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apc_fee_Schedule04172006

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					State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                  1 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

00530      Anesth, pacemaker insertion          N            N        0000    0.0000         0.00         0.00           0.00
00532      Anesth, vascular access              N            N        0000    0.0000         0.00         0.00           0.00
00534      Anesth, cardioverter/defib           N            N        0000    0.0000         0.00         0.00           0.00
00537      Anesth, cardiac electrophys          N            N        0000    0.0000         0.00         0.00           0.00
00539      Anesth, trach-bronch reconst         N            N        0000    0.0000         0.00         0.00           0.00
00540      Anesth, chest surgery                C            C        0000    0.0000         0.00         0.00           0.00
00541      Anesth, one lung ventilation         N            N        0000    0.0000         0.00         0.00           0.00
00542      Anesth, release of lung              C            C        0000    0.0000         0.00         0.00           0.00
00546      Anesth, lung,chest wall surg         C            C        0000    0.0000         0.00         0.00           0.00
00548      Anesth, trachea,bronchi surg         N            N        0000    0.0000         0.00         0.00           0.00
00550      Anesth, sternal debridement          N            N        0000    0.0000         0.00         0.00           0.00
00560      Anesth, heart surg w/o pump          C            C        0000    0.0000         0.00         0.00           0.00
00561      Anesth, heart surg < age 1           C            C        0000    0.0000         0.00         0.00           0.00
00562      Anesth, heart surg w/pump            C            C        0000    0.0000         0.00         0.00           0.00
00563      Anesth, heart surg w/arrest          N            N        0000    0.0000         0.00         0.00           0.00
00566      Anesth, cabg w/o pump                N            N        0000    0.0000         0.00         0.00           0.00
00580      Anesth, heart/lung transplnt         C            C        0000    0.0000         0.00         0.00           0.00
00600      Anesth, spine, cord surgery          N            N        0000    0.0000         0.00         0.00           0.00
00604      Anesth, sitting procedure            C            C        0000    0.0000         0.00         0.00           0.00
00620      Anesth, spine, cord surgery          N            N        0000    0.0000         0.00         0.00           0.00
00622      Anesth, removal of nerves            C            C        0000    0.0000         0.00         0.00           0.00
00630      Anesth, spine, cord surgery          N            N        0000    0.0000         0.00         0.00           0.00
00632      Anesth, removal of nerves            C            C        0000    0.0000         0.00         0.00           0.00
00634      Anesth for chemonucleolysis          N            N        0000    0.0000         0.00         0.00           0.00
00635      Anesth, lumbar puncture              N            N        0000    0.0000         0.00         0.00           0.00
00640      Anesth, spine manipulation           N            N        0000    0.0000         0.00         0.00           0.00
00670      Anesth, spine, cord surgery          C            C        0000    0.0000         0.00         0.00           0.00
00700      Anesth, abdominal wall surg          N            N        0000    0.0000         0.00         0.00           0.00
00702      Anesth, for liver biopsy             N            N        0000    0.0000         0.00         0.00           0.00
00730      Anesth, abdominal wall surg          N            N        0000    0.0000         0.00         0.00           0.00
00740      Anesth, upper gi visualize           N            N        0000    0.0000         0.00         0.00           0.00
00750      Anesth, repair of hernia             N            N        0000    0.0000         0.00         0.00           0.00
00752      Anesth, repair of hernia             N            N        0000    0.0000         0.00         0.00           0.00
00754      Anesth, repair of hernia             N            N        0000    0.0000         0.00         0.00           0.00
00756      Anesth, repair of hernia             N            N        0000    0.0000         0.00         0.00           0.00
00770      Anesth, blood vessel repair          N            N        0000    0.0000         0.00         0.00           0.00
00790      Anesth, surg upper abdomen           N            N        0000    0.0000         0.00         0.00           0.00
00792      Anesth, hemorr/excise liver          C            C        0000    0.0000         0.00         0.00           0.00
00794      Anesth, pancreas removal             C            C        0000    0.0000         0.00         0.00           0.00
00796      Anesth, for liver transplant         C            C        0000    0.0000         0.00         0.00           0.00
00797      Anesth, surgery for obesity          N            N        0000    0.0000         0.00         0.00           0.00
00800      Anesth, abdominal wall surg          N            N        0000    0.0000         0.00         0.00           0.00
00802      Anesth, fat layer removal            C            C        0000    0.0000         0.00         0.00           0.00
00810      Anesth, low intestine scope          N            N        0000    0.0000         0.00         0.00           0.00
00820      Anesth, abdominal wall surg          N            N        0000    0.0000         0.00         0.00           0.00
00830      Anesth, repair of hernia             N            N        0000    0.0000         0.00         0.00           0.00
00832      Anesth, repair of hernia             N            N        0000    0.0000         0.00         0.00           0.00
00834      Anesth, hernia repair< 1 yr          N            N        0000    0.0000         0.00         0.00           0.00
00836      Anesth hernia repair preemie         N            N        0000    0.0000         0.00         0.00           0.00
00840      Anesth, surg lower abdomen           N            N        0000    0.0000         0.00         0.00           0.00
00842      Anesth, amniocentesis                N            N        0000    0.0000         0.00         0.00           0.00
00844      Anesth, pelvis surgery               C            C        0000    0.0000         0.00         0.00           0.00
00846      Anesth, hysterectomy                 C            C        0000    0.0000         0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                  2 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

00848      Anesth, pelvic organ surg            C            C        0000    0.0000         0.00         0.00           0.00
00851      Anesth, tubal ligation               N            N        0000    0.0000         0.00         0.00           0.00
00860      Anesth, surgery of abdomen           N            N        0000    0.0000         0.00         0.00           0.00
00862      Anesth, kidney/ureter surg           N            N        0000    0.0000         0.00         0.00           0.00
00864      Anesth, removal of bladder           C            C        0000    0.0000         0.00         0.00           0.00
00865      Anesth, removal of prostate          C            C        0000    0.0000         0.00         0.00           0.00
00866      Anesth, removal of adrenal           C            C        0000    0.0000         0.00         0.00           0.00
00868      Anesth, kidney transplant            C            C        0000    0.0000         0.00         0.00           0.00
00870      Anesth, bladder stone surg           N            N        0000    0.0000         0.00         0.00           0.00
00872      Anesth kidney stone destruct         N            N        0000    0.0000         0.00         0.00           0.00
00873      Anesth kidney stone destruct         N            N        0000    0.0000         0.00         0.00           0.00
00880      Anesth, abdomen vessel surg          N            N        0000    0.0000         0.00         0.00           0.00
00882      Anesth, major vein ligation          C            C        0000    0.0000         0.00         0.00           0.00
00902      Anesth, anorectal surgery            N            N        0000    0.0000         0.00         0.00           0.00
00904      Anesth, perineal surgery             C            C        0000    0.0000         0.00         0.00           0.00
00906      Anesth, removal of vulva             N            N        0000    0.0000         0.00         0.00           0.00
00908      Anesth, removal of prostate          C            C        0000    0.0000         0.00         0.00           0.00
00910      Anesth, bladder surgery              N            N        0000    0.0000         0.00         0.00           0.00
00912      Anesth, bladder tumor surg           N            N        0000    0.0000         0.00         0.00           0.00
00914      Anesth, removal of prostate          N            N        0000    0.0000         0.00         0.00           0.00
00916      Anesth, bleeding control             N            N        0000    0.0000         0.00         0.00           0.00
00918      Anesth, stone removal                N            N        0000    0.0000         0.00         0.00           0.00
00920      Anesth, genitalia surgery            N            N        0000    0.0000         0.00         0.00           0.00
00921      Anesth, vasectomy                    N            N        0000    0.0000         0.00         0.00           0.00
00922      Anesth, sperm duct surgery           N            N        0000    0.0000         0.00         0.00           0.00
00924      Anesth, testis exploration           N            N        0000    0.0000         0.00         0.00           0.00
00926      Anesth, removal of testis            N            N        0000    0.0000         0.00         0.00           0.00
00928      Anesth, removal of testis            N            N        0000    0.0000         0.00         0.00           0.00
00930      Anesth, testis suspension            N            N        0000    0.0000         0.00         0.00           0.00
00932      Anesth, amputation of penis          C            C        0000    0.0000         0.00         0.00           0.00
00934      Anesth, penis, nodes removal         C            C        0000    0.0000         0.00         0.00           0.00
00936      Anesth, penis, nodes removal         C            C        0000    0.0000         0.00         0.00           0.00
00938      Anesth, insert penis device          N            N        0000    0.0000         0.00         0.00           0.00
00940      Anesth, vaginal procedures           N            N        0000    0.0000         0.00         0.00           0.00
00942      Anesth, surg on vag/urethral         N            N        0000    0.0000         0.00         0.00           0.00
00944      Anesth, vaginal hysterectomy         C            C        0000    0.0000         0.00         0.00           0.00
00948      Anesth, repair of cervix             N            N        0000    0.0000         0.00         0.00           0.00
00950      Anesth, vaginal endoscopy            N            N        0000    0.0000         0.00         0.00           0.00
00952      Anesth, hysteroscope/graph           N            N        0000    0.0000         0.00         0.00           0.00
01112      Anesth, bone aspirate/bx             N            N        0000    0.0000         0.00         0.00           0.00
01120      Anesth, pelvis surgery               N            N        0000    0.0000         0.00         0.00           0.00
01130      Anesth, body cast procedure          N            N        0000    0.0000         0.00         0.00           0.00
01140      Anesth, amputation at pelvis         C            C        0000    0.0000         0.00         0.00           0.00
01150      Anesth, pelvic tumor surgery         C            C        0000    0.0000         0.00         0.00           0.00
01160      Anesth, pelvis procedure             N            N        0000    0.0000         0.00         0.00           0.00
01170      Anesth, pelvis surgery               N            N        0000    0.0000         0.00         0.00           0.00
01173      Anesth, fx repair, pelvis            N            N        0000    0.0000         0.00         0.00           0.00
01180      Anesth, pelvis nerve removal         N            N        0000    0.0000         0.00         0.00           0.00
01190      Anesth, pelvis nerve removal         N            N        0000    0.0000         0.00         0.00           0.00
01200      Anesth, hip joint procedure          N            N        0000    0.0000         0.00         0.00           0.00
01202      Anesth, arthroscopy of hip           N            N        0000    0.0000         0.00         0.00           0.00
01210      Anesth, hip joint surgery            N            N        0000    0.0000         0.00         0.00           0.00
01212      Anesth, hip disarticulation          C            C        0000    0.0000         0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                  3 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

01214      Anesth, hip arthroplasty             C            C        0000    0.0000         0.00         0.00           0.00
01215      Anesth, revise hip repair            N            N        0000    0.0000         0.00         0.00           0.00
01220      Anesth, procedure on femur           N            N        0000    0.0000         0.00         0.00           0.00
01230      Anesth, surgery of femur             N            N        0000    0.0000         0.00         0.00           0.00
01232      Anesth, amputation of femur          C            C        0000    0.0000         0.00         0.00           0.00
01234      Anesth, radical femur surg           C            C        0000    0.0000         0.00         0.00           0.00
01250      Anesth, upper leg surgery            N            N        0000    0.0000         0.00         0.00           0.00
01260      Anesth, upper leg veins surg         N            N        0000    0.0000         0.00         0.00           0.00
01270      Anesth, thigh arteries surg          N            N        0000    0.0000         0.00         0.00           0.00
01272      Anesth, femoral artery surg          C            C        0000    0.0000         0.00         0.00           0.00
01274      Anesth, femoral embolectomy          C            C        0000    0.0000         0.00         0.00           0.00
01320      Anesth, knee area surgery            N            N        0000    0.0000         0.00         0.00           0.00
01340      Anesth, knee area procedure          N            N        0000    0.0000         0.00         0.00           0.00
01360      Anesth, knee area surgery            N            N        0000    0.0000         0.00         0.00           0.00
01380      Anesth, knee joint procedure         N            N        0000    0.0000         0.00         0.00           0.00
01382      Anesth, dx knee arthroscopy          N            N        0000    0.0000         0.00         0.00           0.00
01390      Anesth, knee area procedure          N            N        0000    0.0000         0.00         0.00           0.00
01392      Anesth, knee area surgery            N            N        0000    0.0000         0.00         0.00           0.00
01400      Anesth, knee joint surgery           N            N        0000    0.0000         0.00         0.00           0.00
01402      Anesth, knee arthroplasty            C            C        0000    0.0000         0.00         0.00           0.00
01404      Anesth, amputation at knee           C            C        0000    0.0000         0.00         0.00           0.00
01420      Anesth, knee joint casting           N            N        0000    0.0000         0.00         0.00           0.00
01430      Anesth, knee veins surgery           N            N        0000    0.0000         0.00         0.00           0.00
01432      Anesth, knee vessel surg             N            N        0000    0.0000         0.00         0.00           0.00
01440      Anesth, knee arteries surg           N            N        0000    0.0000         0.00         0.00           0.00
01442      Anesth, knee artery surg             C            C        0000    0.0000         0.00         0.00           0.00
01444      Anesth, knee artery repair           C            C        0000    0.0000         0.00         0.00           0.00
01462      Anesth, lower leg procedure          N            N        0000    0.0000         0.00         0.00           0.00
01464      Anesth, ankle/ft arthroscopy         N            N        0000    0.0000         0.00         0.00           0.00
01470      Anesth, lower leg surgery            N            N        0000    0.0000         0.00         0.00           0.00
01472      Anesth, achilles tendon surg         N            N        0000    0.0000         0.00         0.00           0.00
01474      Anesth, lower leg surgery            N            N        0000    0.0000         0.00         0.00           0.00
01480      Anesth, lower leg bone surg          N            N        0000    0.0000         0.00         0.00           0.00
01482      Anesth, radical leg surgery          N            N        0000    0.0000         0.00         0.00           0.00
01484      Anesth, lower leg revision           N            N        0000    0.0000         0.00         0.00           0.00
01486      Anesth, ankle replacement            C            C        0000    0.0000         0.00         0.00           0.00
01490      Anesth, lower leg casting            N            N        0000    0.0000         0.00         0.00           0.00
01500      Anesth, leg arteries surg            N            N        0000    0.0000         0.00         0.00           0.00
01502      Anesth, lwr leg embolectomy          C            C        0000    0.0000         0.00         0.00           0.00
01520      Anesth, lower leg vein surg          N            N        0000    0.0000         0.00         0.00           0.00
01522      Anesth, lower leg vein surg          N            N        0000    0.0000         0.00         0.00           0.00
01610      Anesth, surgery of shoulder          N            N        0000    0.0000         0.00         0.00           0.00
01620      Anesth, shoulder procedure           N            N        0000    0.0000         0.00         0.00           0.00
01622      Anes dx shoulder arthroscopy         N            N        0000    0.0000         0.00         0.00           0.00
01630      Anesth, surgery of shoulder          N            N        0000    0.0000         0.00         0.00           0.00
01632      Anesth, surgery of shoulder          C            C        0000    0.0000         0.00         0.00           0.00
01634      Anesth, shoulder joint amput         C            C        0000    0.0000         0.00         0.00           0.00
01636      Anesth, forequarter amput            C            C        0000    0.0000         0.00         0.00           0.00
01638      Anesth, shoulder replacement         C            C        0000    0.0000         0.00         0.00           0.00
01650      Anesth, shoulder artery surg         N            N        0000    0.0000         0.00         0.00           0.00
01652      Anesth, shoulder vessel surg         C            C        0000    0.0000         0.00         0.00           0.00
01654      Anesth, shoulder vessel surg         C            C        0000    0.0000         0.00         0.00           0.00
01656      Anesth, arm-leg vessel surg          C            C        0000    0.0000         0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                  4 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

01670      Anesth, shoulder vein surg           N            N        0000    0.0000         0.00         0.00           0.00
01680      Anesth, shoulder casting             N            N        0000    0.0000         0.00         0.00           0.00
01682      Anesth, airplane cast                N            N        0000    0.0000         0.00         0.00           0.00
01710      Anesth, elbow area surgery           N            N        0000    0.0000         0.00         0.00           0.00
01712      Anesth, uppr arm tendon surg         N            N        0000    0.0000         0.00         0.00           0.00
01714      Anesth, uppr arm tendon surg         N            N        0000    0.0000         0.00         0.00           0.00
01716      Anesth, biceps tendon repair         N            N        0000    0.0000         0.00         0.00           0.00
01730      Anesth, uppr arm procedure           N            N        0000    0.0000         0.00         0.00           0.00
01732      Anesth, dx elbow arthroscopy         N            N        0000    0.0000         0.00         0.00           0.00
01740      Anesth, upper arm surgery            N            N        0000    0.0000         0.00         0.00           0.00
01742      Anesth, humerus surgery              N            N        0000    0.0000         0.00         0.00           0.00
01744      Anesth, humerus repair               N            N        0000    0.0000         0.00         0.00           0.00
01756      Anesth, radical humerus surg         C            C        0000    0.0000         0.00         0.00           0.00
01758      Anesth, humeral lesion surg          N            N        0000    0.0000         0.00         0.00           0.00
01760      Anesth, elbow replacement            N            N        0000    0.0000         0.00         0.00           0.00
01770      Anesth, uppr arm artery surg         N            N        0000    0.0000         0.00         0.00           0.00
01772      Anesth, uppr arm embolectomy         N            N        0000    0.0000         0.00         0.00           0.00
01780      Anesth, upper arm vein surg          N            N        0000    0.0000         0.00         0.00           0.00
01782      Anesth, uppr arm vein repair         N            N        0000    0.0000         0.00         0.00           0.00
01810      Anesth, lower arm surgery            N            N        0000    0.0000         0.00         0.00           0.00
01820      Anesth, lower arm procedure          N            N        0000    0.0000         0.00         0.00           0.00
01829      Anesth, dx wrist arthroscopy         N            N        0000    0.0000         0.00         0.00           0.00
01830      Anesth, lower arm surgery            N            N        0000    0.0000         0.00         0.00           0.00
01832      Anesth, wrist replacement            N            N        0000    0.0000         0.00         0.00           0.00
01840      Anesth, lwr arm artery surg          N            N        0000    0.0000         0.00         0.00           0.00
01842      Anesth, lwr arm embolectomy          N            N        0000    0.0000         0.00         0.00           0.00
01844      Anesth, vascular shunt surg          N            N        0000    0.0000         0.00         0.00           0.00
01850      Anesth, lower arm vein surg          N            N        0000    0.0000         0.00         0.00           0.00
01852      Anesth, lwr arm vein repair          N            N        0000    0.0000         0.00         0.00           0.00
01860      Anesth, lower arm casting            N            N        0000    0.0000         0.00         0.00           0.00
01905      Anes, spine inject, x-ray/re         N            N        0000    0.0000         0.00         0.00           0.00
01916      Anesth, dx arteriography             N            N        0000    0.0000         0.00         0.00           0.00
01920      Anesth, catheterize heart            N            N        0000    0.0000         0.00         0.00           0.00
01922      Anesth, cat or MRI scan              N            N        0000    0.0000         0.00         0.00           0.00
01924      Anes, ther interven rad, art         N            N        0000    0.0000         0.00         0.00           0.00
01925      Anes, ther interven rad, car         N            N        0000    0.0000         0.00         0.00           0.00
01926      Anes, tx interv rad hrt/cran         N            N        0000    0.0000         0.00         0.00           0.00
01930      Anes, ther interven rad, vei         N            N        0000    0.0000         0.00         0.00           0.00
01931      Anes, ther interven rad, tip         N            N        0000    0.0000         0.00         0.00           0.00
01932      Anes, tx interv rad, th vein         N            N        0000    0.0000         0.00         0.00           0.00
01933      Anes, tx interv rad, cran v          N            N        0000    0.0000         0.00         0.00           0.00
01951      Anesth, burn, less 4 percent         N            N        0000    0.0000         0.00         0.00           0.00
01952      Anesth, burn, 4-9 percent            N            N        0000    0.0000         0.00         0.00           0.00
01953      Anesth, burn, each 9 percent         N            N        0000    0.0000         0.00         0.00           0.00
01958      Anesth, antepartum manipul           N            N        0000    0.0000         0.00         0.00           0.00
01960      Anesth, vaginal delivery             N            N        0000    0.0000         0.00         0.00           0.00
01961      Anesth, cs delivery                  N            N        0000    0.0000         0.00         0.00           0.00
01962      Anesth, emer hysterectomy            N            N        0000    0.0000         0.00         0.00           0.00
01963      Anesth, cs hysterectomy              N            N        0000    0.0000         0.00         0.00           0.00
01965      Anesth, inc/missed ab proc           N            N        0000    0.0000         0.00         0.00           0.00
01966      Anesth, induced ab procedure         N            N        0000    0.0000         0.00         0.00           0.00
01967      Anesth/analg, vag delivery           N            N        0000    0.0000         0.00         0.00           0.00
01968      Anes/analg cs deliver add-on         N            N        0000    0.0000         0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                  5 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

01969      Anesth/analg cs hyst add-on          N            N        0000     0.0000        0.00         0.00           0.00
01990      Support for organ donor              C            C        0000     0.0000        0.00         0.00           0.00
01991      Anesth, nerve block/inj              N            N        0000     0.0000        0.00         0.00           0.00
01992      Anesth, n block/inj, prone           N            N        0000     0.0000        0.00         0.00           0.00
01995      Regional anesthesia limb             N            N        0000     0.0000        0.00         0.00           0.00
01996      Hosp manage cont drug admin          N            N        0000     0.0000        0.00         0.00           0.00
01999      Unlisted anesth procedure            N            1        0000     0.0000        0.00         0.00           0.00
10021      Fna w/o image                        T            T        0002     0.9357        41.43        95.21         109.10
10022      Fna w/image                          T            T        0036     2.1838        96.70       222.20         254.63
10040      Acne surgery                         T            T        0010     0.5923        26.23        60.27          69.06
10060      Drainage of skin abscess             T            T        0006     1.5100        66.86       153.64         176.07
10061      Drainage of skin abscess             T            T        0006     1.5100        66.86       153.64         176.07
10080      Drainage of pilonidal cyst           T            T        0006     1.5100        66.86       153.64         176.07
10081      Drainage of pilonidal cyst           T            T        0007    11.6717       516.82      1,187.60       1,360.92
10120      Remove foreign body                  T            T        0006     1.5100        66.86       153.64         176.07
10121      Remove foreign body                  T            T        0021    14.9984       664.13      1,526.09       1,748.81
10140      Drainage of hematoma/fluid           T            T        0007    11.6717       516.82      1,187.60       1,360.92
10160      Puncture drainage of lesion          T            T        0018     1.1010        48.75       112.03         128.38
10180      Complex drainage, wound              T            T        0008    16.2953       721.56      1,658.05       1,900.03
11000      Debride infected skin                T            T        0013     1.0603        46.95       107.89         123.63
11001      Debride infected skin add-on         T            T        0012     0.8477        37.54        86.25          98.84
11004      Debride genitalia & perineum         C            C        0000     0.0000        0.00         0.00           0.00
11005      Debride abdom wall                   C            C        0000     0.0000        0.00         0.00           0.00
11006      Debride genit/per/abdom wall         C            C        0000     0.0000        0.00         0.00           0.00
11008      Remove mesh from abd wall            C            C        0000     0.0000        0.00         0.00           0.00
11010      Debride skin, fx                     T            T        0019     4.1481       183.68       422.07         483.67
11011      Debride skin/muscle, fx              T            T        0019     4.1481       183.68       422.07         483.67
11012      Debride skin/muscle/bone, fx         T            T        0019     4.1481       183.68       422.07         483.67
11040      Debride skin, partial                T            T        0015     1.6338        72.34       166.24         190.50
11041      Debride skin, full                   T            T        0015     1.6338        72.34       166.24         190.50
11042      Debride skin/tissue                  T            T        0016     2.5080       111.05       255.19         292.43
11043      Debride tissue/muscle                T            T        0016     2.5080       111.05       255.19         292.43
11044      Debride tissue/muscle/bone           T            T        0682     6.7313       298.06       684.91         784.87
11055      Trim skin lesion                     T            T        0012     0.8477        37.54        86.25          98.84
11056      Trim skin lesions, 2 to 4            T            T        0012     0.8477        37.54        86.25          98.84
11057      Trim skin lesions, over 4            T            T        0013     1.0603        46.95       107.89         123.63
11100      Biopsy, skin lesion                  T            T        0018     1.1010        48.75       112.03         128.38
11101      Biopsy, skin add-on                  T            T        0018     1.1010        48.75       112.03         128.38
11200      Removal of skin tags                 T            T        0013     1.0603        46.95       107.89         123.63
11201      Remove skin tags add-on              T            T        0015     1.6338        72.34       166.24         190.50
11300      Shave skin lesion                    T            T        0012     0.8477        37.54        86.25          98.84
11301      Shave skin lesion                    T            T        0012     0.8477        37.54        86.25          98.84
11302      Shave skin lesion                    T            T        0013     1.0603        46.95       107.89         123.63
11303      Shave skin lesion                    T            T        0015     1.6338        72.34       166.24         190.50
11305      Shave skin lesion                    T            T        0013     1.0603        46.95       107.89         123.63
11306      Shave skin lesion                    T            T        0013     1.0603        46.95       107.89         123.63
11307      Shave skin lesion                    T            T        0013     1.0603        46.95       107.89         123.63
11308      Shave skin lesion                    T            T        0013     1.0603        46.95       107.89         123.63
11310      Shave skin lesion                    T            T        0013     1.0603        46.95       107.89         123.63
11311      Shave skin lesion                    T            T        0013     1.0603        46.95       107.89         123.63
11312      Shave skin lesion                    T            T        0013     1.0603        46.95       107.89         123.63
11313      Shave skin lesion                    T            T        0016     2.5080       111.05       255.19         292.43
11400      Exc tr-ext b9+marg 0.5 < cm          T            T        0019     4.1481       183.68       422.07         483.67

