475, 27485, 27496-27499
 Thigh/Knee Joint, Surgery of
                                    27323, 27370, 27570, 27599        132   198    264    330    396      462     528           594            660
 the (Simple)
 Thoracostomy                              32020-32036                99    149    198    248    298      348     398           448            498
 Thromboendarterectomy                     35301-35381                488   732    976    1220   1464    1708    1952          2196         2440




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          Table of Surgical Indemnity Benefits Schedule
                                                                      Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                     CPT Codes
                                                                      1000   1500   2000   2500   3000   3500    4000           4500           5000
 Thromboendarterectomy
                                               35390                   78    117    156    195    234     273     312           351            390
 (Reoperation)
 Thyroid, Surgery of the
                                            60210-60225                344   516    688    860    1032   1204    1376           1548           1720
 (Complex)
 Thyroid, Surgery of the
                                        60200, 60280-60281             210   315    420    525    630     735     840           945            1050
 (Moderate Complexity)
 Thyroid, Surgery of the
                                            60000-60100                66    99     132    165    198     231     264           297            330
 (Simple)
 Thyroidectomy                              60240-60271                475   713    950    1188   1426   1664    1902           2140           2378
 Tongue and Floor of Mouth,
 Surgery of the (Highly                     41135-41155                760   1140   1520   1900   2280   2660    3040          3420            3800
 Complex)
 Tongue and Floor of Mouth,
 Surgery of the (Moderate          41113-41114, 41120, 41500-41520     194   291    388    485    582     679     776           873            970
 Complexity)
 Tongue and Floor of Mouth,        41010, 41100-41112, 41115-41116,
                                                                       83    125    166    208    250     292     334           376            418
 Surgery of the (Simple)                41250-41252, 41599
 Tonsillectomy                              42820-42826                134   201    268    335    402     469     536           603            670
 Trachea/Bronchi, Surgery of      31750-31760, 31770, 31780, 31785-
                                                                       564   846    1128   1410   1692   1974    2256          2538            2820
 the (Complex)                              31786, 31805
 Trachea/Bronchi, Surgery of
                                        31766, 31775, 31781            690   1035   1380   1725   2070   2415    2760           3105           3450
 the (Highly Complex)
 Trachea/Bronchi, Surgery of
                                            31611, 31800               271   407    542    678    814     950    1086           1222           1358
 the (Moderate Complexity)
 Trachea/Bronchi, Surgery of
                                     31612, 31700-31730, 31899         60    90     120    150    180     210     240           270            300
 the (Simple)
 Trachea/Bronchi, Diagnostic
                                            31622, 31656               110   165    220    275    330     385     440           495            550
 Endoscopy
 Trachea/Bronchi, Surgical
                                            31623-31646                109   164    218    273    328     383     438           493            548
 Endoscopy
 Tracheostoma                                31613-31614               275   413    550    688    826     964    1102           1240           1378
 Tracheostomy                     31600-31610, 31615, 31820-31830      173   260    346    433    520     607     694           781            868
 Transcatheter Therapy and
                                            37195-37209                247   371    494    618    742     866     990           1114           1238
 Biopsy
 Transection of Fallopian Tubes             58600-58605                146   219    292    365    438     511     584           657            730
 Transluminal Angioplasty -
                                            35450-35460                189   284    378    473    568     663     758           853            948
 Open
 Transluminal Angioplasty -
                                            35470-35476                181   272    362    453    544     635     726           817            908
 Percutaneous