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                  6 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

11401      Exc tr-ext b9+marg 0.6-1 cm          T            T        0019     4.1481       183.68       422.07         483.67
11402      Exc tr-ext b9+marg 1.1-2 cm          T            T        0019     4.1481       183.68       422.07         483.67
11403      Exc tr-ext b9+marg 2.1-3 cm          T            T        0020     6.9410       307.35       706.25         809.32
11404      Exc tr-ext b9+marg 3.1-4 cm          T            T        0021    14.9984       664.13      1,526.09       1,748.81
11406      Exc tr-ext b9+marg > 4.0 cm          T            T        0021    14.9984       664.13      1,526.09       1,748.81
11420      Exc h-f-nk-sp b9+marg 0.5 <          T            T        0020     6.9410       307.35       706.25         809.32
11421      Exc h-f-nk-sp b9+marg 0.6-1          T            T        0020     6.9410       307.35       706.25         809.32
11422      Exc h-f-nk-sp b9+marg 1.1-2          T            T        0020     6.9410       307.35       706.25         809.32
11423      Exc h-f-nk-sp b9+marg 2.1-3          T            T        0021    14.9984       664.13      1,526.09       1,748.81
11424      Exc h-f-nk-sp b9+marg 3.1-4          T            T        0021    14.9984       664.13      1,526.09       1,748.81
11426      Exc h-f-nk-sp b9+marg > 4 cm         T            T        0022    19.5716       866.63      1,991.41       2,282.05
11440      Exc face-mm b9+marg 0.5 < cm         T            T        0019     4.1481       183.68       422.07         483.67
11441      Exc face-mm b9+marg 0.6-1 cm         T            T        0019     4.1481       183.68       422.07         483.67
11442      Exc face-mm b9+marg 1.1-2 cm         T            T        0020     6.9410       307.35       706.25         809.32
11443      Exc face-mm b9+marg 2.1-3 cm         T            T        0020     6.9410       307.35       706.25         809.32
11444      Exc face-mm b9+marg 3.1-4 cm         T            T        0020     6.9410       307.35       706.25         809.32
11446      Exc face-mm b9+marg > 4 cm           T            T        0022    19.5716       866.63      1,991.41       2,282.05
11450      Removal, sweat gland lesion          T            T        0022    19.5716       866.63      1,991.41       2,282.05
11451      Removal, sweat gland lesion          T            T        0022    19.5716       866.63      1,991.41       2,282.05
11462      Removal, sweat gland lesion          T            T        0022    19.5716       866.63      1,991.41       2,282.05
11463      Removal, sweat gland lesion          T            T        0022    19.5716       866.63      1,991.41       2,282.05
11470      Removal, sweat gland lesion          T            T        0022    19.5716       866.63      1,991.41       2,282.05
11471      Removal, sweat gland lesion          T            T        0022    19.5716       866.63      1,991.41       2,282.05
11600      Exc tr-ext mlg+marg 0.5 < cm         T            T        0019     4.1481       183.68       422.07         483.67
11601      Exc tr-ext mlg+marg 0.6-1 cm         T            T        0019     4.1481       183.68       422.07         483.67
11602      Exc tr-ext mlg+marg 1.1-2 cm         T            T        0019     4.1481       183.68       422.07         483.67
11603      Exc tr-ext mlg+marg 2.1-3 cm         T            T        0020     6.9410       307.35       706.25         809.32
11604      Exc tr-ext mlg+marg 3.1-4 cm         T            T        0020     6.9410       307.35       706.25         809.32
11606      Exc tr-ext mlg+marg > 4 cm           T            T        0021    14.9984       664.13      1,526.09       1,748.81
11620      Exc h-f-nk-sp mlg+marg 0.5 <         T            T        0020     6.9410       307.35       706.25         809.32
11621      Exc h-f-nk-sp mlg+marg 0.6-1         T            T        0019     4.1481       183.68       422.07         483.67
11622      Exc h-f-nk-sp mlg+marg 1.1-2         T            T        0020     6.9410       307.35       706.25         809.32
11623      Exc h-f-nk-sp mlg+marg 2.1-3         T            T        0021    14.9984       664.13      1,526.09       1,748.81
11624      Exc h-f-nk-sp mlg+marg 3.1-4         T            T        0021    14.9984       664.13      1,526.09       1,748.81
11626      Exc h-f-nk-sp mlg+mar > 4 cm         T            T        0022    19.5716       866.63      1,991.41       2,282.05
11640      Exc face-mm malig+marg 0.5 <         T            T        0020     6.9410       307.35       706.25         809.32
11641      Exc face-mm malig+marg 0.6-1         T            T        0020     6.9410       307.35       706.25         809.32
11642      Exc face-mm malig+marg 1.1-2         T            T        0020     6.9410       307.35       706.25         809.32
11643      Exc face-mm malig+marg 2.1-3         T            T        0020     6.9410       307.35       706.25         809.32
11644      Exc face-mm malig+marg 3.1-4         T            T        0021    14.9984       664.13      1,526.09       1,748.81
11646      Exc face-mm mlg+marg > 4 cm          T            T        0022    19.5716       866.63      1,991.41       2,282.05
11719      Trim nail(s)                         T            T        0009     0.7513        33.27        76.44          87.60
11720      Debride nail, 1-5                    T            T        0009     0.7513        33.27        76.44          87.60
11721      Debride nail, 6 or more              T            T        0009     0.7513        33.27        76.44          87.60
11730      Removal of nail plate                T            T        0013     1.0603        46.95       107.89         123.63
11732      Remove nail plate, add-on            T            T        0012     0.8477        37.54        86.25          98.84
11740      Drain blood from under nail          T            T        0009     0.7513        33.27        76.44          87.60
11750      Removal of nail bed                  T            T        0019     4.1481       183.68       422.07         483.67
11752      Remove nail bed/finger tip           T            T        0022    19.5716       866.63      1,991.41       2,282.05
11755      Biopsy, nail unit                    T            T        0019     4.1481       183.68       422.07         483.67
11760      Repair of nail bed                   T            T        0024     1.5513        68.69       157.84         180.88
11762      Reconstruction of nail bed           T            T        0024     1.5513        68.69       157.84         180.88
11765      Excision of nail fold, toe           T            T        0015     1.6338        72.34       166.24         190.50

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                  7 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

11770      Removal of pilonidal lesion          T            T        0022    19.5716       866.63      1,991.41       2,282.05
11771      Removal of pilonidal lesion          T            T        0022    19.5716       866.63      1,991.41       2,282.05
11772      Removal of pilonidal lesion          T            T        0022    19.5716       866.63      1,991.41       2,282.05
11900      Injection into skin lesions          T            T        0012     0.8477        37.54        86.25          98.84
11901      Added skin lesions injection         T            T        0012     0.8477        37.54        86.25          98.84
11920      Correct skin color defects           T            1        0000     0.0000        0.00         0.00           0.00
11921      Correct skin color defects           T            1        0000     0.0000        0.00         0.00           0.00
11922      Correct skin color defects           T            1        0000     0.0000        0.00         0.00           0.00
11950      Therapy for contour defects          T            1        0000     0.0000        0.00         0.00           0.00
11951      Therapy for contour defects          T            1        0000     0.0000        0.00         0.00           0.00
11952      Therapy for contour defects          T            1        0000     0.0000        0.00         0.00           0.00
11954      Therapy for contour defects          T            1        0000     0.0000        0.00         0.00           0.00
11960      Insert tissue expander(s)            T            T        0027    18.1956       805.70      1,851.40       2,121.61
11970      Replace tissue expander              T            T        0027    18.1956       805.70      1,851.40       2,121.61
11971      Remove tissue expander(s)            T            T        0022    19.5716       866.63      1,991.41       2,282.05
11975      Insert contraceptive cap             E            3        0000     0.0000        M01          M01            M01
11976      Removal of contraceptive cap         T            T        0019     4.1481       183.68       422.07         483.67
11977      Removal/reinsert contra cap          E            3        0000     0.0000        M01          M01            M01
11980      Implant hormone pellet(s)            X            X        0340     0.6137        27.17        62.44          71.56
11981      Insert drug implant device           X            X        0340     0.6137        27.17        62.44          71.56
11982      Remove drug implant device           X            X        0340     0.6137        27.17        62.44          71.56
11983      Remove/insert drug implant           X            X        0340     0.6137        27.17        62.44          71.56
12001      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12002      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12004      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12005      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12006      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12007      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12011      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12013      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12014      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12015      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12016      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12017      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12018      Repair superficial wound(s)          T            T        0024     1.5513        68.69       157.84         180.88
12020      Closure of split wound               T            T        0024     1.5513        68.69       157.84         180.88
12021      Closure of split wound               T            T        0024     1.5513        68.69       157.84         180.88
12031      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12032      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12034      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12035      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12036      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12037      Layer closure of wound(s)            T            T        0025     5.3051       234.91       539.79         618.57
12041      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12042      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12044      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12045      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12046      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12047      Layer closure of wound(s)            T            T        0025     5.3051       234.91       539.79         618.57
12051      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12052      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12053      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12054      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                  8 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

12055      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12056      Layer closure of wound(s)            T            T        0024     1.5513        68.69       157.84         180.88
12057      Layer closure of wound(s)            T            T        0025     5.3051       234.91       539.79         618.57
13100      Repair of wound or lesion            T            T        0025     5.3051       234.91       539.79         618.57
13101      Repair of wound or lesion            T            T        0025     5.3051       234.91       539.79         618.57
13102      Repair wound/lesion add-on           T            T        0024     1.5513        68.69       157.84         180.88
13120      Repair of wound or lesion            T            T        0024     1.5513        68.69       157.84         180.88
13121      Repair of wound or lesion            T            T        0024     1.5513        68.69       157.84         180.88
13122      Repair wound/lesion add-on           T            T        0024     1.5513        68.69       157.84         180.88
13131      Repair of wound or lesion            T            T        0024     1.5513        68.69       157.84         180.88
13132      Repair of wound or lesion            T            T        0024     1.5513        68.69       157.84         180.88
13133      Repair wound/lesion add-on           T            T        0024     1.5513        68.69       157.84         180.88
13150      Repair of wound or lesion            T            T        0025     5.3051       234.91       539.79         618.57
13151      Repair of wound or lesion            T            T        0024     1.5513        68.69       157.84         180.88
13152      Repair of wound or lesion            T            T        0025     5.3051       234.91       539.79         618.57
13153      Repair wound/lesion add-on           T            T        0024     1.5513        68.69       157.84         180.88
13160      Late closure of wound                T            T        0027    18.1956       805.70      1,851.40       2,121.61
14000      Skin tissue rearrangement            T            T        0686    13.4973       597.66      1,373.35       1,573.79
14001      Skin tissue rearrangement            T            T        0027    18.1956       805.70      1,851.40       2,121.61
14020      Skin tissue rearrangement            T            T        0686    13.4973       597.66      1,373.35       1,573.79
14021      Skin tissue rearrangement            T            T        0027    18.1956       805.70      1,851.40       2,121.61
14040      Skin tissue rearrangement            T            T        0686    13.4973       597.66      1,373.35       1,573.79
14041      Skin tissue rearrangement            T            T        0027    18.1956       805.70      1,851.40       2,121.61
14060      Skin tissue rearrangement            T            T        0027    18.1956       805.70      1,851.40       2,121.61
14061      Skin tissue rearrangement            T            T        0686    13.4973       597.66      1,373.35       1,573.79
14300      Skin tissue rearrangement            T            T        0027    18.1956       805.70      1,851.40       2,121.61
14350      Skin tissue rearrangement            T            T        0027    18.1956       805.70      1,851.40       2,121.61
15000      Skin graft                           T            T        0025     5.3051       234.91       539.79         618.57
15001      Skin graft add-on                    T            T        0025     5.3051       234.91       539.79         618.57
15040      Harvest cultured skin graft          T            T        0024     1.5513        68.69       157.84         180.88
15050      Skin pinch graft                     T            T        0025     5.3051       234.91       539.79         618.57
15100      Skin split graft                     T            T        0027    18.1956       805.70      1,851.40       2,121.61
15101      Skin split graft add-on              T            T        0027    18.1956       805.70      1,851.40       2,121.61
15110      Epidrm autogrft trnk/arm/leg         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15111      Epidrm autogrft t/a/l add-on         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15115      Epidrm a-grft face/nck/hf/g          T            T        0027    18.1956       805.70      1,851.40       2,121.61
15116      Epidrm a-grft f/n/hf/g addl          T            T        0027    18.1956       805.70      1,851.40       2,121.61
15120      Skin split graft                     T            T        0027    18.1956       805.70      1,851.40       2,121.61
15121      Skin split graft add-on              T            T        0027    18.1956       805.70      1,851.40       2,121.61
15130      Derm autograft, trnk/arm/leg         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15131      Derm autograft t/a/l add-on          T            T        0027    18.1956       805.70      1,851.40       2,121.61
15135      Derm autograft face/nck/hf/g         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15136      Derm autograft, f/n/hf/g add         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15150      Cult epiderm grft t/arm/leg          T            T        0027    18.1956       805.70      1,851.40       2,121.61
15151      Cult epiderm grft t/a/l addl         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15152      Cult epiderm graft t/a/l +%          T            T        0027    18.1956       805.70      1,851.40       2,121.61
15155      Cult epiderm graft, f/n/hf/g         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15156      Cult epidrm grft f/n/hfg add         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15157      Cult epiderm grft f/n/hfg +%         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15170      Acell graft trunk/arms/legs          T            T        0024     1.5513        68.69       157.84         180.88
15171      Acell graft t/arm/leg add-on         T            T        0024     1.5513        68.69       157.84         180.88
15175      Acellular graft, f/n/hf/g            T            T        0024     1.5513        68.69       157.84         180.88
15176      Acell graft, f/n/hf/g add-on         T            T        0024     1.5513        68.69       157.84         180.88

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                  9 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

15200      Skin full graft                      T            T        0027    18.1956       805.70      1,851.40       2,121.61
15201      Skin full graft add-on               T            T        0025     5.3051       234.91       539.79         618.57
15220      Skin full graft                      T            T        0027    18.1956       805.70      1,851.40       2,121.61
15221      Skin full graft add-on               T            T        0025     5.3051       234.91       539.79         618.57
15240      Skin full graft                      T            T        0686    13.4973       597.66      1,373.35       1,573.79
15241      Skin full graft add-on               T            T        0025     5.3051       234.91       539.79         618.57
15260      Skin full graft                      T            T        0686    13.4973       597.66      1,373.35       1,573.79
15261      Skin full graft add-on               T            T        0025     5.3051       234.91       539.79         618.57
15300      Apply skinallogrft, t/arm/lg         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15301      Apply sknallogrft t/a/l addl         T            T        0025     5.3051       234.91       539.79         618.57
15320      Apply skin allogrft f/n/hf/g         T            T        0025     5.3051       234.91       539.79         618.57
15321      Aply sknallogrft f/n/hfg add         T            T        0025     5.3051       234.91       539.79         618.57
15330      Aply acell alogrft t/arm/leg         T            T        0025     5.3051       234.91       539.79         618.57
15331      Aply acell grft t/a/l add-on         T            T        0025     5.3051       234.91       539.79         618.57
15335      Apply acell graft, f/n/hf/g          T            T        0025     5.3051       234.91       539.79         618.57
15336      Aply acell grft f/n/hf/g add         T            T        0025     5.3051       234.91       539.79         618.57
15340      Apply cult skin substitute           T            T        0024     1.5513        68.69       157.84         180.88
15341      Apply cult skin sub add-on           T            T        0024     1.5513        68.69       157.84         180.88
15360      Apply cult derm sub, t/a/l           T            T        0024     1.5513        68.69       157.84         180.88
15361      Aply cult derm sub t/a/l add         T            T        0024     1.5513        68.69       157.84         180.88
15365      Apply cult derm sub f/n/hf/g         T            T        0024     1.5513        68.69       157.84         180.88
15366      Apply cult derm f/hf/g add           T            T        0024     1.5513        68.69       157.84         180.88
15400      Skin heterograft                     T            T        0025     5.3051       234.91       539.79         618.57
15401      Skin heterograft add-on              T            T        0025     5.3051       234.91       539.79         618.57
15420      Apply skin xgraft, f/n/hf/g          T            T        0025     5.3051       234.91       539.79         618.57
15421      Apply skn xgrft f/n/hf/g add         T            T        0025     5.3051       234.91       539.79         618.57
15430      Apply acellular xenograft            T            T        0025     5.3051       234.91       539.79         618.57
15431      Apply acellular xgraft add           T            T        0025     5.3051       234.91       539.79         618.57
15570      Form skin pedicle flap               T            T        0027    18.1956       805.70      1,851.40       2,121.61
15572      Form skin pedicle flap               T            T        0027    18.1956       805.70      1,851.40       2,121.61
15574      Form skin pedicle flap               T            T        0027    18.1956       805.70      1,851.40       2,121.61
15576      Form skin pedicle flap               T            T        0686    13.4973       597.66      1,373.35       1,573.79
15600      Skin graft                           T            T        0027    18.1956       805.70      1,851.40       2,121.61
15610      Skin graft                           T            T        0027    18.1956       805.70      1,851.40       2,121.61
15620      Skin graft                           T            T        0027    18.1956       805.70      1,851.40       2,121.61
15630      Skin graft                           T            T        0027    18.1956       805.70      1,851.40       2,121.61
15650      Transfer skin pedicle flap           T            T        0027    18.1956       805.70      1,851.40       2,121.61
15732      Muscle-skin graft, head/neck         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15734      Muscle-skin graft, trunk             T            T        0027    18.1956       805.70      1,851.40       2,121.61
15736      Muscle-skin graft, arm               T            T        0027    18.1956       805.70      1,851.40       2,121.61
15738      Muscle-skin graft, leg               T            T        0027    18.1956       805.70      1,851.40       2,121.61
15740      Island pedicle flap graft            T            T        0686    13.4973       597.66      1,373.35       1,573.79
15750      Neurovascular pedicle graft          T            T        0027    18.1956       805.70      1,851.40       2,121.61
15756      Free myo/skin flap microvasc         C            C        0000     0.0000        0.00         0.00           0.00
15757      Free skin flap, microvasc            C            C        0000     0.0000        0.00         0.00           0.00
15758      Free fascial flap, microvasc         C            C        0000     0.0000        0.00         0.00           0.00
15760      Composite skin graft                 T            T        0027    18.1956       805.70      1,851.40       2,121.61
15770      Derma-fat-fascia graft               T            T        0027    18.1956       805.70      1,851.40       2,121.61
15775      Hair transplant punch grafts         T            1        0000     0.0000        0.00         0.00           0.00
15776      Hair transplant punch grafts         T            1        0000     0.0000        0.00         0.00           0.00
15780      Abrasion treatment of skin           T            T        0022    19.5716       866.63      1,991.41       2,282.05
15781      Abrasion treatment of skin           T            1        0000     0.0000        0.00         0.00           0.00
15782      Abrasion treatment of skin           T            1        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 10 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

15783      Abrasion treatment of skin           T            1        0000     0.0000        0.00         0.00           0.00
15786      Abrasion, lesion, single             T            1        0000     0.0000        0.00         0.00           0.00
15787      Abrasion, lesions, add-on            T            1        0000     0.0000        0.00         0.00           0.00
15788      Chemical peel, face, epiderm         T            1        0000     0.0000        0.00         0.00           0.00
15789      Chemical peel, face, dermal          T            1        0000     0.0000        0.00         0.00           0.00
15792      Chemical peel, nonfacial             T            1        0000     0.0000        0.00         0.00           0.00
15793      Chemical peel, nonfacial             T            1        0000     0.0000        0.00         0.00           0.00
15819      Plastic surgery, neck                T            1        0000     0.0000        0.00         0.00           0.00
15820      Revision of lower eyelid             T            T        0027    18.1956       805.70      1,851.40       2,121.61
15821      Revision of lower eyelid             T            T        0027    18.1956       805.70      1,851.40       2,121.61
15822      Revision of upper eyelid             T            T        0027    18.1956       805.70      1,851.40       2,121.61
15823      Revision of upper eyelid             T            T        0027    18.1956       805.70      1,851.40       2,121.61
15824      Removal of forehead wrinkles         T            1        0000     0.0000        0.00         0.00           0.00
15825      Removal of neck wrinkles             T            1        0000     0.0000        0.00         0.00           0.00
15826      Removal of brow wrinkles             T            1        0000     0.0000        0.00         0.00           0.00
15828      Removal of face wrinkles             T            1        0000     0.0000        0.00         0.00           0.00
15829      Removal of skin wrinkles             T            1        0000     0.0000        0.00         0.00           0.00
15831      Excise excessive skin tissue         T            T        0022    19.5716       866.63      1,991.41       2,282.05
15832      Excise excessive skin tissue         T            1        0000     0.0000        0.00         0.00           0.00
15833      Excise excessive skin tissue         T            1        0000     0.0000        0.00         0.00           0.00
15834      Excise excessive skin tissue         T            1        0000     0.0000        0.00         0.00           0.00
15835      Excise excessive skin tissue         T            1        0000     0.0000        0.00         0.00           0.00
15836      Excise excessive skin tissue         T            1        0000     0.0000        0.00         0.00           0.00
15837      Excise excessive skin tissue         T            1        0000     0.0000        0.00         0.00           0.00
15838      Excise excessive skin tissue         T            1        0000     0.0000        0.00         0.00           0.00
15839      Excise excessive skin tissue         T            1        0000     0.0000        0.00         0.00           0.00
15840      Graft for face nerve palsy           T            T        0027    18.1956       805.70      1,851.40       2,121.61
15841      Graft for face nerve palsy           T            T        0027    18.1956       805.70      1,851.40       2,121.61
15842      Flap for face nerve palsy            T            T        0686    13.4973       597.66      1,373.35       1,573.79
15845      Skin and muscle repair, face         T            T        0027    18.1956       805.70      1,851.40       2,121.61
15850      Removal of sutures                   T            T        0016     2.5080       111.05       255.19         292.43
15851      Removal of sutures                   T            T        0016     2.5080       111.05       255.19         292.43
15852      Dressing change not for burn         X            X        0340     0.6137        27.17        62.44          71.56
15860      Test for blood flow in graft         X            X        0359     0.8036        35.58        81.77          93.70
15876      Suction assisted lipectomy           T            1        0000     0.0000        0.00         0.00           0.00
15877      Suction assisted lipectomy           T            1        0000     0.0000        0.00         0.00           0.00
15878      Suction assisted lipectomy           T            1        0000     0.0000        0.00         0.00           0.00
15879      Suction assisted lipectomy           T            1        0000     0.0000        0.00         0.00           0.00
15920      Removal of tail bone ulcer           T            T        0019     4.1481       183.68       422.07         483.67
15922      Removal of tail bone ulcer           T            T        0027    18.1956       805.70      1,851.40       2,121.61
15931      Remove sacrum pressure sore          T            T        0022    19.5716       866.63      1,991.41       2,282.05
15933      Remove sacrum pressure sore          T            T        0022    19.5716       866.63      1,991.41       2,282.05
15934      Remove sacrum pressure sore          T            T        0027    18.1956       805.70      1,851.40       2,121.61
15935      Remove sacrum pressure sore          T            T        0027    18.1956       805.70      1,851.40       2,121.61
15936      Remove sacrum pressure sore          T            T        0027    18.1956       805.70      1,851.40       2,121.61
15937      Remove sacrum pressure sore          T            T        0027    18.1956       805.70      1,851.40       2,121.61
15940      Remove hip pressure sore             T            T        0022    19.5716       866.63      1,991.41       2,282.05
15941      Remove hip pressure sore             T            T        0022    19.5716       866.63      1,991.41       2,282.05
15944      Remove hip pressure sore             T            T        0027    18.1956       805.70      1,851.40       2,121.61
15945      Remove hip pressure sore             T            T        0027    18.1956       805.70      1,851.40       2,121.61
15946      Remove hip pressure sore             T            T        0027    18.1956       805.70      1,851.40       2,121.61
15950      Remove thigh pressure sore           T            T        0022    19.5716       866.63      1,991.41       2,282.05
15951      Remove thigh pressure sore           T            T        0022    19.5716       866.63      1,991.41       2,282.05