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          Table of Surgical Indemnity Benefits Schedule
                                                                       Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                      CPT Codes
                                                                       1000   1500   2000   2500   3000   3500    4000           4500           5000
 Transluminal Atherectomy -
                                             35480-35485                207   311    414    518    622     726     830           934            1038
 Open
 Transluminal Atherectomy -
                                             35490-35495                258   387    516    645    774     903    1032           1161           1290
 Percutaneous
 Treatment of Spinal Deformity               22800-22830                841   1262   1682   2103   2524   2945    3366           3787           4208
 Tympanoplasty                               69631-69646                396   594    792    990    1188   1386    1584           1782           1980
 Tympanostomy                                69433-69436                69    104    138    173    208     243     278           313            348
 Ulcer Surgery                                  43840                   400   600    800    1000   1200   1400    1600           1800           2000
 Upper Arm/Elbow - Closed            24500-24505, 24530-24535,
 Treatment, Fracture and/or          24560-24565, 24576-24577,
                                                                        130   195    260    325    390     455     520           585            650
 Dislocation of                      24600-24605, 24620, 24640-
                                        24655, 24670-24675
 Upper Arm/Elbow - Open              24515-24516, 24545-24546,
 Treatment, Fracture and/or          24575, 24579, 24586-24587,
                                                                        387   581    774    968    1162   1356    1550           1744           1938
 Dislocation of                      24615, 24635, 24665-24666,
                                               24685
 Upper Arm/Elbow -
 Percutaneous Skeletal Fixation
                                         24538, 24566, 24582            353   530    706    883    1060   1237    1414           1591           1768
 Of Humeral Fracture, Fracture
 and/or Dislocation of
 Upper Arm/Elbow, Surgery of       24077, 24116, 24134, 24149-24151,
 the (Complex)                     24153-24155, 24320-24331, 24342,     405   608    810    1013   1216   1419    1622           1825           2028
                                         24400-24435, 24498
 Upper Arm/Elbow, Surgery of       23935, 24066-24076, 24102-24115,
 the (Moderate Complexity)         24120-24130, 24136-24147, 24152,
                                   24160-24164, 24201, 24301-24310,     228   342    456    570    684     798     912           1026           1140
                                      24340-24341, 24350-24356,
                                            24470-24495
 Upper Arm/Elbow, Surgery of         23930-23931, 24065, 24200,
                                                                        152   228    304    380    456     532     608           684            760
 the (Simple)                              24220, 24999
 Ureter, Surgery of the               50600-50660, 50700-50725,
                                                                        501   752    1002   1253   1504   1755    2006          2257            2508
 (Complex)                            50728-50810, 50840-50940
 Ureter, Surgery of the (Highly
                                             50815-50830                709   1064   1418   1773   2128   2483    2838           3193           3548
 Complex)
 Ureter, Surgery of the
                                                50727                   254   381    508    635    762     889    1016           1143           1270
 (Moderate Complexity)
 Ureter, Surgery of the (Simple)             50684-50690                230   345    460    575    690     805     920           1035           1150
 Ureter, Diagnostic Endoscopy         50951-50955, 50970-50974          312   468    624    780    936    1092    1248           1404           1560
 Ureter, Surgical Endoscopy           50957-50961, 50976-50980          448   672    896    1120   1344   1568    1792           2016           2240




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                            Underwritten by Transamerica Life Insurance Company, Cedar Rapids, Iowa.




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                                                                                                                 A
                                                                                                                         SC           ®   P
                                                                                                                              HOICE




           Table of Surgical Indemnity Benefits Schedule
                                                                     Plan   Plan   Plan   Plan   Plan   Plan    Plan           Plan           Plan
      Surgical Procedure                     CPT Codes
                                                                     1000   1500   2000   2500   3000   3500    4000           4500           5000
 Ureterolithotomy, Laparoscopy                 50945                  411   617    822    1028   1234   1440    1646           1852           2058
 Urethra, Surgery of the             52601, 53210-53215, 53400-
                                                                      367   551    734    918    1102   1286    1470           1654           1838
 (Complex)                              53440, 53443-53447
 Urethra, Surgery of the (Highly
                                               53448                  580   870    1160   1450   1740   2030    2320           2610           2900
 Complex)
 Urethra, Surgery of the             53000, 53020-53025, 53060,
 (Simple)                            53200, 53260-53270, 53670-       44    66     88     110    132     154     176           198            220
                                            53675, 53899
 Urethra, Dilation of                       53600-53665               36    54     72      90    108     126     144           162            180
 Urethrorrhaphy                             53502-53515               269   404    538    673    808     943    1078           1213           1348
 Varicose Vein Excision                     37700-37785               198   297    396    495    594     693     792           891            990
 Vasectomy                                     55250                  220   330    440    550    660     770     880           990            1100
 Vein Bypass Graft                          35582-35587               692   1038   1384   1730   2076   2422    2768           3114           3460
 Vertebral Body, Removal Of          63081, 63085, 63087, 63090,
                                                                      800   1200   1600   2000   2400   2800    3200          3600            4000
 (Highly Complex)                           63300-63307
 Vertebral Body, Removal Of          63082, 63086, 63088, 63091,
                                                                      114   171    228    285    342     399     456           513            570
 (Moderate Complexity)                         63308
 Vestibule of Mouth, Surgery of
                                            40814-40816               133   200    266    333    400     467     534           601            668
 the (Moderate Complexity)
 Vestibule of Mouth, Surgery of
                                   40800-40812, 40818-40831, 40899    76    114    152    190    228     266     304           342            380
 the (Simple)
 Vestibuloplasty                            40840-40845               436   654    872    1090   1308   1526    1744           1962           2180
 Vitrectomy                                 67036-67040               574   861    1148   1435   1722   2009    2296          2583            2870
 Vitreous, Surgery of the
                                      67005-67025, 67028-67031        264   396    528    660    792     924    1056           1188           1320
 (Moderate Complexity)
 Vitreous, General Surgery of
                                               67027                  441   662    882    1103   1324   1545    1766           1987           2208
 the
 Vulvectomy                                 56620-56640               271   407    542    678    814     950    1086           1222           1358




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