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 11 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 12 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

19102      Bx breast percut w/image             T            T        0005     3.5834        158.67      364.61         417.82
19103      Bx breast percut w/device            T            T        0658     5.9888        265.18      609.36         698.29
19110      Nipple exploration                   T            T        0028    19.4351        860.59     1,977.52       2,266.13
19112      Excise breast duct fistula           T            T        0028    19.4351        860.59     1,977.52       2,266.13
19120      Removal of breast lesion             T            T        0028    19.4351        860.59     1,977.52       2,266.13
19125      Excision, breast lesion              T            T        0028    19.4351        860.59     1,977.52       2,266.13
19126      Excision, addl breast lesion         T            T        0028    19.4351        860.59     1,977.52       2,266.13
19140      Removal of breast tissue             T            T        0028    19.4351        860.59     1,977.52       2,266.13
19160      Partial mastectomy                   T            T        0028    19.4351        860.59     1,977.52       2,266.13
19162      P-mastectomy w/ln removal            T            T        0693    42.2886       1,872.54    4,302.87       4,930.85
19180      Removal of breast                    T            T        0029    31.4826       1,394.05    3,203.35       3,670.87
19182      Removal of breast                    T            T        0029    31.4826       1,394.05    3,203.35       3,670.87
19200      Removal of breast                    C            C        0000     0.0000         0.00        0.00           0.00
19220      Removal of breast                    C            C        0000     0.0000         0.00        0.00           0.00
19240      Removal of breast                    T            T        0030    39.9779       1,770.22    4,067.75       4,661.42
19260      Removal of chest wall lesion         T            T        0021    14.9984        664.13     1,526.09       1,748.81
19271      Revision of chest wall               C            C        0000     0.0000         0.00        0.00           0.00
19272      Extensive chest wall surgery         C            C        0000     0.0000         0.00        0.00           0.00
19290      Place needle wire, breast            N            N        0000     0.0000         0.00        0.00           0.00
19291      Place needle wire, breast            N            N        0000     0.0000         0.00        0.00           0.00
19295      Place breast clip, percut            S            S        0657     1.6092         71.26      163.74         187.63
19296      Place po breast cath for rad         S            S        1524    54.6118   *   2,418.21    5,556.75       6,367.74
19297      Place breast cath for rad            S            S        1523    46.2099   *   2,046.17    4,701.86       5,388.07
19298      Place breast rad tube/caths          S            S        1524    54.6118   *   2,418.21    5,556.75       6,367.74
19316      Suspension of breast                 T            T        0029    31.4826       1,394.05    3,203.35       3,670.87
19318      Reduction of large breast            T            T        0693    42.2886       1,872.54    4,302.87       4,930.85
19324      Enlarge breast                       T            1        0000     0.0000         0.00        0.00           0.00
19325      Enlarge breast with implant          T            T        0648    53.5307       2,370.34    5,446.75       6,241.68
19328      Removal of breast implant            T            T        0029    31.4826       1,394.05    3,203.35       3,670.87
19330      Removal of implant material          T            T        0029    31.4826       1,394.05    3,203.35       3,670.87
19340      Immediate breast prosthesis          T            T        0030    39.9779       1,770.22    4,067.75       4,661.42
19342      Delayed breast prosthesis            T            T        0648    53.5307       2,370.34    5,446.75       6,241.68
19350      Breast reconstruction                T            T        0028    19.4351        860.59     1,977.52       2,266.13
19355      Correct inverted nipple(s)           T            1        0000     0.0000         0.00        0.00           0.00
19357      Breast reconstruction                T            T        0648    53.5307       2,370.34    5,446.75       6,241.68
19361      Breast reconstruction                C            C        0000     0.0000         0.00        0.00           0.00
19364      Breast reconstruction                C            C        0000     0.0000         0.00        0.00           0.00
19366      Breast reconstruction                T            T        0029    31.4826       1,394.05    3,203.35       3,670.87
19367      Breast reconstruction                C            C        0000     0.0000         0.00        0.00           0.00
19368      Breast reconstruction                C            C        0000     0.0000         0.00        0.00           0.00
19369      Breast reconstruction                C            C        0000     0.0000         0.00        0.00           0.00
19370      Surgery of breast capsule            T            T        0029    31.4826       1,394.05    3,203.35       3,670.87
19371      Removal of breast capsule            T            T        0029    31.4826       1,394.05    3,203.35       3,670.87
19380      Revise breast reconstruction         T            T        0030    39.9779       1,770.22    4,067.75       4,661.42
19396      Design custom breast implant         T            T        0029    31.4826       1,394.05    3,203.35       3,670.87
19499      Breast surgery procedure             T            1        0000     0.0000         0.00        0.00           0.00
20000      Incision of abscess                  T            T        0006     1.5100         66.86      153.64         176.07
20005      Incision of deep abscess             T            T        0049    20.3891        902.83     2,074.59       2,377.37
20100      Explore wound, neck                  T            T        0023     4.7662        211.05      484.96         555.74
20101      Explore wound, chest                 T            T        0027    18.1956        805.70     1,851.40       2,121.61
20102      Explore wound, abdomen               T            T        0027    18.1956        805.70     1,851.40       2,121.61
20103      Explore wound, extremity             T            T        0023     4.7662        211.05      484.96         555.74
20150      Excise epiphyseal bar                T            T        0051    36.6106       1,621.12    3,725.13       4,268.80

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 13 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

20200      Muscle biopsy                        T            T        0021    14.9984       664.13      1,526.09       1,748.81
20205      Deep muscle biopsy                   T            T        0021    14.9984       664.13      1,526.09       1,748.81
20206      Needle biopsy, muscle                T            T        0005     3.5834       158.67       364.61         417.82
20220      Bone biopsy, trocar/needle           T            T        0019     4.1481       183.68       422.07         483.67
20225      Bone biopsy, trocar/needle           T            T        0020     6.9410       307.35       706.25         809.32
20240      Bone biopsy, excisional              T            T        0022    19.5716       866.63      1,991.41       2,282.05
20245      Bone biopsy, excisional              T            T        0022    19.5716       866.63      1,991.41       2,282.05
20250      Open bone biopsy                     T            T        0049    20.3891       902.83      2,074.59       2,377.37
20251      Open bone biopsy                     T            T        0049    20.3891       902.83      2,074.59       2,377.37
20500      Injection of sinus tract             T            T        0251     2.0789        92.05       211.53         242.40
20501      Inject sinus tract for x-ray         N            N        0000     0.0000        0.00         0.00           0.00
20520      Removal of foreign body              T            T        0019     4.1481       183.68       422.07         483.67
20525      Removal of foreign body              T            T        0022    19.5716       866.63      1,991.41       2,282.05
20526      Ther injection, carp tunnel          T            T        0204     2.2667       100.37       230.64         264.30
20550      Inj tendon sheath/ligament           T            T        0204     2.2667       100.37       230.64         264.30
20551      Inj tendon origin/insertion          T            T        0204     2.2667       100.37       230.64         264.30
20552      Inj trigger point, 1/2 muscl         T            T        0204     2.2667       100.37       230.64         264.30
20553      Inject trigger points, =/> 3         T            T        0204     2.2667       100.37       230.64         264.30
20600      Drain/inject, joint/bursa            T            T        0204     2.2667       100.37       230.64         264.30
20605      Drain/inject, joint/bursa            T            T        0204     2.2667       100.37       230.64         264.30
20610      Drain/inject, joint/bursa            T            T        0204     2.2667       100.37       230.64         264.30
20612      Aspirate/inj ganglion cyst           T            T        0204     2.2667       100.37       230.64         264.30
20615      Treatment of bone cyst               T            T        0004     1.7771        78.69       180.82         207.21
20650      Insert and remove bone pin           T            T        0049    20.3891       902.83      2,074.59       2,377.37
20660      Apply, rem fixation device           C            C        0000     0.0000        0.00         0.00           0.00
20661      Application of head brace            C            C        0000     0.0000        0.00         0.00           0.00
20662      Application of pelvis brace          T            T        0049    20.3891       902.83      2,074.59       2,377.37
20663      Application of thigh brace           T            T        0049    20.3891       902.83      2,074.59       2,377.37
20664      Halo brace application               C            C        0000     0.0000        0.00         0.00           0.00
20665      Removal of fixation device           X            X        0340     0.6137        27.17        62.44          71.56
20670      Removal of support implant           T            T        0021    14.9984       664.13      1,526.09       1,748.81
20680      Removal of support implant           T            T        0022    19.5716       866.63      1,991.41       2,282.05
20690      Apply bone fixation device           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
20692      Apply bone fixation device           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
20693      Adjust bone fixation device          T            T        0049    20.3891       902.83      2,074.59       2,377.37
20694      Remove bone fixation device          T            T        0049    20.3891       902.83      2,074.59       2,377.37
20802      Replantation, arm, complete          C            C        0000     0.0000        0.00         0.00           0.00
20805      Replant forearm, complete            C            C        0000     0.0000        0.00         0.00           0.00
20808      Replantation hand, complete          C            C        0000     0.0000        0.00         0.00           0.00
20816      Replantation digit, complete         C            C        0000     0.0000        0.00         0.00           0.00
20822      Replantation digit, complete         T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
20824      Replantation thumb, complete         C            C        0000     0.0000        0.00         0.00           0.00
20827      Replantation thumb, complete         C            C        0000     0.0000        0.00         0.00           0.00
20838      Replantation foot, complete          C            C        0000     0.0000        0.00         0.00           0.00
20900      Removal of bone for graft            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
20902      Removal of bone for graft            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
20910      Remove cartilage for graft           T            T        0027    18.1956       805.70      1,851.40       2,121.61
20912      Remove cartilage for graft           T            T        0027    18.1956       805.70      1,851.40       2,121.61
20920      Removal of fascia for graft          T            T        0686    13.4973       597.66      1,373.35       1,573.79
20922      Removal of fascia for graft          T            T        0027    18.1956       805.70      1,851.40       2,121.61
20924      Removal of tendon for graft          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
20926      Removal of tissue for graft          T            T        0686    13.4973       597.66      1,373.35       1,573.79
20930      Spinal bone allograft                C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 14 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

20931      Spinal bone allograft                C            C        0000     0.0000         0.00        0.00           0.00
20936      Spinal bone autograft                C            C        0000     0.0000         0.00        0.00           0.00
20937      Spinal bone autograft                C            C        0000     0.0000         0.00        0.00           0.00
20938      Spinal bone autograft                C            C        0000     0.0000         0.00        0.00           0.00
20950      Fluid pressure, muscle               T            T        0006     1.5100         66.86      153.64         176.07
20955      Fibula bone graft, microvasc         C            C        0000     0.0000         0.00        0.00           0.00
20956      Iliac bone graft, microvasc          C            C        0000     0.0000         0.00        0.00           0.00
20957      Mt bone graft, microvasc             C            C        0000     0.0000         0.00        0.00           0.00
20962      Other bone graft, microvasc          C            C        0000     0.0000         0.00        0.00           0.00
20969      Bone/skin graft, microvasc           C            C        0000     0.0000         0.00        0.00           0.00
20970      Bone/skin graft, iliac crest         C            C        0000     0.0000         0.00        0.00           0.00
20972      Bone/skin graft, metatarsal          T            T        0056    40.5436       1,795.27    4,125.31       4,727.38
20973      Bone/skin graft, great toe           T            T        0056    40.5436       1,795.27    4,125.31       4,727.38
20974      Electrical bone stimulation          A            3        0000     0.0000         M01         M01            M01
20975      Electrical bone stimulation          X            X        0340     0.6137         27.17       62.44          71.56
20979      Us bone stimulation                  B            1        0000     0.0000         0.00        0.00           0.00
20982      Ablate, bone tumor(s) perq           T            T        1557    31.0867   *   1,376.52    3,163.07       3,624.71
20999      Musculoskeletal surgery              T            1        0000     0.0000         0.00        0.00           0.00
21010      Incision of jaw joint                T            T        0254    23.3114       1,032.23    2,371.93       2,718.11
21015      Resection of facial tumor            T            T        0253    16.0740        711.76     1,635.53       1,874.23
21025      Excision of bone, lower jaw          T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21026      Excision of facial bone(s)           T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21029      Contour of face bone lesion          T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21030      Excise max/zygoma b9 tumor           T            T        0254    23.3114       1,032.23    2,371.93       2,718.11
21031      Remove exostosis, mandible           T            T        0254    23.3114       1,032.23    2,371.93       2,718.11
21032      Remove exostosis, maxilla            T            T        0254    23.3114       1,032.23    2,371.93       2,718.11
21034      Excise max/zygoma mlg tumor          T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21040      Excise mandible lesion               T            T        0254    23.3114       1,032.23    2,371.93       2,718.11
21044      Removal of jaw bone lesion           T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21045      Extensive jaw surgery                C            C        0000     0.0000         0.00        0.00           0.00
21046      Remove mandible cyst complex         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21047      Excise lwr jaw cyst w/repair         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21048      Remove maxilla cyst complex          T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21049      Excis uppr jaw cyst w/repair         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21050      Removal of jaw joint                 T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21060      Remove jaw joint cartilage           T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21070      Remove coronoid process              T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21076      Prepare face/oral prosthesis         T            T        0254    23.3114       1,032.23    2,371.93       2,718.11
21077      Prepare face/oral prosthesis         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21079      Prepare face/oral prosthesis         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21080      Prepare face/oral prosthesis         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21081      Prepare face/oral prosthesis         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21082      Prepare face/oral prosthesis         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21083      Prepare face/oral prosthesis         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21084      Prepare face/oral prosthesis         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21085      Prepare face/oral prosthesis         T            T        0253    16.0740        711.76     1,635.53       1,874.23
21086      Prepare face/oral prosthesis         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21087      Prepare face/oral prosthesis         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21088      Prepare face/oral prosthesis         T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21089      Prepare face/oral prosthesis         T            1        0000     0.0000         0.00        0.00           0.00
21100      Maxillofacial fixation               T            T        0256    37.0000       1,638.36    3,764.75       4,314.20
21110      Interdental fixation                 T            T        0252     8.1033        358.81      824.51         944.84
21116      Injection, jaw joint x-ray           N            N        0000     0.0000         0.00        0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 15 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

21120      Reconstruction of chin               T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21121      Reconstruction of chin               T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21122      Reconstruction of chin               T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21123      Reconstruction of chin               T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21125      Augmentation, lower jaw bone         T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21127      Augmentation, lower jaw bone         T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21137      Reduction of forehead                T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21138      Reduction of forehead                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21139      Reduction of forehead                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21141      Reconstruct midface, lefort          C            C        0000     0.0000        0.00         0.00           0.00
21142      Reconstruct midface, lefort          C            C        0000     0.0000        0.00         0.00           0.00
21143      Reconstruct midface, lefort          C            C        0000     0.0000        0.00         0.00           0.00
21145      Reconstruct midface, lefort          C            C        0000     0.0000        0.00         0.00           0.00
21146      Reconstruct midface, lefort          C            C        0000     0.0000        0.00         0.00           0.00
21147      Reconstruct midface, lefort          C            C        0000     0.0000        0.00         0.00           0.00
21150      Reconstruct midface, lefort          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21151      Reconstruct midface, lefort          C            C        0000     0.0000        0.00         0.00           0.00
21154      Reconstruct midface, lefort          C            C        0000     0.0000        0.00         0.00           0.00
21155      Reconstruct midface, lefort          C            C        0000     0.0000        0.00         0.00           0.00
21159      Reconstruct midface, lefort          C            C        0000     0.0000        0.00         0.00           0.00
21160      Reconstruct midface, lefort          C            C        0000     0.0000        0.00         0.00           0.00
21172      Reconstruct orbit/forehead           C            C        0000     0.0000        0.00         0.00           0.00
21175      Reconstruct orbit/forehead           T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21179      Reconstruct entire forehead          C            C        0000     0.0000        0.00         0.00           0.00
21180      Reconstruct entire forehead          C            C        0000     0.0000        0.00         0.00           0.00
21181      Contour cranial bone lesion          T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21182      Reconstruct cranial bone             C            C        0000     0.0000        0.00         0.00           0.00
21183      Reconstruct cranial bone             C            C        0000     0.0000        0.00         0.00           0.00
21184      Reconstruct cranial bone             C            C        0000     0.0000        0.00         0.00           0.00
21188      Reconstruction of midface            C            C        0000     0.0000        0.00         0.00           0.00
21193      Reconst lwr jaw w/o graft            C            C        0000     0.0000        0.00         0.00           0.00
21194      Reconst lwr jaw w/graft              C            C        0000     0.0000        0.00         0.00           0.00
21195      Reconst lwr jaw w/o fixation         T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21196      Reconst lwr jaw w/fixation           C            C        0000     0.0000        0.00         0.00           0.00
21198      Reconstr lwr jaw segment             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21199      Reconstr lwr jaw w/advance           T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21206      Reconstruct upper jaw bone           T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21208      Augmentation of facial bones         T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21209      Reduction of facial bones            T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21210      Face bone graft                      T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21215      Lower jaw bone graft                 T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21230      Rib cartilage graft                  T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21235      Ear cartilage graft                  T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21240      Reconstruction of jaw joint          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21242      Reconstruction of jaw joint          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21243      Reconstruction of jaw joint          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21244      Reconstruction of lower jaw          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21245      Reconstruction of jaw                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21246      Reconstruction of jaw                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21247      Reconstruct lower jaw bone           C            C        0000     0.0000        0.00         0.00           0.00
21248      Reconstruction of jaw                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21249      Reconstruction of jaw                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21255      Reconstruct lower jaw bone           C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 16 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

21256      Reconstruction of orbit              C            C        0000     0.0000        0.00         0.00           0.00
21260      Revise eye sockets                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21261      Revise eye sockets                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21263      Revise eye sockets                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21267      Revise eye sockets                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21268      Revise eye sockets                   C            C        0000     0.0000        0.00         0.00           0.00
21270      Augmentation, cheek bone             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21275      Revision, orbitofacial bones         T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21280      Revision of eyelid                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21282      Revision of eyelid                   T            T        0253    16.0740       711.76      1,635.53       1,874.23
21295      Revision of jaw muscle/bone          T            T        0252     8.1033       358.81       824.51         944.84
21296      Revision of jaw muscle/bone          T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21299      Cranio/maxillofacial surgery         T            1        0000     0.0000        0.00         0.00           0.00
21300      Treatment of skull fracture          T            T        0253    16.0740       711.76      1,635.53       1,874.23
21310      Treatment of nose fracture           T            T        0251     2.0789        92.05       211.53         242.40
21315      Treatment of nose fracture           T            T        0251     2.0789        92.05       211.53         242.40
21320      Treatment of nose fracture           T            T        0252     8.1033       358.81       824.51         944.84
21325      Treatment of nose fracture           T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21330      Treatment of nose fracture           T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21335      Treatment of nose fracture           T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21336      Treat nasal septal fracture          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
21337      Treat nasal septal fracture          T            T        0253    16.0740       711.76      1,635.53       1,874.23
21338      Treat nasoethmoid fracture           T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21339      Treat nasoethmoid fracture           T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21340      Treatment of nose fracture           T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21343      Treatment of sinus fracture          C            C        0000     0.0000        0.00         0.00           0.00
21344      Treatment of sinus fracture          C            C        0000     0.0000        0.00         0.00           0.00
21345      Treat nose/jaw fracture              T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21346      Treat nose/jaw fracture              C            C        0000     0.0000        0.00         0.00           0.00
21347      Treat nose/jaw fracture              C            C        0000     0.0000        0.00         0.00           0.00
21348      Treat nose/jaw fracture              C            C        0000     0.0000        0.00         0.00           0.00
21355      Treat cheek bone fracture            T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21356      Treat cheek bone fracture            T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21360      Treat cheek bone fracture            C            C        0000     0.0000        0.00         0.00           0.00
21365      Treat cheek bone fracture            C            C        0000     0.0000        0.00         0.00           0.00
21366      Treat cheek bone fracture            C            C        0000     0.0000        0.00         0.00           0.00
21385      Treat eye socket fracture            C            C        0000     0.0000        0.00         0.00           0.00
21386      Treat eye socket fracture            C            C        0000     0.0000        0.00         0.00           0.00
21387      Treat eye socket fracture            C            C        0000     0.0000        0.00         0.00           0.00
21390      Treat eye socket fracture            T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21395      Treat eye socket fracture            C            C        0000     0.0000        0.00         0.00           0.00
21400      Treat eye socket fracture            T            T        0252     8.1033       358.81       824.51         944.84
21401      Treat eye socket fracture            T            T        0253    16.0740       711.76      1,635.53       1,874.23
21406      Treat eye socket fracture            T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21407      Treat eye socket fracture            T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21408      Treat eye socket fracture            T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21421      Treat mouth roof fracture            T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21422      Treat mouth roof fracture            C            C        0000     0.0000        0.00         0.00           0.00
21423      Treat mouth roof fracture            C            C        0000     0.0000        0.00         0.00           0.00
21431      Treat craniofacial fracture          C            C        0000     0.0000        0.00         0.00           0.00
21432      Treat craniofacial fracture          C            C        0000     0.0000        0.00         0.00           0.00
21433      Treat craniofacial fracture          C            C        0000     0.0000        0.00         0.00           0.00
21435      Treat craniofacial fracture          C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 17 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

21436      Treat craniofacial fracture          C            C        0000     0.0000        0.00         0.00           0.00
21440      Treat dental ridge fracture          T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21445      Treat dental ridge fracture          T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21450      Treat lower jaw fracture             T            T        0251     2.0789        92.05       211.53         242.40
21451      Treat lower jaw fracture             T            T        0252     8.1033       358.81       824.51         944.84
21452      Treat lower jaw fracture             T            T        0253    16.0740       711.76      1,635.53       1,874.23
21453      Treat lower jaw fracture             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21454      Treat lower jaw fracture             T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
21461      Treat lower jaw fracture             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21462      Treat lower jaw fracture             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21465      Treat lower jaw fracture             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21470      Treat lower jaw fracture             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21480      Reset dislocated jaw                 T            T        0251     2.0789        92.05       211.53         242.40
21485      Reset dislocated jaw                 T            T        0253    16.0740       711.76      1,635.53       1,874.23
21490      Repair dislocated jaw                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
21495      Treat hyoid bone fracture            T            T        0253    16.0740       711.76      1,635.53       1,874.23
21497      Interdental wiring                   T            T        0253    16.0740       711.76      1,635.53       1,874.23
21499      Head surgery procedure               T            1        0000     0.0000        0.00         0.00           0.00
21501      Drain neck/chest lesion              T            T        0008    16.2953       721.56      1,658.05       1,900.03
21502      Drain chest lesion                   T            T        0049    20.3891       902.83      2,074.59       2,377.37
21510      Drainage of bone lesion              C            C        0000     0.0000        0.00         0.00           0.00
21550      Biopsy of neck/chest                 T            T        0021    14.9984       664.13      1,526.09       1,748.81
21555      Remove lesion, neck/chest            T            T        0022    19.5716       866.63      1,991.41       2,282.05
21556      Remove lesion, neck/chest            T            T        0022    19.5716       866.63      1,991.41       2,282.05
21557      Remove tumor, neck/chest             T            T        0022    19.5716       866.63      1,991.41       2,282.05
21600      Partial removal of rib               T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
21610      Partial removal of rib               T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
21615      Removal of rib                       C            C        0000     0.0000        0.00         0.00           0.00
21616      Removal of rib and nerves            C            C        0000     0.0000        0.00         0.00           0.00
21620      Partial removal of sternum           C            C        0000     0.0000        0.00         0.00           0.00
21627      Sternal debridement                  C            C        0000     0.0000        0.00         0.00           0.00
21630      Extensive sternum surgery            C            C        0000     0.0000        0.00         0.00           0.00
21632      Extensive sternum surgery            C            C        0000     0.0000        0.00         0.00           0.00
21685      Hyoid myotomy & suspension           T            T        0252     8.1033       358.81       824.51         944.84
21700      Revision of neck muscle              T            T        0049    20.3891       902.83      2,074.59       2,377.37
21705      Revision of neck muscle/rib          C            C        0000     0.0000        0.00         0.00           0.00
21720      Revision of neck muscle              T            T        0049    20.3891       902.83      2,074.59       2,377.37
21725      Revision of neck muscle              T            T        0006     1.5100        66.86       153.64         176.07
21740      Reconstruction of sternum            C            C        0000     0.0000        0.00         0.00           0.00
21742      Repair stern/nuss w/o scope          T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
21743      Repair sternum/nuss w/scope          T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
21750      Repair of sternum separation         C            C        0000     0.0000        0.00         0.00           0.00
21800      Treatment of rib fracture            T            T        0043     1.7200        76.16       175.01         200.55
21805      Treatment of rib fracture            T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
21810      Treatment of rib fracture(s)         C            C        0000     0.0000        0.00         0.00           0.00
21820      Treat sternum fracture               T            T        0043     1.7200        76.16       175.01         200.55
21825      Treat sternum fracture               C            C        0000     0.0000        0.00         0.00           0.00
21899      Neck/chest surgery procedure         T            1        0000     0.0000        0.00         0.00           0.00
21920      Biopsy soft tissue of back           T            T        0020     6.9410       307.35       706.25         809.32
21925      Biopsy soft tissue of back           T            T        0022    19.5716       866.63      1,991.41       2,282.05
21930      Remove lesion, back or flank         T            T        0022    19.5716       866.63      1,991.41       2,282.05
21935      Remove tumor, back                   T            T        0022    19.5716       866.63      1,991.41       2,282.05
22010      I&d, p-spine, c/t/cerv-thor          C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 18 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

22015      I&d, p-spine, l/s/ls                 C            C        0000     0.0000        0.00         0.00           0.00
22100      Remove part of neck vertebra         T            T        0208    42.5200      1,882.79     4,326.41       4,957.83
22101      Remove part, thorax vertebra         T            T        0208    42.5200      1,882.79     4,326.41       4,957.83
22102      Remove part, lumbar vertebra         T            T        0208    42.5200      1,882.79     4,326.41       4,957.83
22103      Remove extra spine segment           T            T        0208    42.5200      1,882.79     4,326.41       4,957.83
22110      Remove part of neck vertebra         C            C        0000     0.0000        0.00         0.00           0.00
22112      Remove part, thorax vertebra         C            C        0000     0.0000        0.00         0.00           0.00
22114      Remove part, lumbar vertebra         C            C        0000     0.0000        0.00         0.00           0.00
22116      Remove extra spine segment           C            C        0000     0.0000        0.00         0.00           0.00
22210      Revision of neck spine               C            C        0000     0.0000        0.00         0.00           0.00
22212      Revision of thorax spine             C            C        0000     0.0000        0.00         0.00           0.00
22214      Revision of lumbar spine             C            C        0000     0.0000        0.00         0.00           0.00
22216      Revise, extra spine segment          C            C        0000     0.0000        0.00         0.00           0.00
22220      Revision of neck spine               C            C        0000     0.0000        0.00         0.00           0.00
22222      Revision of thorax spine             T            T        0208    42.5200      1,882.79     4,326.41       4,957.83
22224      Revision of lumbar spine             C            C        0000     0.0000        0.00         0.00           0.00
22226      Revise, extra spine segment          C            C        0000     0.0000        0.00         0.00           0.00
22305      Treat spine process fracture         T            T        0043     1.7200        76.16       175.01         200.55
22310      Treat spine fracture                 T            T        0043     1.7200        76.16       175.01         200.55
22315      Treat spine fracture                 T            T        0043     1.7200        76.16       175.01         200.55
22318      Treat odontoid fx w/o graft          C            C        0000     0.0000        0.00         0.00           0.00
22319      Treat odontoid fx w/graft            C            C        0000     0.0000        0.00         0.00           0.00
22325      Treat spine fracture                 C            C        0000     0.0000        0.00         0.00           0.00
22326      Treat neck spine fracture            C            C        0000     0.0000        0.00         0.00           0.00
22327      Treat thorax spine fracture          C            C        0000     0.0000        0.00         0.00           0.00
22328      Treat each add spine fx              C            C        0000     0.0000        0.00         0.00           0.00
22505      Manipulation of spine                T            T        0045    14.3413       635.03      1,459.23       1,672.20
22520      Percut vertebroplasty thor           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
22521      Percut vertebroplasty lumb           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
22522      Percut vertebroplasty add’l          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
22523      Percut kyphoplasty, thor             T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
22524      Percut kyphoplasty, lumbar           T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
22525      Percut kyphoplasty, add-on           T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
22532      Lat thorax spine fusion              C            C        0000     0.0000        0.00         0.00           0.00
22533      Lat lumbar spine fusion              C            C        0000     0.0000        0.00         0.00           0.00
22534      Lat thor/lumb, add’l seg             C            C        0000     0.0000        0.00         0.00           0.00
22548      Neck spine fusion                    C            C        0000     0.0000        0.00         0.00           0.00
22554      Neck spine fusion                    C            C        0000     0.0000        0.00         0.00           0.00
22556      Thorax spine fusion                  C            C        0000     0.0000        0.00         0.00           0.00
22558      Lumbar spine fusion                  C            C        0000     0.0000        0.00         0.00           0.00
22585      Additional spinal fusion             C            C        0000     0.0000        0.00         0.00           0.00
22590      Spine & skull spinal fusion          C            C        0000     0.0000        0.00         0.00           0.00
22595      Neck spinal fusion                   C            C        0000     0.0000        0.00         0.00           0.00
22600      Neck spine fusion                    C            C        0000     0.0000        0.00         0.00           0.00
22610      Thorax spine fusion                  C            C        0000     0.0000        0.00         0.00           0.00
22612      Lumbar spine fusion                  T            T        0208    42.5200      1,882.79     4,326.41       4,957.83
22614      Spine fusion, extra segment          T            T        0208    42.5200      1,882.79     4,326.41       4,957.83
22630      Lumbar spine fusion                  C            C        0000     0.0000        0.00         0.00           0.00
22632      Spine fusion, extra segment          C            C        0000     0.0000        0.00         0.00           0.00
22800      Fusion of spine                      C            C        0000     0.0000        0.00         0.00           0.00
22802      Fusion of spine                      C            C        0000     0.0000        0.00         0.00           0.00
22804      Fusion of spine                      C            C        0000     0.0000        0.00         0.00           0.00
22808      Fusion of spine                      C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 19 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

22810      Fusion of spine                      C            C        0000     0.0000        0.00         0.00           0.00
22812      Fusion of spine                      C            C        0000     0.0000        0.00         0.00           0.00
22818      Kyphectomy, 1-2 segments             C            C        0000     0.0000        0.00         0.00           0.00
22819      Kyphectomy, 3 or more                C            C        0000     0.0000        0.00         0.00           0.00
22830      Exploration of spinal fusion         C            C        0000     0.0000        0.00         0.00           0.00
22840      Insert spine fixation device         C            C        0000     0.0000        0.00         0.00           0.00
22841      Insert spine fixation device         C            C        0000     0.0000        0.00         0.00           0.00
22842      Insert spine fixation device         C            C        0000     0.0000        0.00         0.00           0.00
22843      Insert spine fixation device         C            C        0000     0.0000        0.00         0.00           0.00
22844      Insert spine fixation device         C            C        0000     0.0000        0.00         0.00           0.00
22845      Insert spine fixation device         C            C        0000     0.0000        0.00         0.00           0.00
22846      Insert spine fixation device         C            C        0000     0.0000        0.00         0.00           0.00
22847      Insert spine fixation device         C            C        0000     0.0000        0.00         0.00           0.00
22848      Insert pelv fixation device          C            C        0000     0.0000        0.00         0.00           0.00
22849      Reinsert spinal fixation             C            C        0000     0.0000        0.00         0.00           0.00
22850      Remove spine fixation device         C            C        0000     0.0000        0.00         0.00           0.00
22851      Apply spine prosth device            C            C        0000     0.0000        0.00         0.00           0.00
22852      Remove spine fixation device         C            C        0000     0.0000        0.00         0.00           0.00
22855      Remove spine fixation device         C            C        0000     0.0000        0.00         0.00           0.00
22899      Spine surgery procedure              T            1        0000     0.0000        0.00         0.00           0.00
22900      Remove abdominal wall lesion         T            T        0022    19.5716       866.63      1,991.41       2,282.05
22999      Abdomen surgery procedure            T            1        0000     0.0000        0.00         0.00           0.00
23000      Removal of calcium deposits          T            T        0021    14.9984       664.13      1,526.09       1,748.81
23020      Release shoulder joint               T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
23030      Drain shoulder lesion                T            T        0008    16.2953       721.56      1,658.05       1,900.03
23031      Drain shoulder bursa                 T            T        0008    16.2953       721.56      1,658.05       1,900.03
23035      Drain shoulder bone lesion           T            T        0049    20.3891       902.83      2,074.59       2,377.37
23040      Exploratory shoulder surgery         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23044      Exploratory shoulder surgery         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23065      Biopsy shoulder tissues              T            T        0021    14.9984       664.13      1,526.09       1,748.81
23066      Biopsy shoulder tissues              T            T        0022    19.5716       866.63      1,991.41       2,282.05
23075      Removal of shoulder lesion           T            T        0021    14.9984       664.13      1,526.09       1,748.81
23076      Removal of shoulder lesion           T            T        0022    19.5716       866.63      1,991.41       2,282.05
23077      Remove tumor of shoulder             T            T        0022    19.5716       866.63      1,991.41       2,282.05
23100      Biopsy of shoulder joint             T            T        0049    20.3891       902.83      2,074.59       2,377.37
23101      Shoulder joint surgery               T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23105      Remove shoulder joint lining         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23106      Incision of collarbone joint         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23107      Explore treat shoulder joint         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23120      Partial removal, collar bone         T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
23125      Removal of collar bone               T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
23130      Remove shoulder bone, part           T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
23140      Removal of bone lesion               T            T        0049    20.3891       902.83      2,074.59       2,377.37
23145      Removal of bone lesion               T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23146      Removal of bone lesion               T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23150      Removal of humerus lesion            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23155      Removal of humerus lesion            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23156      Removal of humerus lesion            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23170      Remove collar bone lesion            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23172      Remove shoulder blade lesion         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23174      Remove humerus lesion                T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23180      Remove collar bone lesion            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
23182      Remove shoulder blade lesion         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 20 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

23184      Remove humerus lesion                T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
23190      Partial removal of scapula           T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
23195      Removal of head of humerus           T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
23200      Removal of collar bone               C            C        0000    0.0000         0.00         0.00         0.00
23210      Removal of shoulder blade            C            C        0000    0.0000         0.00         0.00         0.00
23220      Partial removal of humerus           C            C        0000    0.0000         0.00         0.00         0.00
23221      Partial removal of humerus           C            C        0000    0.0000         0.00         0.00         0.00
23222      Partial removal of humerus           C            C        0000    0.0000         0.00         0.00         0.00
23330      Remove shoulder foreign body         T            T        0020    6.9410        307.35       706.25       809.32
23331      Remove shoulder foreign body         T            T        0022   19.5716        866.63      1,991.41     2,282.05
23332      Remove shoulder foreign body         C            C        0000    0.0000         0.00         0.00         0.00
23350      Injection for shoulder x-ray         N            N        0000    0.0000         0.00         0.00         0.00
23395      Muscle transfer,shoulder/arm         T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
23397      Muscle transfers                     T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23400      Fixation of shoulder blade           T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
23405      Incision of tendon & muscle          T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
23406      Incise tendon(s) & muscle(s)         T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
23410      Repair rotator cuff, acute           T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23412      Repair rotator cuff, chronic         T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23415      Release of shoulder ligament         T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
23420      Repair of shoulder                   T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23430      Repair biceps tendon                 T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23440      Remove/transplant tendon             T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23450      Repair shoulder capsule              T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23455      Repair shoulder capsule              T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23460      Repair shoulder capsule              T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23462      Repair shoulder capsule              T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23465      Repair shoulder capsule              T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23466      Repair shoulder capsule              T            T        0052   43.5555       1,928.64     4,431.77     5,078.57
23470      Reconstruct shoulder joint           T            T        0425   104.7352      4,637.67    10,656.81    12,212.12
23472      Reconstruct shoulder joint           C            C        0000    0.0000         0.00         0.00         0.00
23480      Revision of collar bone              T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
23485      Revision of collar bone              T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
23490      Reinforce clavicle                   T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
23491      Reinforce shoulder bones             T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
23500      Treat clavicle fracture              T            T        0043    1.7200         76.16       175.01       200.55
23505      Treat clavicle fracture              T            T        0043    1.7200         76.16       175.01       200.55
23515      Treat clavicle fracture              T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
23520      Treat clavicle dislocation           T            T        0043    1.7200         76.16       175.01       200.55
23525      Treat clavicle dislocation           T            T        0043    1.7200         76.16       175.01       200.55
23530      Treat clavicle dislocation           T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
23532      Treat clavicle dislocation           T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
23540      Treat clavicle dislocation           T            T        0043    1.7200         76.16       175.01       200.55
23545      Treat clavicle dislocation           T            T        0043    1.7200         76.16       175.01       200.55
23550      Treat clavicle dislocation           T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
23552      Treat clavicle dislocation           T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
23570      Treat shoulder blade fx              T            T        0043    1.7200         76.16       175.01       200.55
23575      Treat shoulder blade fx              T            T        0043    1.7200         76.16       175.01       200.55
23585      Treat scapula fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
23600      Treat humerus fracture               T            T        0043    1.7200         76.16       175.01       200.55
23605      Treat humerus fracture               T            T        0043    1.7200         76.16       175.01       200.55
23615      Treat humerus fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
23616      Treat humerus fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                             21 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

23620      Treat humerus fracture               T            T        0043     1.7200        76.16       175.01         200.55
23625      Treat humerus fracture               T            T        0043     1.7200        76.16       175.01         200.55
23630      Treat humerus fracture               T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
23650      Treat shoulder dislocation           T            T        0043     1.7200        76.16       175.01         200.55
23655      Treat shoulder dislocation           T            T        0045    14.3413       635.03      1,459.23       1,672.20
23660      Treat shoulder dislocation           T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
23665      Treat dislocation/fracture           T            T        0043     1.7200        76.16       175.01         200.55
23670      Treat dislocation/fracture           T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
23675      Treat dislocation/fracture           T            T        0043     1.7200        76.16       175.01         200.55
23680      Treat dislocation/fracture           T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
23700      Fixation of shoulder                 T            T        0045    14.3413       635.03      1,459.23       1,672.20
23800      Fusion of shoulder joint             T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
23802      Fusion of shoulder joint             T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
23900      Amputation of arm & girdle           C            C        0000     0.0000        0.00         0.00           0.00
23920      Amputation at shoulder joint         C            C        0000     0.0000        0.00         0.00           0.00
23921      Amputation follow-up surgery         T            T        0025     5.3051       234.91       539.79         618.57
23929      Shoulder surgery procedure           T            1        0000     0.0000        0.00         0.00           0.00
23930      Drainage of arm lesion               T            T        0008    16.2953       721.56      1,658.05       1,900.03
23931      Drainage of arm bursa                T            T        0008    16.2953       721.56      1,658.05       1,900.03
23935      Drain arm/elbow bone lesion          T            T        0049    20.3891       902.83      2,074.59       2,377.37
24000      Exploratory elbow surgery            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24006      Release elbow joint                  T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24065      Biopsy arm/elbow soft tissue         T            T        0021    14.9984       664.13      1,526.09       1,748.81
24066      Biopsy arm/elbow soft tissue         T            T        0021    14.9984       664.13      1,526.09       1,748.81
24075      Remove arm/elbow lesion              T            T        0021    14.9984       664.13      1,526.09       1,748.81
24076      Remove arm/elbow lesion              T            T        0022    19.5716       866.63      1,991.41       2,282.05
24077      Remove tumor of arm/elbow            T            T        0022    19.5716       866.63      1,991.41       2,282.05
24100      Biopsy elbow joint lining            T            T        0049    20.3891       902.83      2,074.59       2,377.37
24101      Explore/treat elbow joint            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24102      Remove elbow joint lining            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24105      Removal of elbow bursa               T            T        0049    20.3891       902.83      2,074.59       2,377.37
24110      Remove humerus lesion                T            T        0049    20.3891       902.83      2,074.59       2,377.37
24115      Remove/graft bone lesion             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24116      Remove/graft bone lesion             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24120      Remove elbow lesion                  T            T        0049    20.3891       902.83      2,074.59       2,377.37
24125      Remove/graft bone lesion             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24126      Remove/graft bone lesion             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24130      Removal of head of radius            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24134      Removal of arm bone lesion           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24136      Remove radius bone lesion            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24138      Remove elbow bone lesion             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24140      Partial removal of arm bone          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24145      Partial removal of radius            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24147      Partial removal of elbow             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24149      Radical resection of elbow           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24150      Extensive humerus surgery            T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
24151      Extensive humerus surgery            T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
24152      Extensive radius surgery             T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
24153      Extensive radius surgery             T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
24155      Removal of elbow joint               T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
24160      Remove elbow joint implant           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24164      Remove radius head implant           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
24200      Removal of arm foreign body          T            T        0019     4.1481       183.68       422.07         483.67

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 22 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

24201      Removal of arm foreign body          T            T        0021   14.9984        664.13      1,526.09     1,748.81
24220      Injection for elbow x-ray            N            N        0000    0.0000         0.00         0.00         0.00
24300      Manipulate elbow w/anesth            T            T        0045   14.3413        635.03      1,459.23     1,672.20
24301      Muscle/tendon transfer               T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24305      Arm tendon lengthening               T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24310      Revision of arm tendon               T            T        0049   20.3891        902.83      2,074.59     2,377.37
24320      Repair of arm tendon                 T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24330      Revision of arm muscles              T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24331      Revision of arm muscles              T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24332      Tenolysis, triceps                   T            T        0049   20.3891        902.83      2,074.59     2,377.37
24340      Repair of biceps tendon              T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24341      Repair arm tendon/muscle             T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24342      Repair of ruptured tendon            T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24343      Repr elbow lat ligmnt w/tiss         T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24344      Reconstruct elbow lat ligmnt         T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24345      Repr elbw med ligmnt w/tissu         T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24346      Reconstruct elbow med ligmnt         T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24350      Repair of tennis elbow               T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24351      Repair of tennis elbow               T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24352      Repair of tennis elbow               T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24354      Repair of tennis elbow               T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24356      Revision of tennis elbow             T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24360      Reconstruct elbow joint              T            T        0047   31.2345       1,383.06     3,178.11     3,641.94
24361      Reconstruct elbow joint              T            T        0425   104.7352      4,637.67    10,656.81    12,212.12
24362      Reconstruct elbow joint              T            T        0048   43.3955       1,921.55     4,415.49     5,059.92
24363      Replace elbow joint                  T            T        0425   104.7352      4,637.67    10,656.81    12,212.12
24365      Reconstruct head of radius           T            T        0047   31.2345       1,383.06     3,178.11     3,641.94
24366      Reconstruct head of radius           T            T        0425   104.7352      4,637.67    10,656.81    12,212.12
24400      Revision of humerus                  T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24410      Revision of humerus                  T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24420      Revision of humerus                  T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24430      Repair of humerus                    T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24435      Repair humerus with graft            T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24470      Revision of elbow joint              T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24495      Decompression of forearm             T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
24498      Reinforce humerus                    T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
24500      Treat humerus fracture               T            T        0043    1.7200         76.16       175.01       200.55
24505      Treat humerus fracture               T            T        0043    1.7200         76.16       175.01       200.55
24515      Treat humerus fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
24516      Treat humerus fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
24530      Treat humerus fracture               T            T        0043    1.7200         76.16       175.01       200.55
24535      Treat humerus fracture               T            T        0043    1.7200         76.16       175.01       200.55
24538      Treat humerus fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
24545      Treat humerus fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
24546      Treat humerus fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
24560      Treat humerus fracture               T            T        0043    1.7200         76.16       175.01       200.55
24565      Treat humerus fracture               T            T        0043    1.7200         76.16       175.01       200.55
24566      Treat humerus fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
24575      Treat humerus fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
24576      Treat humerus fracture               T            T        0043    1.7200         76.16       175.01       200.55
24577      Treat humerus fracture               T            T        0043    1.7200         76.16       175.01       200.55
24579      Treat humerus fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
24582      Treat humerus fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                             23 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 24 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

25125      Remove/graft forearm lesion          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25126      Remove/graft forearm lesion          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25130      Removal of wrist lesion              T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25135      Remove & graft wrist lesion          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25136      Remove & graft wrist lesion          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25145      Remove forearm bone lesion           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25150      Partial removal of ulna              T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25151      Partial removal of radius            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25170      Extensive forearm surgery            T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
25210      Removal of wrist bone                T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
25215      Removal of wrist bones               T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
25230      Partial removal of radius            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25240      Partial removal of ulna              T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25246      Injection for wrist x-ray            N            N        0000     0.0000        0.00         0.00           0.00
25248      Remove forearm foreign body          T            T        0049    20.3891       902.83      2,074.59       2,377.37
25250      Removal of wrist prosthesis          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25251      Removal of wrist prosthesis          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25259      Manipulate wrist w/anesthes          T            T        0043     1.7200        76.16       175.01         200.55
25260      Repair forearm tendon/muscle         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25263      Repair forearm tendon/muscle         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25265      Repair forearm tendon/muscle         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25270      Repair forearm tendon/muscle         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25272      Repair forearm tendon/muscle         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25274      Repair forearm tendon/muscle         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25275      Repair forearm tendon sheath         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25280      Revise wrist/forearm tendon          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25290      Incise wrist/forearm tendon          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25295      Release wrist/forearm tendon         T            T        0049    20.3891       902.83      2,074.59       2,377.37
25300      Fusion of tendons at wrist           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25301      Fusion of tendons at wrist           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25310      Transplant forearm tendon            T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25312      Transplant forearm tendon            T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25315      Revise palsy hand tendon(s)          T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25316      Revise palsy hand tendon(s)          T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25320      Repair/revise wrist joint            T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25332      Revise wrist joint                   T            T        0047    31.2345      1,383.06     3,178.11       3,641.94
25335      Realignment of hand                  T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25337      Reconstruct ulna/radioulnar          T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25350      Revision of radius                   T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25355      Revision of radius                   T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25360      Revision of ulna                     T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25365      Revise radius & ulna                 T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25370      Revise radius or ulna                T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25375      Revise radius & ulna                 T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25390      Shorten radius or ulna               T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25391      Lengthen radius or ulna              T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25392      Shorten radius & ulna                T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25393      Lengthen radius & ulna               T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25394      Repair carpal bone, shorten          T            T        0053    15.6396       692.52      1,591.33       1,823.58
25400      Repair radius or ulna                T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25405      Repair/graft radius or ulna          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25415      Repair radius & ulna                 T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
25420      Repair/graft radius & ulna           T            T        0051    36.6106      1,621.12     3,725.13       4,268.80

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 25 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

25425      Repair/graft radius or ulna          T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
25426      Repair/graft radius & ulna           T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
25430      Vasc graft into carpal bone          T            T        0054   25.1321       1,112.85     2,557.19     2,930.40
25431      Repair nonunion carpal bone          T            T        0054   25.1321       1,112.85     2,557.19     2,930.40
25440      Repair/graft wrist bone              T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
25441      Reconstruct wrist joint              T            T        0425   104.7352      4,637.67    10,656.81    12,212.12
25442      Reconstruct wrist joint              T            T        0425   104.7352      4,637.67    10,656.81    12,212.12
25443      Reconstruct wrist joint              T            T        0048   43.3955       1,921.55     4,415.49     5,059.92
25444      Reconstruct wrist joint              T            T        0048   43.3955       1,921.55     4,415.49     5,059.92
25445      Reconstruct wrist joint              T            T        0048   43.3955       1,921.55     4,415.49     5,059.92
25446      Wrist replacement                    T            T        0425   104.7352      4,637.67    10,656.81    12,212.12
25447      Repair wrist joint(s)                T            T        0047   31.2345       1,383.06     3,178.11     3,641.94
25449      Remove wrist joint implant           T            T        0047   31.2345       1,383.06     3,178.11     3,641.94
25450      Revision of wrist joint              T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
25455      Revision of wrist joint              T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
25490      Reinforce radius                     T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
25491      Reinforce ulna                       T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
25492      Reinforce radius and ulna            T            T        0051   36.6106       1,621.12     3,725.13     4,268.80
25500      Treat fracture of radius             T            T        0043    1.7200         76.16       175.01       200.55
25505      Treat fracture of radius             T            T        0043    1.7200         76.16       175.01       200.55
25515      Treat fracture of radius             T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25520      Treat fracture of radius             T            T        0043    1.7200         76.16       175.01       200.55
25525      Treat fracture of radius             T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25526      Treat fracture of radius             T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25530      Treat fracture of ulna               T            T        0043    1.7200         76.16       175.01       200.55
25535      Treat fracture of ulna               T            T        0043    1.7200         76.16       175.01       200.55
25545      Treat fracture of ulna               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25560      Treat fracture radius & ulna         T            T        0043    1.7200         76.16       175.01       200.55
25565      Treat fracture radius & ulna         T            T        0043    1.7200         76.16       175.01       200.55
25574      Treat fracture radius & ulna         T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25575      Treat fracture radius/ulna           T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25600      Treat fracture radius/ulna           T            T        0043    1.7200         76.16       175.01       200.55
25605      Treat fracture radius/ulna           T            T        0043    1.7200         76.16       175.01       200.55
25611      Treat fracture radius/ulna           T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25620      Treat fracture radius/ulna           T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25622      Treat wrist bone fracture            T            T        0043    1.7200         76.16       175.01       200.55
25624      Treat wrist bone fracture            T            T        0043    1.7200         76.16       175.01       200.55
25628      Treat wrist bone fracture            T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25630      Treat wrist bone fracture            T            T        0043    1.7200         76.16       175.01       200.55
25635      Treat wrist bone fracture            T            T        0043    1.7200         76.16       175.01       200.55
25645      Treat wrist bone fracture            T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25650      Treat wrist bone fracture            T            T        0043    1.7200         76.16       175.01       200.55
25651      Pin ulnar styloid fracture           T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25652      Treat fracture ulnar styloid         T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25660      Treat wrist dislocation              T            T        0043    1.7200         76.16       175.01       200.55
25670      Treat wrist dislocation              T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25671      Pin radioulnar dislocation           T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25675      Treat wrist dislocation              T            T        0043    1.7200         76.16       175.01       200.55
25676      Treat wrist dislocation              T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25680      Treat wrist fracture                 T            T        0043    1.7200         76.16       175.01       200.55
25685      Treat wrist fracture                 T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
25690      Treat wrist dislocation              T            T        0043    1.7200         76.16       175.01       200.55
25695      Treat wrist dislocation              T            T        0046   37.8852       1,677.56     3,854.82     4,417.41

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                             26 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

25800      Fusion of wrist joint                T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25805      Fusion/graft of wrist joint          T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25810      Fusion/graft of wrist joint          T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25820      Fusion of hand bones                 T            T        0053    15.6396       692.52      1,591.33       1,823.58
25825      Fuse hand bones with graft           T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
25830      Fusion, radioulnar jnt/ulna          T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
25900      Amputation of forearm                C            C        0000     0.0000        0.00         0.00           0.00
25905      Amputation of forearm                C            C        0000     0.0000        0.00         0.00           0.00
25907      Amputation follow-up surgery         T            T        0049    20.3891       902.83      2,074.59       2,377.37
25909      Amputation follow-up surgery         C            C        0000     0.0000        0.00         0.00           0.00
25915      Amputation of forearm                C            C        0000     0.0000        0.00         0.00           0.00
25920      Amputate hand at wrist               C            C        0000     0.0000        0.00         0.00           0.00
25922      Amputate hand at wrist               T            T        0049    20.3891       902.83      2,074.59       2,377.37
25924      Amputation follow-up surgery         C            C        0000     0.0000        0.00         0.00           0.00
25927      Amputation of hand                   C            C        0000     0.0000        0.00         0.00           0.00
25929      Amputation follow-up surgery         T            T        0686    13.4973       597.66      1,373.35       1,573.79
25931      Amputation follow-up surgery         C            C        0000     0.0000        0.00         0.00           0.00
25999      Forearm or wrist surgery             T            1        0000     0.0000        0.00         0.00           0.00
26010      Drainage of finger abscess           T            T        0006     1.5100        66.86       153.64         176.07
26011      Drainage of finger abscess           T            T        0007    11.6717       516.82      1,187.60       1,360.92
26020      Drain hand tendon sheath             T            T        0053    15.6396       692.52      1,591.33       1,823.58
26025      Drainage of palm bursa               T            T        0053    15.6396       692.52      1,591.33       1,823.58
26030      Drainage of palm bursa(s)            T            T        0053    15.6396       692.52      1,591.33       1,823.58
26034      Treat hand bone lesion               T            T        0053    15.6396       692.52      1,591.33       1,823.58
26035      Decompress fingers/hand              T            T        0053    15.6396       692.52      1,591.33       1,823.58
26037      Decompress fingers/hand              T            T        0053    15.6396       692.52      1,591.33       1,823.58
26040      Release palm contracture             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26045      Release palm contracture             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26055      Incise finger tendon sheath          T            T        0053    15.6396       692.52      1,591.33       1,823.58
26060      Incision of finger tendon            T            T        0053    15.6396       692.52      1,591.33       1,823.58
26070      Explore/treat hand joint             T            T        0053    15.6396       692.52      1,591.33       1,823.58
26075      Explore/treat finger joint           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26080      Explore/treat finger joint           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26100      Biopsy hand joint lining             T            T        0053    15.6396       692.52      1,591.33       1,823.58
26105      Biopsy finger joint lining           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26110      Biopsy finger joint lining           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26115      Removal hand lesion subcut           T            T        0022    19.5716       866.63      1,991.41       2,282.05
26116      Removal hand lesion, deep            T            T        0022    19.5716       866.63      1,991.41       2,282.05
26117      Remove tumor, hand/finger            T            T        0022    19.5716       866.63      1,991.41       2,282.05
26121      Release palm contracture             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26123      Release palm contracture             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26125      Release palm contracture             T            T        0053    15.6396       692.52      1,591.33       1,823.58
26130      Remove wrist joint lining            T            T        0053    15.6396       692.52      1,591.33       1,823.58
26135      Revise finger joint, each            T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26140      Revise finger joint, each            T            T        0053    15.6396       692.52      1,591.33       1,823.58
26145      Tendon excision, palm/finger         T            T        0053    15.6396       692.52      1,591.33       1,823.58
26160      Remove tendon sheath lesion          T            T        0053    15.6396       692.52      1,591.33       1,823.58
26170      Removal of palm tendon, each         T            T        0053    15.6396       692.52      1,591.33       1,823.58
26180      Removal of finger tendon             T            T        0053    15.6396       692.52      1,591.33       1,823.58
26185      Remove finger bone                   T            T        0053    15.6396       692.52      1,591.33       1,823.58
26200      Remove hand bone lesion              T            T        0053    15.6396       692.52      1,591.33       1,823.58
26205      Remove/graft bone lesion             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26210      Removal of finger lesion             T            T        0053    15.6396       692.52      1,591.33       1,823.58

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 27 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

26215      Remove/graft finger lesion           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26230      Partial removal of hand bone         T            T        0053    15.6396       692.52      1,591.33       1,823.58
26235      Partial removal, finger bone         T            T        0053    15.6396       692.52      1,591.33       1,823.58
26236      Partial removal, finger bone         T            T        0053    15.6396       692.52      1,591.33       1,823.58
26250      Extensive hand surgery               T            T        0053    15.6396       692.52      1,591.33       1,823.58
26255      Extensive hand surgery               T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26260      Extensive finger surgery             T            T        0053    15.6396       692.52      1,591.33       1,823.58
26261      Extensive finger surgery             T            T        0053    15.6396       692.52      1,591.33       1,823.58
26262      Partial removal of finger            T            T        0053    15.6396       692.52      1,591.33       1,823.58
26320      Removal of implant from hand         T            T        0021    14.9984       664.13      1,526.09       1,748.81
26340      Manipulate finger w/anesth           T            T        0043     1.7200        76.16       175.01         200.55
26350      Repair finger/hand tendon            T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26352      Repair/graft hand tendon             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26356      Repair finger/hand tendon            T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26357      Repair finger/hand tendon            T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26358      Repair/graft hand tendon             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26370      Repair finger/hand tendon            T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26372      Repair/graft hand tendon             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26373      Repair finger/hand tendon            T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26390      Revise hand/finger tendon            T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26392      Repair/graft hand tendon             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26410      Repair hand tendon                   T            T        0053    15.6396       692.52      1,591.33       1,823.58
26412      Repair/graft hand tendon             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26415      Excision, hand/finger tendon         T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26416      Graft hand or finger tendon          T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26418      Repair finger tendon                 T            T        0053    15.6396       692.52      1,591.33       1,823.58
26420      Repair/graft finger tendon           T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26426      Repair finger/hand tendon            T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26428      Repair/graft finger tendon           T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26432      Repair finger tendon                 T            T        0053    15.6396       692.52      1,591.33       1,823.58
26433      Repair finger tendon                 T            T        0053    15.6396       692.52      1,591.33       1,823.58
26434      Repair/graft finger tendon           T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26437      Realignment of tendons               T            T        0053    15.6396       692.52      1,591.33       1,823.58
26440      Release palm/finger tendon           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26442      Release palm & finger tendon         T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26445      Release hand/finger tendon           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26449      Release forearm/hand tendon          T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26450      Incision of palm tendon              T            T        0053    15.6396       692.52      1,591.33       1,823.58
26455      Incision of finger tendon            T            T        0053    15.6396       692.52      1,591.33       1,823.58
26460      Incise hand/finger tendon            T            T        0053    15.6396       692.52      1,591.33       1,823.58
26471      Fusion of finger tendons             T            T        0053    15.6396       692.52      1,591.33       1,823.58
26474      Fusion of finger tendons             T            T        0053    15.6396       692.52      1,591.33       1,823.58
26476      Tendon lengthening                   T            T        0053    15.6396       692.52      1,591.33       1,823.58
26477      Tendon shortening                    T            T        0053    15.6396       692.52      1,591.33       1,823.58
26478      Lengthening of hand tendon           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26479      Shortening of hand tendon            T            T        0053    15.6396       692.52      1,591.33       1,823.58
26480      Transplant hand tendon               T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26483      Transplant/graft hand tendon         T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26485      Transplant palm tendon               T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26489      Transplant/graft palm tendon         T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26490      Revise thumb tendon                  T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26492      Tendon transfer with graft           T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26494      Hand tendon/muscle transfer          T            T        0054    25.1321      1,112.85     2,557.19       2,930.40

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 28 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

26496      Revise thumb tendon                  T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26497      Finger tendon transfer               T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26498      Finger tendon transfer               T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26499      Revision of finger                   T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26500      Hand tendon reconstruction           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26502      Hand tendon reconstruction           T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26504      Hand tendon reconstruction           T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26508      Release thumb contracture            T            T        0053    15.6396       692.52      1,591.33       1,823.58
26510      Thumb tendon transfer                T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26516      Fusion of knuckle joint              T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26517      Fusion of knuckle joints             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26518      Fusion of knuckle joints             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26520      Release knuckle contracture          T            T        0053    15.6396       692.52      1,591.33       1,823.58
26525      Release finger contracture           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26530      Revise knuckle joint                 T            T        0047    31.2345      1,383.06     3,178.11       3,641.94
26531      Revise knuckle with implant          T            T        0048    43.3955      1,921.55     4,415.49       5,059.92
26535      Revise finger joint                  T            T        0047    31.2345      1,383.06     3,178.11       3,641.94
26536      Revise/implant finger joint          T            T        0048    43.3955      1,921.55     4,415.49       5,059.92
26540      Repair hand joint                    T            T        0053    15.6396       692.52      1,591.33       1,823.58
26541      Repair hand joint with graft         T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26542      Repair hand joint with graft         T            T        0053    15.6396       692.52      1,591.33       1,823.58
26545      Reconstruct finger joint             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26546      Repair nonunion hand                 T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26548      Reconstruct finger joint             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26550      Construct thumb replacement          T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26551      Great toe-hand transfer              C            C        0000     0.0000        0.00         0.00           0.00
26553      Single transfer, toe-hand            C            C        0000     0.0000        0.00         0.00           0.00
26554      Double transfer, toe-hand            C            C        0000     0.0000        0.00         0.00           0.00
26555      Positional change of finger          T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26556      Toe joint transfer                   C            C        0000     0.0000        0.00         0.00           0.00
26560      Repair of web finger                 T            T        0053    15.6396       692.52      1,591.33       1,823.58
26561      Repair of web finger                 T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26562      Repair of web finger                 T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26565      Correct metacarpal flaw              T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26567      Correct finger deformity             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26568      Lengthen metacarpal/finger           T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26580      Repair hand deformity                T            T        0053    15.6396       692.52      1,591.33       1,823.58
26587      Reconstruct extra finger             T            T        0053    15.6396       692.52      1,591.33       1,823.58
26590      Repair finger deformity              T            T        0053    15.6396       692.52      1,591.33       1,823.58
26591      Repair muscles of hand               T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26593      Release muscles of hand              T            T        0053    15.6396       692.52      1,591.33       1,823.58
26596      Excision constricting tissue         T            T        0053    15.6396       692.52      1,591.33       1,823.58
26600      Treat metacarpal fracture            T            T        0043     1.7200        76.16       175.01         200.55
26605      Treat metacarpal fracture            T            T        0043     1.7200        76.16       175.01         200.55
26607      Treat metacarpal fracture            T            T        0043     1.7200        76.16       175.01         200.55
26608      Treat metacarpal fracture            T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26615      Treat metacarpal fracture            T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26641      Treat thumb dislocation              T            T        0043     1.7200        76.16       175.01         200.55
26645      Treat thumb fracture                 T            T        0043     1.7200        76.16       175.01         200.55
26650      Treat thumb fracture                 T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26665      Treat thumb fracture                 T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26670      Treat hand dislocation               T            T        0043     1.7200        76.16       175.01         200.55
26675      Treat hand dislocation               T            T        0043     1.7200        76.16       175.01         200.55

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 29 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                    Description (short)                     Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

26676      Pin hand dislocation                 T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26685      Treat hand dislocation               T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26686      Treat hand dislocation               T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26700      Treat knuckle dislocation            T            T        0043     1.7200        76.16       175.01         200.55
26705      Treat knuckle dislocation            T            T        0043     1.7200        76.16       175.01         200.55
26706      Pin knuckle dislocation              T            T        0043     1.7200        76.16       175.01         200.55
26715      Treat knuckle dislocation            T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26720      Treat finger fracture, each          T            T        0043     1.7200        76.16       175.01         200.55
26725      Treat finger fracture, each          T            T        0043     1.7200        76.16       175.01         200.55
26727      Treat finger fracture, each          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26735      Treat finger fracture, each          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26740      Treat finger fracture, each          T            T        0043     1.7200        76.16       175.01         200.55
26742      Treat finger fracture, each          T            T        0043     1.7200        76.16       175.01         200.55
26746      Treat finger fracture, each          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26750      Treat finger fracture, each          T            T        0043     1.7200        76.16       175.01         200.55
26755      Treat finger fracture, each          T            T        0043     1.7200        76.16       175.01         200.55
26756      Pin finger fracture, each            T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26765      Treat finger fracture, each          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26770      Treat finger dislocation             T            T        0043     1.7200        76.16       175.01         200.55
26775      Treat finger dislocation             T            T        0045    14.3413       635.03      1,459.23       1,672.20
26776      Pin finger dislocation               T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26785      Treat finger dislocation             T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
26820      Thumb fusion with graft              T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26841      Fusion of thumb                      T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26842      Thumb fusion with graft              T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26843      Fusion of hand joint                 T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26844      Fusion/graft of hand joint           T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26850      Fusion of knuckle                    T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26852      Fusion of knuckle with graft         T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26860      Fusion of finger joint               T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26861      Fusion of finger jnt, add-on         T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26862      Fusion/graft of finger joint         T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26863      Fuse/graft added joint               T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26910      Amputate metacarpal bone             T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
26951      Amputation of finger/thumb           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26952      Amputation of finger/thumb           T            T        0053    15.6396       692.52      1,591.33       1,823.58
26989      Hand/finger surgery                  T            1        0000     0.0000        0.00         0.00           0.00
26990      Drainage of pelvis lesion            T            T        0049    20.3891       902.83      2,074.59       2,377.37
26991      Drainage of pelvis bursa             T            T        0049    20.3891       902.83      2,074.59       2,377.37
26992      Drainage of bone lesion              C            C        0000     0.0000        0.00         0.00           0.00
27000      Incision of hip tendon               T            T        0049    20.3891       902.83      2,074.59       2,377.37
27001      Incision of hip tendon               T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27003      Incision of hip tendon               T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27005      Incision of hip tendon               C            C        0000     0.0000        0.00         0.00           0.00
27006      Incision of hip tendons              C            C        0000     0.0000        0.00         0.00           0.00
27025      Incision of hip/thigh fascia         C            C        0000     0.0000        0.00         0.00           0.00
27030      Drainage of hip joint                C            C        0000     0.0000        0.00         0.00           0.00
27033      Exploration of hip joint             T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27035      Denervation of hip joint             T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
27036      Excision of hip joint/muscle         C            C        0000     0.0000        0.00         0.00           0.00
27040      Biopsy of soft tissues               T            T        0020     6.9410       307.35       706.25         809.32
27041      Biopsy of soft tissues               T            T        0020     6.9410       307.35       706.25         809.32
27047      Remove hip/pelvis lesion             T            T        0022    19.5716       866.63      1,991.41       2,282.05

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 30 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

27048      Remove hip/pelvis lesion             T            T        0022    19.5716       866.63      1,991.41       2,282.05
27049      Remove tumor, hip/pelvis             T            T        0022    19.5716       866.63      1,991.41       2,282.05
27050      Biopsy of sacroiliac joint           T            T        0049    20.3891       902.83      2,074.59       2,377.37
27052      Biopsy of hip joint                  T            T        0049    20.3891       902.83      2,074.59       2,377.37
27054      Removal of hip joint lining          C            C        0000     0.0000        0.00         0.00           0.00
27060      Removal of ischial bursa             T            T        0049    20.3891       902.83      2,074.59       2,377.37
27062      Remove femur lesion/bursa            T            T        0049    20.3891       902.83      2,074.59       2,377.37
27065      Removal of hip bone lesion           T            T        0049    20.3891       902.83      2,074.59       2,377.37
27066      Removal of hip bone lesion           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27067      Remove/graft hip bone lesion         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27070      Partial removal of hip bone          C            C        0000     0.0000        0.00         0.00           0.00
27071      Partial removal of hip bone          C            C        0000     0.0000        0.00         0.00           0.00
27075      Extensive hip surgery                C            C        0000     0.0000        0.00         0.00           0.00
27076      Extensive hip surgery                C            C        0000     0.0000        0.00         0.00           0.00
27077      Extensive hip surgery                C            C        0000     0.0000        0.00         0.00           0.00
27078      Extensive hip surgery                C            C        0000     0.0000        0.00         0.00           0.00
27079      Extensive hip surgery                C            C        0000     0.0000        0.00         0.00           0.00
27080      Removal of tail bone                 T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27086      Remove hip foreign body              T            T        0020     6.9410       307.35       706.25         809.32
27087      Remove hip foreign body              T            T        0049    20.3891       902.83      2,074.59       2,377.37
27090      Removal of hip prosthesis            C            C        0000     0.0000        0.00         0.00           0.00
27091      Removal of hip prosthesis            C            C        0000     0.0000        0.00         0.00           0.00
27093      Injection for hip x-ray              N            N        0000     0.0000        0.00         0.00           0.00
27095      Injection for hip x-ray              N            N        0000     0.0000        0.00         0.00           0.00
27096      Inject sacroiliac joint              B            1        0000     0.0000        0.00         0.00           0.00
27097      Revision of hip tendon               T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27098      Transfer tendon to pelvis            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27100      Transfer of abdominal muscle         T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27105      Transfer of spinal muscle            T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27110      Transfer of iliopsoas muscle         T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27111      Transfer of iliopsoas muscle         T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27120      Reconstruction of hip socket         C            C        0000     0.0000        0.00         0.00           0.00
27122      Reconstruction of hip socket         C            C        0000     0.0000        0.00         0.00           0.00
27125      Partial hip replacement              C            C        0000     0.0000        0.00         0.00           0.00
27130      Total hip arthroplasty               C            C        0000     0.0000        0.00         0.00           0.00
27132      Total hip arthroplasty               C            C        0000     0.0000        0.00         0.00           0.00
27134      Revise hip joint replacement         C            C        0000     0.0000        0.00         0.00           0.00
27137      Revise hip joint replacement         C            C        0000     0.0000        0.00         0.00           0.00
27138      Revise hip joint replacement         C            C        0000     0.0000        0.00         0.00           0.00
27140      Transplant femur ridge               C            C        0000     0.0000        0.00         0.00           0.00
27146      Incision of hip bone                 C            C        0000     0.0000        0.00         0.00           0.00
27147      Revision of hip bone                 C            C        0000     0.0000        0.00         0.00           0.00
27151      Incision of hip bones                C            C        0000     0.0000        0.00         0.00           0.00
27156      Revision of hip bones                C            C        0000     0.0000        0.00         0.00           0.00
27158      Revision of pelvis                   C            C        0000     0.0000        0.00         0.00           0.00
27161      Incision of neck of femur            C            C        0000     0.0000        0.00         0.00           0.00
27165      Incision/fixation of femur           C            C        0000     0.0000        0.00         0.00           0.00
27170      Repair/graft femur head/neck         C            C        0000     0.0000        0.00         0.00           0.00
27175      Treat slipped epiphysis              C            C        0000     0.0000        0.00         0.00           0.00
27176      Treat slipped epiphysis              C            C        0000     0.0000        0.00         0.00           0.00
27177      Treat slipped epiphysis              C            C        0000     0.0000        0.00         0.00           0.00
27178      Treat slipped epiphysis              C            C        0000     0.0000        0.00         0.00           0.00
27179      Revise head/neck of femur            C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 31 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                    Description (short)                     Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

27181      Treat slipped epiphysis              C            C        0000     0.0000        0.00         0.00           0.00
27185      Revision of femur epiphysis          C            C        0000     0.0000        0.00         0.00           0.00
27187      Reinforce hip bones                  C            C        0000     0.0000        0.00         0.00           0.00
27193      Treat pelvic ring fracture           T            T        0043     1.7200        76.16       175.01         200.55
27194      Treat pelvic ring fracture           T            T        0045    14.3413       635.03      1,459.23       1,672.20
27200      Treat tail bone fracture             T            T        0043     1.7200        76.16       175.01         200.55
27202      Treat tail bone fracture             T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27215      Treat pelvic fracture(s)             C            C        0000     0.0000        0.00         0.00           0.00
27216      Treat pelvic ring fracture           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27217      Treat pelvic ring fracture           C            C        0000     0.0000        0.00         0.00           0.00
27218      Treat pelvic ring fracture           C            C        0000     0.0000        0.00         0.00           0.00
27220      Treat hip socket fracture            T            T        0043     1.7200        76.16       175.01         200.55
27222      Treat hip socket fracture            C            C        0000     0.0000        0.00         0.00           0.00
27226      Treat hip wall fracture              C            C        0000     0.0000        0.00         0.00           0.00
27227      Treat hip fracture(s)                C            C        0000     0.0000        0.00         0.00           0.00
27228      Treat hip fracture(s)                C            C        0000     0.0000        0.00         0.00           0.00
27230      Treat thigh fracture                 T            T        0043     1.7200        76.16       175.01         200.55
27232      Treat thigh fracture                 C            C        0000     0.0000        0.00         0.00           0.00
27235      Treat thigh fracture                 T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27236      Treat thigh fracture                 C            C        0000     0.0000        0.00         0.00           0.00
27238      Treat thigh fracture                 T            T        0043     1.7200        76.16       175.01         200.55
27240      Treat thigh fracture                 C            C        0000     0.0000        0.00         0.00           0.00
27244      Treat thigh fracture                 C            C        0000     0.0000        0.00         0.00           0.00
27245      Treat thigh fracture                 C            C        0000     0.0000        0.00         0.00           0.00
27246      Treat thigh fracture                 T            T        0043     1.7200        76.16       175.01         200.55
27248      Treat thigh fracture                 C            C        0000     0.0000        0.00         0.00           0.00
27250      Treat hip dislocation                T            T        0043     1.7200        76.16       175.01         200.55
27252      Treat hip dislocation                T            T        0045    14.3413       635.03      1,459.23       1,672.20
27253      Treat hip dislocation                C            C        0000     0.0000        0.00         0.00           0.00
27254      Treat hip dislocation                C            C        0000     0.0000        0.00         0.00           0.00
27256      Treat hip dislocation                T            T        0043     1.7200        76.16       175.01         200.55
27257      Treat hip dislocation                T            T        0045    14.3413       635.03      1,459.23       1,672.20
27258      Treat hip dislocation                C            C        0000     0.0000        0.00         0.00           0.00
27259      Treat hip dislocation                C            C        0000     0.0000        0.00         0.00           0.00
27265      Treat hip dislocation                T            T        0043     1.7200        76.16       175.01         200.55
27266      Treat hip dislocation                T            T        0045    14.3413       635.03      1,459.23       1,672.20
27275      Manipulation of hip joint            T            T        0045    14.3413       635.03      1,459.23       1,672.20
27280      Fusion of sacroiliac joint           C            C        0000     0.0000        0.00         0.00           0.00
27282      Fusion of pubic bones                C            C        0000     0.0000        0.00         0.00           0.00
27284      Fusion of hip joint                  C            C        0000     0.0000        0.00         0.00           0.00
27286      Fusion of hip joint                  C            C        0000     0.0000        0.00         0.00           0.00
27290      Amputation of leg at hip             C            C        0000     0.0000        0.00         0.00           0.00
27295      Amputation of leg at hip             C            C        0000     0.0000        0.00         0.00           0.00
27299      Pelvis/hip joint surgery             T            1        0000     0.0000        0.00         0.00           0.00
27301      Drain thigh/knee lesion              T            T        0008    16.2953       721.56      1,658.05       1,900.03
27303      Drainage of bone lesion              C            C        0000     0.0000        0.00         0.00           0.00
27305      Incise thigh tendon & fascia         T            T        0049    20.3891       902.83      2,074.59       2,377.37
27306      Incision of thigh tendon             T            T        0049    20.3891       902.83      2,074.59       2,377.37
27307      Incision of thigh tendons            T            T        0049    20.3891       902.83      2,074.59       2,377.37
27310      Exploration of knee joint            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27315      Partial removal, thigh nerve         T            T        0220    17.3203       766.94      1,762.34       2,019.55
27320      Partial removal, thigh nerve         T            T        0220    17.3203       766.94      1,762.34       2,019.55
27323      Biopsy, thigh soft tissues           T            T        0021    14.9984       664.13      1,526.09       1,748.81

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 32 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

27324      Biopsy, thigh soft tissues           T            T        0022    19.5716       866.63      1,991.41       2,282.05
27327      Removal of thigh lesion              T            T        0022    19.5716       866.63      1,991.41       2,282.05
27328      Removal of thigh lesion              T            T        0022    19.5716       866.63      1,991.41       2,282.05
27329      Remove tumor, thigh/knee             T            T        0022    19.5716       866.63      1,991.41       2,282.05
27330      Biopsy, knee joint lining            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27331      Explore/treat knee joint             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27332      Removal of knee cartilage            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27333      Removal of knee cartilage            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27334      Remove knee joint lining             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27335      Remove knee joint lining             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27340      Removal of kneecap bursa             T            T        0049    20.3891       902.83      2,074.59       2,377.37
27345      Removal of knee cyst                 T            T        0049    20.3891       902.83      2,074.59       2,377.37
27347      Remove knee cyst                     T            T        0049    20.3891       902.83      2,074.59       2,377.37
27350      Removal of kneecap                   T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27355      Remove femur lesion                  T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27356      Remove femur lesion/graft            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27357      Remove femur lesion/graft            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27358      Remove femur lesion/fixation         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27360      Partial removal, leg bone(s)         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27365      Extensive leg surgery                C            C        0000     0.0000        0.00         0.00           0.00
27370      Injection for knee x-ray             N            N        0000     0.0000        0.00         0.00           0.00
27372      Removal of foreign body              T            T        0022    19.5716       866.63      1,991.41       2,282.05
27380      Repair of kneecap tendon             T            T        0049    20.3891       902.83      2,074.59       2,377.37
27381      Repair/graft kneecap tendon          T            T        0049    20.3891       902.83      2,074.59       2,377.37
27385      Repair of thigh muscle               T            T        0049    20.3891       902.83      2,074.59       2,377.37
27386      Repair/graft of thigh muscle         T            T        0049    20.3891       902.83      2,074.59       2,377.37
27390      Incision of thigh tendon             T            T        0049    20.3891       902.83      2,074.59       2,377.37
27391      Incision of thigh tendons            T            T        0049    20.3891       902.83      2,074.59       2,377.37
27392      Incision of thigh tendons            T            T        0049    20.3891       902.83      2,074.59       2,377.37
27393      Lengthening of thigh tendon          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27394      Lengthening of thigh tendons         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27395      Lengthening of thigh tendons         T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27396      Transplant of thigh tendon           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27397      Transplants of thigh tendons         T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27400      Revise thigh muscles/tendons         T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27403      Repair of knee cartilage             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27405      Repair of knee ligament              T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27407      Repair of knee ligament              T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27409      Repair of knee ligaments             T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27412      Autochondrocyte implant knee         T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
27415      Osteochondral knee allograft         T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
27418      Repair degenerated kneecap           T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27420      Revision of unstable kneecap         T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27422      Revision of unstable kneecap         T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27424      Revision/removal of kneecap          T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27425      Lat retinacular release open         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27427      Reconstruction, knee                 T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
27428      Reconstruction, knee                 T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
27429      Reconstruction, knee                 T            T        0052    43.5555      1,928.64     4,431.77       5,078.57
27430      Revision of thigh muscles            T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27435      Incision of knee joint               T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27437      Revise kneecap                       T            T        0047    31.2345      1,383.06     3,178.11       3,641.94
27438      Revise kneecap with implant          T            T        0048    43.3955      1,921.55     4,415.49       5,059.92

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 33 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

27440      Revision of knee joint               T            T        0047   31.2345       1,383.06     3,178.11     3,641.94
27441      Revision of knee joint               T            T        0047   31.2345       1,383.06     3,178.11     3,641.94
27442      Revision of knee joint               T            T        0047   31.2345       1,383.06     3,178.11     3,641.94
27443      Revision of knee joint               T            T        0047   31.2345       1,383.06     3,178.11     3,641.94
27445      Revision of knee joint               C            C        0000    0.0000         0.00         0.00         0.00
27446      Revision of knee joint               T            T        0681   135.4643      5,998.36    13,783.49    15,795.14
27447      Total knee arthroplasty              C            C        0000    0.0000         0.00         0.00         0.00
27448      Incision of thigh                    C            C        0000    0.0000         0.00         0.00         0.00
27450      Incision of thigh                    C            C        0000    0.0000         0.00         0.00         0.00
27454      Realignment of thigh bone            C            C        0000    0.0000         0.00         0.00         0.00
27455      Realignment of knee                  C            C        0000    0.0000         0.00         0.00         0.00
27457      Realignment of knee                  C            C        0000    0.0000         0.00         0.00         0.00
27465      Shortening of thigh bone             C            C        0000    0.0000         0.00         0.00         0.00
27466      Lengthening of thigh bone            C            C        0000    0.0000         0.00         0.00         0.00
27468      Shorten/lengthen thighs              C            C        0000    0.0000         0.00         0.00         0.00
27470      Repair of thigh                      C            C        0000    0.0000         0.00         0.00         0.00
27472      Repair/graft of thigh                C            C        0000    0.0000         0.00         0.00         0.00
27475      Surgery to stop leg growth           T            T        0050   23.9367       1,059.92     2,435.56     2,791.02
27477      Surgery to stop leg growth           C            C        0000    0.0000         0.00         0.00         0.00
27479      Surgery to stop leg growth           C            C        0000    0.0000         0.00         0.00         0.00
27485      Surgery to stop leg growth           C            C        0000    0.0000         0.00         0.00         0.00
27486      Revise/replace knee joint            C            C        0000    0.0000         0.00         0.00         0.00
27487      Revise/replace knee joint            C            C        0000    0.0000         0.00         0.00         0.00
27488      Removal of knee prosthesis           C            C        0000    0.0000         0.00         0.00         0.00
27495      Reinforce thigh                      C            C        0000    0.0000         0.00         0.00         0.00
27496      Decompression of thigh/knee          T            T        0049   20.3891        902.83      2,074.59     2,377.37
27497      Decompression of thigh/knee          T            T        0049   20.3891        902.83      2,074.59     2,377.37
27498      Decompression of thigh/knee          T            T        0049   20.3891        902.83      2,074.59     2,377.37
27499      Decompression of thigh/knee          T            T        0049   20.3891        902.83      2,074.59     2,377.37
27500      Treatment of thigh fracture          T            T        0043    1.7200         76.16       175.01       200.55
27501      Treatment of thigh fracture          T            T        0043    1.7200         76.16       175.01       200.55
27502      Treatment of thigh fracture          T            T        0043    1.7200         76.16       175.01       200.55
27503      Treatment of thigh fracture          T            T        0043    1.7200         76.16       175.01       200.55
27506      Treatment of thigh fracture          C            C        0000    0.0000         0.00         0.00         0.00
27507      Treatment of thigh fracture          C            C        0000    0.0000         0.00         0.00         0.00
27508      Treatment of thigh fracture          T            T        0043    1.7200         76.16       175.01       200.55
27509      Treatment of thigh fracture          T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
27510      Treatment of thigh fracture          T            T        0043    1.7200         76.16       175.01       200.55
27511      Treatment of thigh fracture          C            C        0000    0.0000         0.00         0.00         0.00
27513      Treatment of thigh fracture          C            C        0000    0.0000         0.00         0.00         0.00
27514      Treatment of thigh fracture          C            C        0000    0.0000         0.00         0.00         0.00
27516      Treat thigh fx growth plate          T            T        0043    1.7200         76.16       175.01       200.55
27517      Treat thigh fx growth plate          T            T        0043    1.7200         76.16       175.01       200.55
27519      Treat thigh fx growth plate          C            C        0000    0.0000         0.00         0.00         0.00
27520      Treat kneecap fracture               T            T        0043    1.7200         76.16       175.01       200.55
27524      Treat kneecap fracture               T            T        0046   37.8852       1,677.56     3,854.82     4,417.41
27530      Treat knee fracture                  T            T        0043    1.7200         76.16       175.01       200.55
27532      Treat knee fracture                  T            T        0043    1.7200         76.16       175.01       200.55
27535      Treat knee fracture                  C            C        0000    0.0000         0.00         0.00         0.00
27536      Treat knee fracture                  C            C        0000    0.0000         0.00         0.00         0.00
27538      Treat knee fracture(s)               T            T        0043    1.7200         76.16       175.01       200.55
27540      Treat knee fracture                  C            C        0000    0.0000         0.00         0.00         0.00
27550      Treat knee dislocation               T            T        0043    1.7200         76.16       175.01       200.55

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                             34 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 35 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

27676      Repair lower leg tendons             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27680      Release of lower leg tendon          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27681      Release of lower leg tendons         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27685      Revision of lower leg tendon         T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27686      Revise lower leg tendons             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27687      Revision of calf tendon              T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27690      Revise lower leg tendon              T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27691      Revise lower leg tendon              T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27692      Revise additional leg tendon         T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27695      Repair of ankle ligament             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27696      Repair of ankle ligaments            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27698      Repair of ankle ligament             T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27700      Revision of ankle joint              T            T        0047    31.2345      1,383.06     3,178.11       3,641.94
27702      Reconstruct ankle joint              C            C        0000     0.0000        0.00         0.00           0.00
27703      Reconstruction, ankle joint          C            C        0000     0.0000        0.00         0.00           0.00
27704      Removal of ankle implant             T            T        0049    20.3891       902.83      2,074.59       2,377.37
27705      Incision of tibia                    T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27707      Incision of fibula                   T            T        0049    20.3891       902.83      2,074.59       2,377.37
27709      Incision of tibia & fibula           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27712      Realignment of lower leg             C            C        0000     0.0000        0.00         0.00           0.00
27715      Revision of lower leg                C            C        0000     0.0000        0.00         0.00           0.00
27720      Repair of tibia                      C            C        0000     0.0000        0.00         0.00           0.00
27722      Repair/graft of tibia                C            C        0000     0.0000        0.00         0.00           0.00
27724      Repair/graft of tibia                C            C        0000     0.0000        0.00         0.00           0.00
27725      Repair of lower leg                  C            C        0000     0.0000        0.00         0.00           0.00
27727      Repair of lower leg                  C            C        0000     0.0000        0.00         0.00           0.00
27730      Repair of tibia epiphysis            T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27732      Repair of fibula epiphysis           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27734      Repair lower leg epiphyses           T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27740      Repair of leg epiphyses              T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27742      Repair of leg epiphyses              T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27745      Reinforce tibia                      T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27750      Treatment of tibia fracture          T            T        0043     1.7200        76.16       175.01         200.55
27752      Treatment of tibia fracture          T            T        0043     1.7200        76.16       175.01         200.55
27756      Treatment of tibia fracture          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27758      Treatment of tibia fracture          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27759      Treatment of tibia fracture          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27760      Treatment of ankle fracture          T            T        0043     1.7200        76.16       175.01         200.55
27762      Treatment of ankle fracture          T            T        0043     1.7200        76.16       175.01         200.55
27766      Treatment of ankle fracture          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27780      Treatment of fibula fracture         T            T        0043     1.7200        76.16       175.01         200.55
27781      Treatment of fibula fracture         T            T        0043     1.7200        76.16       175.01         200.55
27784      Treatment of fibula fracture         T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27786      Treatment of ankle fracture          T            T        0043     1.7200        76.16       175.01         200.55
27788      Treatment of ankle fracture          T            T        0043     1.7200        76.16       175.01         200.55
27792      Treatment of ankle fracture          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27808      Treatment of ankle fracture          T            T        0043     1.7200        76.16       175.01         200.55
27810      Treatment of ankle fracture          T            T        0043     1.7200        76.16       175.01         200.55
27814      Treatment of ankle fracture          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27816      Treatment of ankle fracture          T            T        0043     1.7200        76.16       175.01         200.55
27818      Treatment of ankle fracture          T            T        0043     1.7200        76.16       175.01         200.55
27822      Treatment of ankle fracture          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27823      Treatment of ankle fracture          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 36 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

27824      Treat lower leg fracture             T            T        0043     1.7200        76.16       175.01         200.55
27825      Treat lower leg fracture             T            T        0043     1.7200        76.16       175.01         200.55
27826      Treat lower leg fracture             T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27827      Treat lower leg fracture             T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27828      Treat lower leg fracture             T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27829      Treat lower leg joint                T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27830      Treat lower leg dislocation          T            T        0043     1.7200        76.16       175.01         200.55
27831      Treat lower leg dislocation          T            T        0043     1.7200        76.16       175.01         200.55
27832      Treat lower leg dislocation          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27840      Treat ankle dislocation              T            T        0043     1.7200        76.16       175.01         200.55
27842      Treat ankle dislocation              T            T        0045    14.3413       635.03      1,459.23       1,672.20
27846      Treat ankle dislocation              T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27848      Treat ankle dislocation              T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
27860      Fixation of ankle joint              T            T        0045    14.3413       635.03      1,459.23       1,672.20
27870      Fusion of ankle joint, open          T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27871      Fusion of tibiofibular joint         T            T        0051    36.6106      1,621.12     3,725.13       4,268.80
27880      Amputation of lower leg              C            C        0000     0.0000        0.00         0.00           0.00
27881      Amputation of lower leg              C            C        0000     0.0000        0.00         0.00           0.00
27882      Amputation of lower leg              C            C        0000     0.0000        0.00         0.00           0.00
27884      Amputation follow-up surgery         T            T        0049    20.3891       902.83      2,074.59       2,377.37
27886      Amputation follow-up surgery         C            C        0000     0.0000        0.00         0.00           0.00
27888      Amputation of foot at ankle          C            C        0000     0.0000        0.00         0.00           0.00
27889      Amputation of foot at ankle          T            T        0050    23.9367      1,059.92     2,435.56       2,791.02
27892      Decompression of leg                 T            T        0049    20.3891       902.83      2,074.59       2,377.37
27893      Decompression of leg                 T            T        0049    20.3891       902.83      2,074.59       2,377.37
27894      Decompression of leg                 T            T        0049    20.3891       902.83      2,074.59       2,377.37
27899      Leg/ankle surgery procedure          T            1        0000     0.0000        0.00         0.00           0.00
28001      Drainage of bursa of foot            T            T        0007    11.6717       516.82      1,187.60       1,360.92
28002      Treatment of foot infection          T            T        0049    20.3891       902.83      2,074.59       2,377.37
28003      Treatment of foot infection          T            T        0049    20.3891       902.83      2,074.59       2,377.37
28005      Treat foot bone lesion               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28008      Incision of foot fascia              T            T        0055    19.9374       882.83      2,028.63       2,324.70
28010      Incision of toe tendon               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28011      Incision of toe tendons              T            T        0055    19.9374       882.83      2,028.63       2,324.70
28020      Exploration of foot joint            T            T        0055    19.9374       882.83      2,028.63       2,324.70
28022      Exploration of foot joint            T            T        0055    19.9374       882.83      2,028.63       2,324.70
28024      Exploration of toe joint             T            T        0055    19.9374       882.83      2,028.63       2,324.70
28030      Removal of foot nerve                T            T        0220    17.3203       766.94      1,762.34       2,019.55
28035      Decompression of tibia nerve         T            T        0220    17.3203       766.94      1,762.34       2,019.55
28043      Excision of foot lesion              T            T        0021    14.9984       664.13      1,526.09       1,748.81
28045      Excision of foot lesion              T            T        0055    19.9374       882.83      2,028.63       2,324.70
28046      Resection of tumor, foot             T            T        0055    19.9374       882.83      2,028.63       2,324.70
28050      Biopsy of foot joint lining          T            T        0055    19.9374       882.83      2,028.63       2,324.70
28052      Biopsy of foot joint lining          T            T        0055    19.9374       882.83      2,028.63       2,324.70
28054      Biopsy of toe joint lining           T            T        0055    19.9374       882.83      2,028.63       2,324.70
28060      Partial removal, foot fascia         T            T        0055    19.9374       882.83      2,028.63       2,324.70
28062      Removal of foot fascia               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28070      Removal of foot joint lining         T            T        0055    19.9374       882.83      2,028.63       2,324.70
28072      Removal of foot joint lining         T            T        0055    19.9374       882.83      2,028.63       2,324.70
28080      Removal of foot lesion               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28086      Excise foot tendon sheath            T            T        0055    19.9374       882.83      2,028.63       2,324.70
28088      Excise foot tendon sheath            T            T        0055    19.9374       882.83      2,028.63       2,324.70
28090      Removal of foot lesion               T            T        0055    19.9374       882.83      2,028.63       2,324.70

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 37 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

28092      Removal of toe lesions               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28100      Removal of ankle/heel lesion         T            T        0055    19.9374       882.83      2,028.63       2,324.70
28102      Remove/graft foot lesion             T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28103      Remove/graft foot lesion             T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28104      Removal of foot lesion               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28106      Remove/graft foot lesion             T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28107      Remove/graft foot lesion             T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28108      Removal of toe lesions               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28110      Part removal of metatarsal           T            T        0055    19.9374       882.83      2,028.63       2,324.70
28111      Part removal of metatarsal           T            T        0055    19.9374       882.83      2,028.63       2,324.70
28112      Part removal of metatarsal           T            T        0055    19.9374       882.83      2,028.63       2,324.70
28113      Part removal of metatarsal           T            T        0055    19.9374       882.83      2,028.63       2,324.70
28114      Removal of metatarsal heads          T            T        0055    19.9374       882.83      2,028.63       2,324.70
28116      Revision of foot                     T            T        0055    19.9374       882.83      2,028.63       2,324.70
28118      Removal of heel bone                 T            T        0055    19.9374       882.83      2,028.63       2,324.70
28119      Removal of heel spur                 T            T        0055    19.9374       882.83      2,028.63       2,324.70
28120      Part removal of ankle/heel           T            T        0055    19.9374       882.83      2,028.63       2,324.70
28122      Partial removal of foot bone         T            T        0055    19.9374       882.83      2,028.63       2,324.70
28124      Partial removal of toe               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28126      Partial removal of toe               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28130      Removal of ankle bone                T            T        0055    19.9374       882.83      2,028.63       2,324.70
28140      Removal of metatarsal                T            T        0055    19.9374       882.83      2,028.63       2,324.70
28150      Removal of toe                       T            T        0055    19.9374       882.83      2,028.63       2,324.70
28153      Partial removal of toe               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28160      Partial removal of toe               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28171      Extensive foot surgery               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28173      Extensive foot surgery               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28175      Extensive foot surgery               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28190      Removal of foot foreign body         T            T        0019     4.1481       183.68       422.07         483.67
28192      Removal of foot foreign body         T            T        0021    14.9984       664.13      1,526.09       1,748.81
28193      Removal of foot foreign body         T            T        0020     6.9410       307.35       706.25         809.32
28200      Repair of foot tendon                T            T        0055    19.9374       882.83      2,028.63       2,324.70
28202      Repair/graft of foot tendon          T            T        0055    19.9374       882.83      2,028.63       2,324.70
28208      Repair of foot tendon                T            T        0055    19.9374       882.83      2,028.63       2,324.70
28210      Repair/graft of foot tendon          T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28220      Release of foot tendon               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28222      Release of foot tendons              T            T        0055    19.9374       882.83      2,028.63       2,324.70
28225      Release of foot tendon               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28226      Release of foot tendons              T            T        0055    19.9374       882.83      2,028.63       2,324.70
28230      Incision of foot tendon(s)           T            T        0055    19.9374       882.83      2,028.63       2,324.70
28232      Incision of toe tendon               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28234      Incision of foot tendon              T            T        0055    19.9374       882.83      2,028.63       2,324.70
28238      Revision of foot tendon              T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28240      Release of big toe                   T            T        0055    19.9374       882.83      2,028.63       2,324.70
28250      Revision of foot fascia              T            T        0055    19.9374       882.83      2,028.63       2,324.70
28260      Release of midfoot joint             T            T        0055    19.9374       882.83      2,028.63       2,324.70
28261      Revision of foot tendon              T            T        0055    19.9374       882.83      2,028.63       2,324.70
28262      Revision of foot and ankle           T            T        0055    19.9374       882.83      2,028.63       2,324.70
28264      Release of midfoot joint             T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28270      Release of foot contracture          T            T        0055    19.9374       882.83      2,028.63       2,324.70
28272      Release of toe joint, each           T            T        0055    19.9374       882.83      2,028.63       2,324.70
28280      Fusion of toes                       T            T        0055    19.9374       882.83      2,028.63       2,324.70
28285      Repair of hammertoe                  T            T        0055    19.9374       882.83      2,028.63       2,324.70

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 38 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                    Description (short)                     Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

28286      Repair of hammertoe                  T            T        0055    19.9374       882.83      2,028.63       2,324.70
28288      Partial removal of foot bone         T            T        0055    19.9374       882.83      2,028.63       2,324.70
28289      Repair hallux rigidus                T            T        0055    19.9374       882.83      2,028.63       2,324.70
28290      Correction of bunion                 T            T        0057    27.3981      1,213.19     2,787.76       3,194.62
28292      Correction of bunion                 T            T        0057    27.3981      1,213.19     2,787.76       3,194.62
28293      Correction of bunion                 T            T        0057    27.3981      1,213.19     2,787.76       3,194.62
28294      Correction of bunion                 T            T        0057    27.3981      1,213.19     2,787.76       3,194.62
28296      Correction of bunion                 T            T        0057    27.3981      1,213.19     2,787.76       3,194.62
28297      Correction of bunion                 T            T        0057    27.3981      1,213.19     2,787.76       3,194.62
28298      Correction of bunion                 T            T        0057    27.3981      1,213.19     2,787.76       3,194.62
28299      Correction of bunion                 T            T        0057    27.3981      1,213.19     2,787.76       3,194.62
28300      Incision of heel bone                T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28302      Incision of ankle bone               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28304      Incision of midfoot bones            T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28305      Incise/graft midfoot bones           T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28306      Incision of metatarsal               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28307      Incision of metatarsal               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28308      Incision of metatarsal               T            T        0055    19.9374       882.83      2,028.63       2,324.70
28309      Incision of metatarsals              T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28310      Revision of big toe                  T            T        0055    19.9374       882.83      2,028.63       2,324.70
28312      Revision of toe                      T            T        0055    19.9374       882.83      2,028.63       2,324.70
28313      Repair deformity of toe              T            T        0055    19.9374       882.83      2,028.63       2,324.70
28315      Removal of sesamoid bone             T            T        0055    19.9374       882.83      2,028.63       2,324.70
28320      Repair of foot bones                 T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28322      Repair of metatarsals                T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28340      Resect enlarged toe tissue           T            T        0055    19.9374       882.83      2,028.63       2,324.70
28341      Resect enlarged toe                  T            T        0055    19.9374       882.83      2,028.63       2,324.70
28344      Repair extra toe(s)                  T            T        0055    19.9374       882.83      2,028.63       2,324.70
28345      Repair webbed toe(s)                 T            T        0055    19.9374       882.83      2,028.63       2,324.70
28360      Reconstruct cleft foot               T            T        0056    40.5436      1,795.27     4,125.31       4,727.38
28400      Treatment of heel fracture           T            T        0043     1.7200        76.16       175.01         200.55
28405      Treatment of heel fracture           T            T        0043     1.7200        76.16       175.01         200.55
28406      Treatment of heel fracture           T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
28415      Treat heel fracture                  T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
28420      Treat/graft heel fracture            T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
28430      Treatment of ankle fracture          T            T        0043     1.7200        76.16       175.01         200.55
28435      Treatment of ankle fracture          T            T        0043     1.7200        76.16       175.01         200.55
28436      Treatment of ankle fracture          T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
28445      Treat ankle fracture                 T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
28450      Treat midfoot fracture, each         T            T        0043     1.7200        76.16       175.01         200.55
28455      Treat midfoot fracture, each         T            T        0043     1.7200        76.16       175.01         200.55
28456      Treat midfoot fracture               T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
28465      Treat midfoot fracture, each         T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
28470      Treat metatarsal fracture            T            T        0043     1.7200        76.16       175.01         200.55
28475      Treat metatarsal fracture            T            T        0043     1.7200        76.16       175.01         200.55
28476      Treat metatarsal fracture            T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
28485      Treat metatarsal fracture            T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
28490      Treat big toe fracture               T            T        0043     1.7200        76.16       175.01         200.55
28495      Treat big toe fracture               T            T        0043     1.7200        76.16       175.01         200.55
28496      Treat big toe fracture               T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
28505      Treat big toe fracture               T            T        0046    37.8852      1,677.56     3,854.82       4,417.41
28510      Treatment of toe fracture            T            T        0043     1.7200        76.16       175.01         200.55
28515      Treatment of toe fracture            T            T        0043     1.7200        76.16       175.01         200.55

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 39 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

28525      Treat toe fracture                   T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28530      Treat sesamoid bone fracture         T            T        0043     1.7200         76.16      175.01         200.55
28531      Treat sesamoid bone fracture         T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28540      Treat foot dislocation               T            T        0043     1.7200         76.16      175.01         200.55
28545      Treat foot dislocation               T            T        0045    14.3413        635.03     1,459.23       1,672.20
28546      Treat foot dislocation               T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28555      Repair foot dislocation              T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28570      Treat foot dislocation               T            T        0043     1.7200         76.16      175.01         200.55
28575      Treat foot dislocation               T            T        0043     1.7200         76.16      175.01         200.55
28576      Treat foot dislocation               T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28585      Repair foot dislocation              T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28600      Treat foot dislocation               T            T        0043     1.7200         76.16      175.01         200.55
28605      Treat foot dislocation               T            T        0043     1.7200         76.16      175.01         200.55
28606      Treat foot dislocation               T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28615      Repair foot dislocation              T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28630      Treat toe dislocation                T            T        0043     1.7200         76.16      175.01         200.55
28635      Treat toe dislocation                T            T        0045    14.3413        635.03     1,459.23       1,672.20
28636      Treat toe dislocation                T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28645      Repair toe dislocation               T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28660      Treat toe dislocation                T            T        0043     1.7200         76.16      175.01         200.55
28665      Treat toe dislocation                T            T        0045    14.3413        635.03     1,459.23       1,672.20
28666      Treat toe dislocation                T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28675      Repair of toe dislocation            T            T        0046    37.8852       1,677.56    3,854.82       4,417.41
28705      Fusion of foot bones                 T            T        0056    40.5436       1,795.27    4,125.31       4,727.38
28715      Fusion of foot bones                 T            T        0056    40.5436       1,795.27    4,125.31       4,727.38
28725      Fusion of foot bones                 T            T        0056    40.5436       1,795.27    4,125.31       4,727.38
28730      Fusion of foot bones                 T            T        0056    40.5436       1,795.27    4,125.31       4,727.38
28735      Fusion of foot bones                 T            T        0056    40.5436       1,795.27    4,125.31       4,727.38
28737      Revision of foot bones               T            T        0056    40.5436       1,795.27    4,125.31       4,727.38
28740      Fusion of foot bones                 T            T        0056    40.5436       1,795.27    4,125.31       4,727.38
28750      Fusion of big toe joint              T            T        0056    40.5436       1,795.27    4,125.31       4,727.38
28755      Fusion of big toe joint              T            T        0055    19.9374        882.83     2,028.63       2,324.70
28760      Fusion of big toe joint              T            T        0056    40.5436       1,795.27    4,125.31       4,727.38
28800      Amputation of midfoot                C            C        0000     0.0000         0.00        0.00           0.00
28805      Amputation thru metatarsal           C            C        0000     0.0000         0.00        0.00           0.00
28810      Amputation toe & metatarsal          T            T        0055    19.9374        882.83     2,028.63       2,324.70
28820      Amputation of toe                    T            T        0055    19.9374        882.83     2,028.63       2,324.70
28825      Partial amputation of toe            T            T        0055    19.9374        882.83     2,028.63       2,324.70
28890      High energy eswt, plantar f          T            T        1547    14.2831   *    632.46     1,453.31       1,665.41
28899      Foot/toes surgery procedure          T            1        0000     0.0000         0.00        0.00           0.00
29000      Application of body cast             S            S        0058     1.0803         47.84      109.92         125.96
29010      Application of body cast             S            S        0426     2.2146         98.06      225.34         258.22
29015      Application of body cast             S            S        0426     2.2146         98.06      225.34         258.22
29020      Application of body cast             S            S        0058     1.0803         47.84      109.92         125.96
29025      Application of body cast             S            S        0058     1.0803         47.84      109.92         125.96
29035      Application of body cast             S            S        0426     2.2146         98.06      225.34         258.22
29040      Application of body cast             S            S        0058     1.0803         47.84      109.92         125.96
29044      Application of body cast             S            S        0426     2.2146         98.06      225.34         258.22
29046      Application of body cast             S            S        0426     2.2146         98.06      225.34         258.22
29049      Application of figure eight          S            S        0058     1.0803         47.84      109.92         125.96
29055      Application of shoulder cast         S            S        0426     2.2146         98.06      225.34         258.22
29058      Application of shoulder cast         S            S        0058     1.0803         47.84      109.92         125.96
29065      Application of long arm cast         S            S        0426     2.2146         98.06      225.34         258.22

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 40 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

29075      Application of forearm cast          S            S        0426     2.2146        98.06       225.34         258.22
29085      Apply hand/wrist cast                S            S        0058     1.0803        47.84       109.92         125.96
29086      Apply finger cast                    S            S        0058     1.0803        47.84       109.92         125.96
29105      Apply long arm splint                S            S        0058     1.0803        47.84       109.92         125.96
29125      Apply forearm splint                 S            S        0058     1.0803        47.84       109.92         125.96
29126      Apply forearm splint                 S            S        0058     1.0803        47.84       109.92         125.96
29130      Application of finger splint         S            S        0058     1.0803        47.84       109.92         125.96
29131      Application of finger splint         S            S        0058     1.0803        47.84       109.92         125.96
29200      Strapping of chest                   S            S        0058     1.0803        47.84       109.92         125.96
29220      Strapping of low back                S            S        0058     1.0803        47.84       109.92         125.96
29240      Strapping of shoulder                S            S        0058     1.0803        47.84       109.92         125.96
29260      Strapping of elbow or wrist          S            S        0058     1.0803        47.84       109.92         125.96
29280      Strapping of hand or finger          S            S        0058     1.0803        47.84       109.92         125.96
29305      Application of hip cast              S            S        0426     2.2146        98.06       225.34         258.22
29325      Application of hip casts             S            S        0426     2.2146        98.06       225.34         258.22
29345      Application of long leg cast         S            S        0426     2.2146        98.06       225.34         258.22
29355      Application of long leg cast         S            S        0426     2.2146        98.06       225.34         258.22
29358      Apply long leg cast brace            S            S        0426     2.2146        98.06       225.34         258.22
29365      Application of long leg cast         S            S        0426     2.2146        98.06       225.34         258.22
29405      Apply short leg cast                 S            S        0426     2.2146        98.06       225.34         258.22
29425      Apply short leg cast                 S            S        0426     2.2146        98.06       225.34         258.22
29435      Apply short leg cast                 S            S        0426     2.2146        98.06       225.34         258.22
29440      Addition of walker to cast           S            S        0058     1.0803        47.84       109.92         125.96
29445      Apply rigid leg cast                 S            S        0426     2.2146        98.06       225.34         258.22
29450      Application of leg cast              S            S        0058     1.0803        47.84       109.92         125.96
29505      Application, long leg splint         S            S        0058     1.0803        47.84       109.92         125.96
29515      Application lower leg splint         S            S        0058     1.0803        47.84       109.92         125.96
29520      Strapping of hip                     S            S        0058     1.0803        47.84       109.92         125.96
29530      Strapping of knee                    S            S        0058     1.0803        47.84       109.92         125.96
29540      Strapping of ankle and/or ft         S            S        0058     1.0803        47.84       109.92         125.96
29550      Strapping of toes                    S            S        0058     1.0803        47.84       109.92         125.96
29580      Application of paste boot            S            S        0058     1.0803        47.84       109.92         125.96
29590      Application of foot splint           S            S        0058     1.0803        47.84       109.92         125.96
29700      Removal/revision of cast             S            S        0058     1.0803        47.84       109.92         125.96
29705      Removal/revision of cast             S            S        0058     1.0803        47.84       109.92         125.96
29710      Removal/revision of cast             S            S        0426     2.2146        98.06       225.34         258.22
29715      Removal/revision of cast             S            S        0058     1.0803        47.84       109.92         125.96
29720      Repair of body cast                  S            S        0058     1.0803        47.84       109.92         125.96
29730      Windowing of cast                    S            S        0058     1.0803        47.84       109.92         125.96
29740      Wedging of cast                      S            S        0058     1.0803        47.84       109.92         125.96
29750      Wedging of clubfoot cast             S            S        0058     1.0803        47.84       109.92         125.96
29799      Casting/strapping procedure          S            1        0000     0.0000        0.00         0.00           0.00
29800      Jaw arthroscopy/surgery              T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29804      Jaw arthroscopy/surgery              T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29805      Shoulder arthroscopy, dx             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29806      Shoulder arthroscopy/surgery         T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29807      Shoulder arthroscopy/surgery         T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29819      Shoulder arthroscopy/surgery         T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29820      Shoulder arthroscopy/surgery         T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29821      Shoulder arthroscopy/surgery         T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29822      Shoulder arthroscopy/surgery         T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29823      Shoulder arthroscopy/surgery         T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29824      Shoulder arthroscopy/surgery         T            T        0041    28.0686      1,242.88     2,855.98       3,272.80

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 41 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

29825      Shoulder arthroscopy/surgery         T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29826      Shoulder arthroscopy/surgery         T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29827      Arthroscop rotator cuff repr         T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29830      Elbow arthroscopy                    T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29834      Elbow arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29835      Elbow arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29836      Elbow arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29837      Elbow arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29838      Elbow arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29840      Wrist arthroscopy                    T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29843      Wrist arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29844      Wrist arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29845      Wrist arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29846      Wrist arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29847      Wrist arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29848      Wrist endoscopy/surgery              T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29850      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29851      Knee arthroscopy/surgery             T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29855      Tibial arthroscopy/surgery           T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29856      Tibial arthroscopy/surgery           T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29860      Hip arthroscopy, dx                  T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29861      Hip arthroscopy/surgery              T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29862      Hip arthroscopy/surgery              T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29863      Hip arthroscopy/surgery              T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29866      Autgrft implnt, knee w/scope         T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29867      Allgrft implnt, knee w/scope         T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29868      Meniscal trnspl, knee w/scpe         T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29870      Knee arthroscopy, dx                 T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29871      Knee arthroscopy/drainage            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29873      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29874      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29875      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29876      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29877      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29879      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29880      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29881      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29882      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29883      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29884      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29885      Knee arthroscopy/surgery             T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29886      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29887      Knee arthroscopy/surgery             T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29888      Knee arthroscopy/surgery             T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29889      Knee arthroscopy/surgery             T            T        0042    44.2075      1,957.51     4,498.11       5,154.59
29891      Ankle arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29892      Ankle arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29893      Scope, plantar fasciotomy            T            T        0055    19.9374       882.83      2,028.63       2,324.70
29894      Ankle arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29895      Ankle arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29897      Ankle arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29898      Ankle arthroscopy/surgery            T            T        0041    28.0686      1,242.88     2,855.98       3,272.80
29899      Ankle arthroscopy/surgery            T            T        0042    44.2075      1,957.51     4,498.11       5,154.59

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 42 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

29900      Mcp joint arthroscopy, dx            T            T        0053    15.6396       692.52      1,591.33       1,823.58
29901      Mcp joint arthroscopy, surg          T            T        0053    15.6396       692.52      1,591.33       1,823.58
29902      Mcp joint arthroscopy, surg          T            T        0053    15.6396       692.52      1,591.33       1,823.58
29999      Arthroscopy of joint                 T            1        0000     0.0000        0.00         0.00           0.00
30000      Drainage of nose lesion              T            T        0251     2.0789        92.05       211.53         242.40
30020      Drainage of nose lesion              T            T        0251     2.0789        92.05       211.53         242.40
30100      Intranasal biopsy                    T            T        0252     8.1033       358.81       824.51         944.84
30110      Removal of nose polyp(s)             T            T        0253    16.0740       711.76      1,635.53       1,874.23
30115      Removal of nose polyp(s)             T            T        0253    16.0740       711.76      1,635.53       1,874.23
30117      Removal of intranasal lesion         T            T        0253    16.0740       711.76      1,635.53       1,874.23
30118      Removal of intranasal lesion         T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
30120      Revision of nose                     T            T        0253    16.0740       711.76      1,635.53       1,874.23
30124      Removal of nose lesion               T            T        0252     8.1033       358.81       824.51         944.84
30125      Removal of nose lesion               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30130      Removal of turbinate bones           T            T        0253    16.0740       711.76      1,635.53       1,874.23
30140      Removal of turbinate bones           T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
30150      Partial removal of nose              T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30160      Removal of nose                      T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30200      Injection treatment of nose          T            T        0252     8.1033       358.81       824.51         944.84
30210      Nasal sinus therapy                  T            T        0252     8.1033       358.81       824.51         944.84
30220      Insert nasal septal button           T            T        0252     8.1033       358.81       824.51         944.84
30300      Remove nasal foreign body            X            X        0340     0.6137        27.17        62.44          71.56
30310      Remove nasal foreign body            T            T        0253    16.0740       711.76      1,635.53       1,874.23
30320      Remove nasal foreign body            T            T        0253    16.0740       711.76      1,635.53       1,874.23
30400      Reconstruction of nose               T            1        0000     0.0000        0.00         0.00           0.00
30410      Reconstruction of nose               T            1        0000     0.0000        0.00         0.00           0.00
30420      Reconstruction of nose               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30430      Revision of nose                     T            1        0000     0.0000        0.00         0.00           0.00
30435      Revision of nose                     T            1        0000     0.0000        0.00         0.00           0.00
30450      Revision of nose                     T            1        0000     0.0000        0.00         0.00           0.00
30460      Revision of nose                     T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30462      Revision of nose                     T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30465      Repair nasal stenosis                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30520      Repair of nasal septum               T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
30540      Repair nasal defect                  T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30545      Repair nasal defect                  T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30560      Release of nasal adhesions           T            T        0251     2.0789        92.05       211.53         242.40
30580      Repair upper jaw fistula             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30600      Repair mouth/nose fistula            T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30620      Intranasal reconstruction            T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
30630      Repair nasal septum defect           T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
30801      Cauterization, inner nose            T            T        0252     8.1033       358.81       824.51         944.84
30802      Cauterization, inner nose            T            T        0252     8.1033       358.81       824.51         944.84
30901      Control of nosebleed                 T            T        0250     1.2241        54.20       124.55         142.73
30903      Control of nosebleed                 T            T        0250     1.2241        54.20       124.55         142.73
30905      Control of nosebleed                 T            T        0250     1.2241        54.20       124.55         142.73
30906      Repeat control of nosebleed          T            T        0250     1.2241        54.20       124.55         142.73
30915      Ligation, nasal sinus artery         T            T        0091    28.8805      1,278.83     2,938.59       3,367.47
30920      Ligation, upper jaw artery           T            T        0092    26.5104      1,173.88     2,697.43       3,091.11
30930      Therapy, fracture of nose            T            T        0253    16.0740       711.76      1,635.53       1,874.23
30999      Nasal surgery procedure              T            1        0000     0.0000        0.00         0.00           0.00
31000      Irrigation, maxillary sinus          T            T        0251     2.0789        92.05       211.53         242.40
31002      Irrigation, sphenoid sinus           T            T        0252     8.1033       358.81       824.51         944.84

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 43 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

31020      Exploration, maxillary sinus         T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31030      Exploration, maxillary sinus         T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31032      Explore sinus, remove polyps         T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31040      Exploration behind upper jaw         T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31050      Exploration, sphenoid sinus          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31051      Sphenoid sinus surgery               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31070      Exploration of frontal sinus         T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31075      Exploration of frontal sinus         T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31080      Removal of frontal sinus             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31081      Removal of frontal sinus             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31084      Removal of frontal sinus             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31085      Removal of frontal sinus             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31086      Removal of frontal sinus             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31087      Removal of frontal sinus             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31090      Exploration of sinuses               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31200      Removal of ethmoid sinus             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31201      Removal of ethmoid sinus             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31205      Removal of ethmoid sinus             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31225      Removal of upper jaw                 C            C        0000     0.0000        0.00         0.00           0.00
31230      Removal of upper jaw                 C            C        0000     0.0000        0.00         0.00           0.00
31231      Nasal endoscopy, dx                  T            T        0072     1.4448        63.98       147.01         168.46
31233      Nasal/sinus endoscopy, dx            T            T        0072     1.4448        63.98       147.01         168.46
31235      Nasal/sinus endoscopy, dx            T            T        0074    15.4603       684.58      1,573.09       1,802.67
31237      Nasal/sinus endoscopy, surg          T            T        0075    21.2258       939.88      2,159.73       2,474.93
31238      Nasal/sinus endoscopy, surg          T            T        0074    15.4603       684.58      1,573.09       1,802.67
31239      Nasal/sinus endoscopy, surg          T            T        0075    21.2258       939.88      2,159.73       2,474.93
31240      Nasal/sinus endoscopy, surg          T            T        0074    15.4603       684.58      1,573.09       1,802.67
31254      Revision of ethmoid sinus            T            T        0075    21.2258       939.88      2,159.73       2,474.93
31255      Removal of ethmoid sinus             T            T        0075    21.2258       939.88      2,159.73       2,474.93
31256      Exploration maxillary sinus          T            T        0075    21.2258       939.88      2,159.73       2,474.93
31267      Endoscopy, maxillary sinus           T            T        0075    21.2258       939.88      2,159.73       2,474.93
31276      Sinus endoscopy, surgical            T            T        0075    21.2258       939.88      2,159.73       2,474.93
31287      Nasal/sinus endoscopy, surg          T            T        0075    21.2258       939.88      2,159.73       2,474.93
31288      Nasal/sinus endoscopy, surg          T            T        0075    21.2258       939.88      2,159.73       2,474.93
31290      Nasal/sinus endoscopy, surg          C            C        0000     0.0000        0.00         0.00           0.00
31291      Nasal/sinus endoscopy, surg          C            C        0000     0.0000        0.00         0.00           0.00
31292      Nasal/sinus endoscopy, surg          T            T        0075    21.2258       939.88      2,159.73       2,474.93
31293      Nasal/sinus endoscopy, surg          T            T        0075    21.2258       939.88      2,159.73       2,474.93
31294      Nasal/sinus endoscopy, surg          T            T        0075    21.2258       939.88      2,159.73       2,474.93
31299      Sinus surgery procedure              T            1        0000     0.0000        0.00         0.00           0.00
31300      Removal of larynx lesion             T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31320      Diagnostic incision, larynx          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31360      Removal of larynx                    C            C        0000     0.0000        0.00         0.00           0.00
31365      Removal of larynx                    C            C        0000     0.0000        0.00         0.00           0.00
31367      Partial removal of larynx            C            C        0000     0.0000        0.00         0.00           0.00
31368      Partial removal of larynx            C            C        0000     0.0000        0.00         0.00           0.00
31370      Partial removal of larynx            C            C        0000     0.0000        0.00         0.00           0.00
31375      Partial removal of larynx            C            C        0000     0.0000        0.00         0.00           0.00
31380      Partial removal of larynx            C            C        0000     0.0000        0.00         0.00           0.00
31382      Partial removal of larynx            C            C        0000     0.0000        0.00         0.00           0.00
31390      Removal of larynx & pharynx          C            C        0000     0.0000        0.00         0.00           0.00
31395      Reconstruct larynx & pharynx         C            C        0000     0.0000        0.00         0.00           0.00
31400      Revision of larynx                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 44 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

31420      Removal of epiglottis                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31500      Insert emergency airway              S            S        0094     2.4582       108.85       250.12         286.63
31502      Change of windpipe airway            T            T        0121     2.2374        99.07       227.66         260.88
31505      Diagnostic laryngoscopy              T            T        0071     0.8034        35.57        81.75          93.68
31510      Laryngoscopy with biopsy             T            T        0074    15.4603       684.58      1,573.09       1,802.67
31511      Remove foreign body, larynx          T            T        0072     1.4448        63.98       147.01         168.46
31512      Removal of larynx lesion             T            T        0074    15.4603       684.58      1,573.09       1,802.67
31513      Injection into vocal cord            T            T        0072     1.4448        63.98       147.01         168.46
31515      Laryngoscopy for aspiration          T            T        0074    15.4603       684.58      1,573.09       1,802.67
31520      Diagnostic laryngoscopy              T            T        0072     1.4448        63.98       147.01         168.46
31525      Diagnostic laryngoscopy              T            T        0074    15.4603       684.58      1,573.09       1,802.67
31526      Diagnostic laryngoscopy              T            T        0075    21.2258       939.88      2,159.73       2,474.93
31527      Laryngoscopy for treatment           T            T        0075    21.2258       939.88      2,159.73       2,474.93
31528      Laryngoscopy and dilation            T            T        0074    15.4603       684.58      1,573.09       1,802.67
31529      Laryngoscopy and dilation            T            T        0074    15.4603       684.58      1,573.09       1,802.67
31530      Operative laryngoscopy               T            T        0075    21.2258       939.88      2,159.73       2,474.93
31531      Operative laryngoscopy               T            T        0075    21.2258       939.88      2,159.73       2,474.93
31535      Operative laryngoscopy               T            T        0075    21.2258       939.88      2,159.73       2,474.93
31536      Operative laryngoscopy               T            T        0075    21.2258       939.88      2,159.73       2,474.93
31540      Operative laryngoscopy               T            T        0075    21.2258       939.88      2,159.73       2,474.93
31541      Operative laryngoscopy               T            T        0075    21.2258       939.88      2,159.73       2,474.93
31545      Remove vc lesion w/scope             T            T        0075    21.2258       939.88      2,159.73       2,474.93
31546      Remove vc lesion scope/graft         T            T        0075    21.2258       939.88      2,159.73       2,474.93
31560      Operative laryngoscopy               T            T        0075    21.2258       939.88      2,159.73       2,474.93
31561      Operative laryngoscopy               T            T        0075    21.2258       939.88      2,159.73       2,474.93
31570      Laryngoscopy with injection          T            T        0074    15.4603       684.58      1,573.09       1,802.67
31571      Laryngoscopy with injection          T            T        0075    21.2258       939.88      2,159.73       2,474.93
31575      Diagnostic laryngoscopy              T            T        0072     1.4448        63.98       147.01         168.46
31576      Laryngoscopy with biopsy             T            T        0075    21.2258       939.88      2,159.73       2,474.93
31577      Remove foreign body, larynx          T            T        0073     4.2171       186.73       429.09         491.71
31578      Removal of larynx lesion             T            T        0075    21.2258       939.88      2,159.73       2,474.93
31579      Diagnostic laryngoscopy              T            T        0073     4.2171       186.73       429.09         491.71
31580      Revision of larynx                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31582      Revision of larynx                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31584      Treat larynx fracture                C            C        0000     0.0000        0.00         0.00           0.00
31587      Revision of larynx                   C            C        0000     0.0000        0.00         0.00           0.00
31588      Revision of larynx                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31590      Reinnervate larynx                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31595      Larynx nerve surgery                 T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31599      Larynx surgery procedure             T            1        0000     0.0000        0.00         0.00           0.00
31600      Incision of windpipe                 T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31601      Incision of windpipe                 T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31603      Incision of windpipe                 T            T        0252     8.1033       358.81       824.51         944.84
31605      Incision of windpipe                 T            T        0252     8.1033       358.81       824.51         944.84
31610      Incision of windpipe                 T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31611      Surgery/speech prosthesis            T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31612      Puncture/clear windpipe              T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31613      Repair windpipe opening              T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31614      Repair windpipe opening              T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31615      Visualization of windpipe            T            T        0076     9.4030       416.36       956.76        1,096.39
31620      Endobronchial us add-on              S            S        0670    28.7546      1,273.25     2,925.78       3,352.79
31622      Dx bronchoscope/wash                 T            T        0076     9.4030       416.36       956.76        1,096.39
31623      Dx bronchoscope/brush                T            T        0076     9.4030       416.36       956.76        1,096.39

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 45 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

31624      Dx bronchoscope/lavage               T            T        0076     9.4030       416.36       956.76        1,096.39
31625      Bronchoscopy w/biopsy(s)             T            T        0076     9.4030       416.36       956.76        1,096.39
31628      Bronchoscopy/lung bx, each           T            T        0076     9.4030       416.36       956.76        1,096.39
31629      Bronchoscopy/needle bx, each         T            T        0076     9.4030       416.36       956.76        1,096.39
31630      Bronchoscopy dilate/fx repr          T            T        0415    22.0722       977.36      2,245.85       2,573.62
31631      Bronchoscopy, dilate w/stent         T            T        0415    22.0722       977.36      2,245.85       2,573.62
31632      Bronchoscopy/lung bx, add’l          T            T        0076     9.4030       416.36       956.76        1,096.39
31633      Bronchoscopy/needle bx add’l         T            T        0076     9.4030       416.36       956.76        1,096.39
31635      Bronchoscopy w/fb removal            T            T        0076     9.4030       416.36       956.76        1,096.39
31636      Bronchoscopy, bronch stents          T            T        0415    22.0722       977.36      2,245.85       2,573.62
31637      Bronchoscopy, stent add-on           T            T        0076     9.4030       416.36       956.76        1,096.39
31638      Bronchoscopy, revise stent           T            T        0415    22.0722       977.36      2,245.85       2,573.62
31640      Bronchoscopy w/tumor excise          T            T        0415    22.0722       977.36      2,245.85       2,573.62
31641      Bronchoscopy, treat blockage         T            T        0415    22.0722       977.36      2,245.85       2,573.62
31643      Diag bronchoscope/catheter           T            T        0076     9.4030       416.36       956.76        1,096.39
31645      Bronchoscopy, clear airways          T            T        0076     9.4030       416.36       956.76        1,096.39
31646      Bronchoscopy, reclear airway         T            T        0076     9.4030       416.36       956.76        1,096.39
31656      Bronchoscopy, inj for x-ray          T            T        0076     9.4030       416.36       956.76        1,096.39
31700      Insertion of airway catheter         T            T        0072     1.4448        63.98       147.01         168.46
31708      Instill airway contrast dye          N            N        0000     0.0000        0.00         0.00           0.00
31710      Insertion of airway catheter         N            N        0000     0.0000        0.00         0.00           0.00
31715      Injection for bronchus x-ray         N            N        0000     0.0000        0.00         0.00           0.00
31717      Bronchial brush biopsy               T            T        0073     4.2171       186.73       429.09         491.71
31720      Clearance of airways                 T            T        0071     0.8034        35.57        81.75          93.68
31725      Clearance of airways                 C            C        0000     0.0000        0.00         0.00           0.00
31730      Intro, windpipe wire/tube            T            T        0073     4.2171       186.73       429.09         491.71
31750      Repair of windpipe                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31755      Repair of windpipe                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
31760      Repair of windpipe                   C            C        0000     0.0000        0.00         0.00           0.00
31766      Reconstruction of windpipe           C            C        0000     0.0000        0.00         0.00           0.00
31770      Repair/graft of bronchus             C            C        0000     0.0000        0.00         0.00           0.00
31775      Reconstruct bronchus                 C            C        0000     0.0000        0.00         0.00           0.00
31780      Reconstruct windpipe                 C            C        0000     0.0000        0.00         0.00           0.00
31781      Reconstruct windpipe                 C            C        0000     0.0000        0.00         0.00           0.00
31785      Remove windpipe lesion               T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31786      Remove windpipe lesion               C            C        0000     0.0000        0.00         0.00           0.00
31800      Repair of windpipe injury            C            C        0000     0.0000        0.00         0.00           0.00
31805      Repair of windpipe injury            C            C        0000     0.0000        0.00         0.00           0.00
31820      Closure of windpipe lesion           T            T        0253    16.0740       711.76      1,635.53       1,874.23
31825      Repair of windpipe defect            T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31830      Revise windpipe scar                 T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
31899      Airways surgical procedure           T            1        0000     0.0000        0.00         0.00           0.00
32000      Drainage of chest                    T            T        0070     3.2141       142.32       327.03         374.76
32002      Treatment of collapsed lung          T            T        0070     3.2141       142.32       327.03         374.76
32005      Treat lung lining chemically         T            T        0070     3.2141       142.32       327.03         374.76
32019      Insert pleural catheter              T            T        0427    10.0109       443.28      1,018.61       1,167.27
32020      Insertion of chest tube              T            T        0070     3.2141       142.32       327.03         374.76
32035      Exploration of chest                 C            C        0000     0.0000        0.00         0.00           0.00
32036      Exploration of chest                 C            C        0000     0.0000        0.00         0.00           0.00
32095      Biopsy through chest wall            C            C        0000     0.0000        0.00         0.00           0.00
32100      Exploration/biopsy of chest          C            C        0000     0.0000        0.00         0.00           0.00
32110      Explore/repair chest                 C            C        0000     0.0000        0.00         0.00           0.00
32120      Re-exploration of chest              C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 46 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 47 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

32800      Repair lung hernia                   C            C        0000    0.0000         0.00         0.00         0.00
32810      Close chest after drainage           C            C        0000    0.0000         0.00         0.00         0.00
32815      Close bronchial fistula              C            C        0000    0.0000         0.00         0.00         0.00
32820      Reconstruct injured chest            C            C        0000    0.0000         0.00         0.00         0.00
32850      Donor pneumonectomy                  C            C        0000    0.0000         0.00         0.00         0.00
32851      Lung transplant, single              C            C        0000    0.0000         0.00         0.00         0.00
32852      Lung transplant with bypass          C            C        0000    0.0000         0.00         0.00         0.00
32853      Lung transplant, double              C            C        0000    0.0000         0.00         0.00         0.00
32854      Lung transplant with bypass          C            C        0000    0.0000         0.00         0.00         0.00
32855      Prepare donor lung, single           C            C        0000    0.0000         0.00         0.00         0.00
32856      Prepare donor lung, double           C            C        0000    0.0000         0.00         0.00         0.00
32900      Removal of rib(s)                    C            C        0000    0.0000         0.00         0.00         0.00
32905      Revise & repair chest wall           C            C        0000    0.0000         0.00         0.00         0.00
32906      Revise & repair chest wall           C            C        0000    0.0000         0.00         0.00         0.00
32940      Revision of lung                     C            C        0000    0.0000         0.00         0.00         0.00
32960      Therapeutic pneumothorax             T            T        0070    3.2141        142.32       327.03       374.76
32997      Total lung lavage                    C            C        0000    0.0000         0.00         0.00         0.00
32999      Chest surgery procedure              T            1        0000    0.0000         0.00         0.00         0.00
33010      Drainage of heart sac                T            T        0070    3.2141        142.32       327.03       374.76
33011      Repeat drainage of heart sac         T            T        0070    3.2141        142.32       327.03       374.76
33015      Incision of heart sac                C            C        0000    0.0000         0.00         0.00         0.00
33020      Incision of heart sac                C            C        0000    0.0000         0.00         0.00         0.00
33025      Incision of heart sac                C            C        0000    0.0000         0.00         0.00         0.00
33030      Partial removal of heart sac         C            C        0000    0.0000         0.00         0.00         0.00
33031      Partial removal of heart sac         C            C        0000    0.0000         0.00         0.00         0.00
33050      Removal of heart sac lesion          C            C        0000    0.0000         0.00         0.00         0.00
33120      Removal of heart lesion              C            C        0000    0.0000         0.00         0.00         0.00
33130      Removal of heart lesion              C            C        0000    0.0000         0.00         0.00         0.00
33140      Heart revascularize (tmr)            C            C        0000    0.0000         0.00         0.00         0.00
33141      Heart tmr w/other procedure          C            C        0000    0.0000         0.00         0.00         0.00
33200      Insertion of heart pacemaker         C            C        0000    0.0000         0.00         0.00         0.00
33201      Insertion of heart pacemaker         C            C        0000    0.0000         0.00         0.00         0.00
33206      Insertion of heart pacemaker         T            T        0089   117.0463      5,182.81    11,909.46    13,647.60
33207      Insertion of heart pacemaker         T            T        0089   117.0463      5,182.81    11,909.46    13,647.60
33208      Insertion of heart pacemaker         T            T        0655   136.8448      6,059.49    13,923.96    15,956.10
33210      Insertion of heart electrode         T            T        0106   55.9362       2,476.85     5,691.51     6,522.16
33211      Insertion of heart electrode         T            T        0106   55.9362       2,476.85     5,691.51     6,522.16
33212      Insertion of pulse generator         T            T        0090   90.2017       3,994.13     9,178.02    10,517.52
33213      Insertion of pulse generator         T            T        0654   112.0279      4,960.60    11,398.84    13,062.45
33214      Upgrade of pacemaker system          T            T        0655   136.8448      6,059.49    13,923.96    15,956.10
33215      Reposition pacing-defib lead         T            T        0105   21.9865        973.56      2,237.13     2,563.63
33216      Insert lead pace-defib, one          T            T        0106   55.9362       2,476.85     5,691.51     6,522.16
33217      Insert lead pace-defib, dual         T            T        0106   55.9362       2,476.85     5,691.51     6,522.16
33218      Repair lead pace-defib, one          T            T        0106   55.9362       2,476.85     5,691.51     6,522.16
33220      Repair lead pace-defib, dual         T            T        0106   55.9362       2,476.85     5,691.51     6,522.16
33222      Revise pocket, pacemaker             T            T        0027   18.1956        805.70      1,851.40     2,121.61
33223      Revise pocket, pacing-defib          T            T        0027   18.1956        805.70      1,851.40     2,121.61
33224      Insert pacing lead & connect         T            T        0418   169.3514      7,498.88    17,231.50    19,746.37
33225      L ventric pacing lead add-on         T            T        0418   169.3514      7,498.88    17,231.50    19,746.37
33226      Reposition l ventric lead            T            T        0105   21.9865        973.56      2,237.13     2,563.63
33233      Removal of pacemaker system          T            T        0105   21.9865        973.56      2,237.13     2,563.63
33234      Removal of pacemaker system          T            T        0105   21.9865        973.56      2,237.13     2,563.63
33235      Removal pacemaker electrode          T            T        0105   21.9865        973.56      2,237.13     2,563.63

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                             48 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

33236      Remove electrode/thoracotomy         C            C        0000     0.0000        0.00         0.00           0.00
33237      Remove electrode/thoracotomy         C            C        0000     0.0000        0.00         0.00           0.00
33238      Remove electrode/thoracotomy         C            C        0000     0.0000        0.00         0.00           0.00
33240      Insert pulse generator               B            1        0000     0.0000        0.00         0.00           0.00
33241      Remove pulse generator               T            T        0105    21.9865       973.56      2,237.13       2,563.63
33243      Remove eltrd/thoracotomy             C            C        0000     0.0000        0.00         0.00           0.00
33244      Remove eltrd, transven               T            T        0105    21.9865       973.56      2,237.13       2,563.63
33245      Insert epic eltrd pace-defib         C            C        0000     0.0000        0.00         0.00           0.00
33246      Insert epic eltrd/generator          C            C        0000     0.0000        0.00         0.00           0.00
33249      Eltrd/insert pace-defib              B            1        0000     0.0000        0.00         0.00           0.00
33250      Ablate heart dysrhythm focus         C            C        0000     0.0000        0.00         0.00           0.00
33251      Ablate heart dysrhythm focus         C            C        0000     0.0000        0.00         0.00           0.00
33253      Reconstruct atria                    C            C        0000     0.0000        0.00         0.00           0.00
33261      Ablate heart dysrhythm focus         C            C        0000     0.0000        0.00         0.00           0.00
33282      Implant pat-active ht record         S            S        0680    74.9052      3,316.80     7,621.60       8,733.95
33284      Remove pat-active ht record          T            T        0109    11.1714       494.67      1,136.69       1,302.59
33300      Repair of heart wound                C            C        0000     0.0000        0.00         0.00           0.00
33305      Repair of heart wound                C            C        0000     0.0000        0.00         0.00           0.00
33310      Exploratory heart surgery            C            C        0000     0.0000        0.00         0.00           0.00
33315      Exploratory heart surgery            C            C        0000     0.0000        0.00         0.00           0.00
33320      Repair major blood vessel(s)         C            C        0000     0.0000        0.00         0.00           0.00
33321      Repair major vessel                  C            C        0000     0.0000        0.00         0.00           0.00
33322      Repair major blood vessel(s)         C            C        0000     0.0000        0.00         0.00           0.00
33330      Insert major vessel graft            C            C        0000     0.0000        0.00         0.00           0.00
33332      Insert major vessel graft            C            C        0000     0.0000        0.00         0.00           0.00
33335      Insert major vessel graft            C            C        0000     0.0000        0.00         0.00           0.00
33400      Repair of aortic valve               C            C        0000     0.0000        0.00         0.00           0.00
33401      Valvuloplasty, open                  C            C        0000     0.0000        0.00         0.00           0.00
33403      Valvuloplasty, w/cp bypass           C            C        0000     0.0000        0.00         0.00           0.00
33404      Prepare heart-aorta conduit          C            C        0000     0.0000        0.00         0.00           0.00
33405      Replacement of aortic valve          C            C        0000     0.0000        0.00         0.00           0.00
33406      Replacement of aortic valve          C            C        0000     0.0000        0.00         0.00           0.00
33410      Replacement of aortic valve          C            C        0000     0.0000        0.00         0.00           0.00
33411      Replacement of aortic valve          C            C        0000     0.0000        0.00         0.00           0.00
33412      Replacement of aortic valve          C            C        0000     0.0000        0.00         0.00           0.00
33413      Replacement of aortic valve          C            C        0000     0.0000        0.00         0.00           0.00
33414      Repair of aortic valve               C            C        0000     0.0000        0.00         0.00           0.00
33415      Revision, subvalvular tissue         C            C        0000     0.0000        0.00         0.00           0.00
33416      Revise ventricle muscle              C            C        0000     0.0000        0.00         0.00           0.00
33417      Repair of aortic valve               C            C        0000     0.0000        0.00         0.00           0.00
33420      Revision of mitral valve             C            C        0000     0.0000        0.00         0.00           0.00
33422      Revision of mitral valve             C            C        0000     0.0000        0.00         0.00           0.00
33425      Repair of mitral valve               C            C        0000     0.0000        0.00         0.00           0.00
33426      Repair of mitral valve               C            C        0000     0.0000        0.00         0.00           0.00
33427      Repair of mitral valve               C            C        0000     0.0000        0.00         0.00           0.00
33430      Replacement of mitral valve          C            C        0000     0.0000        0.00         0.00           0.00
33460      Revision of tricuspid valve          C            C        0000     0.0000        0.00         0.00           0.00
33463      Valvuloplasty, tricuspid             C            C        0000     0.0000        0.00         0.00           0.00
33464      Valvuloplasty, tricuspid             C            C        0000     0.0000        0.00         0.00           0.00
33465      Replace tricuspid valve              C            C        0000     0.0000        0.00         0.00           0.00
33468      Revision of tricuspid valve          C            C        0000     0.0000        0.00         0.00           0.00
33470      Revision of pulmonary valve          C            C        0000     0.0000        0.00         0.00           0.00
33471      Valvotomy, pulmonary valve           C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 49 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated     4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

33472      Revision of pulmonary valve          C            C        0000    0.0000         0.00         0.00         0.00
33474      Revision of pulmonary valve          C            C        0000    0.0000         0.00         0.00         0.00
33475      Replacement, pulmonary valve         C            C        0000    0.0000         0.00         0.00         0.00
33476      Revision of heart chamber            C            C        0000    0.0000         0.00         0.00         0.00
33478      Revision of heart chamber            C            C        0000    0.0000         0.00         0.00         0.00
33496      Repair, prosth valve clot            C            C        0000    0.0000         0.00         0.00         0.00
33500      Repair heart vessel fistula          C            C        0000    0.0000         0.00         0.00         0.00
33501      Repair heart vessel fistula          C            C        0000    0.0000         0.00         0.00         0.00
33502      Coronary artery correction           C            C        0000    0.0000         0.00         0.00         0.00
33503      Coronary artery graft                C            C        0000    0.0000         0.00         0.00         0.00
33504      Coronary artery graft                C            C        0000    0.0000         0.00         0.00         0.00
33505      Repair artery w/tunnel               C            C        0000    0.0000         0.00         0.00         0.00
33506      Repair artery, translocation         C            C        0000    0.0000         0.00         0.00         0.00
33507      Repair art, intramural               C            C        0000    0.0000         0.00         0.00         0.00
33508      Endoscopic vein harvest              N            N        0000    0.0000         0.00         0.00         0.00
33510      CABG, vein, single                   C            C        0000    0.0000         0.00         0.00         0.00
33511      CABG, vein, two                      C            C        0000    0.0000         0.00         0.00         0.00
33512      CABG, vein, three                    C            C        0000    0.0000         0.00         0.00         0.00
33513      CABG, vein, four                     C            C        0000    0.0000         0.00         0.00         0.00
33514      CABG, vein, five                     C            C        0000    0.0000         0.00         0.00         0.00
33516      Cabg, vein, six or more              C            C        0000    0.0000         0.00         0.00         0.00
33517      CABG, artery-vein, single            C            C        0000    0.0000         0.00         0.00         0.00
33518      CABG, artery-vein, two               C            C        0000    0.0000         0.00         0.00         0.00
33519      CABG, artery-vein, three             C            C        0000    0.0000         0.00         0.00         0.00
33521      CABG, artery-vein, four              C            C        0000    0.0000         0.00         0.00         0.00
33522      CABG, artery-vein, five              C            C        0000    0.0000         0.00         0.00         0.00
33523      Cabg, art-vein, six or more          C            C        0000    0.0000         0.00         0.00         0.00
33530      Coronary artery, bypass/reop         C            C        0000    0.0000         0.00         0.00         0.00
33533      CABG, arterial, single               C            C        0000    0.0000         0.00         0.00         0.00
33534      CABG, arterial, two                  C            C        0000    0.0000         0.00         0.00         0.00
33535      CABG, arterial, three                C            C        0000    0.0000         0.00         0.00         0.00
33536      Cabg, arterial, four or more         C            C        0000    0.0000         0.00         0.00         0.00
33542      Removal of heart lesion              C            C        0000    0.0000         0.00         0.00         0.00
33545      Repair of heart damage               C            C        0000    0.0000         0.00         0.00         0.00
33548      Restore/remodel, ventricle           C            C        0000    0.0000         0.00         0.00         0.00
33572      Open coronary endarterectomy         C            C        0000    0.0000         0.00         0.00         0.00
33600      Closure of valve                     C            C        0000    0.0000         0.00         0.00         0.00
33602      Closure of valve                     C            C        0000    0.0000         0.00         0.00         0.00
33606      Anastomosis/artery-aorta             C            C        0000    0.0000         0.00         0.00         0.00
33608      Repair anomaly w/conduit             C            C        0000    0.0000         0.00         0.00         0.00
33610      Repair by enlargement                C            C        0000    0.0000         0.00         0.00         0.00
33611      Repair double ventricle              C            C        0000    0.0000         0.00         0.00         0.00
33612      Repair double ventricle              C            C        0000    0.0000         0.00         0.00         0.00
33615      Repair, modified fontan              C            C        0000    0.0000         0.00         0.00         0.00
33617      Repair single ventricle              C            C        0000    0.0000         0.00         0.00         0.00
33619      Repair single ventricle              C            C        0000    0.0000         0.00         0.00         0.00
33641      Repair heart septum defect           C            C        0000    0.0000         0.00         0.00         0.00
33645      Revision of heart veins              C            C        0000    0.0000         0.00         0.00         0.00
33647      Repair heart septum defects          C            C        0000    0.0000         0.00         0.00         0.00
33660      Repair of heart defects              C            C        0000    0.0000         0.00         0.00         0.00
33665      Repair of heart defects              C            C        0000    0.0000         0.00         0.00         0.00
33670      Repair of heart chambers             C            C        0000    0.0000         0.00         0.00         0.00
33681      Repair heart septum defect           C            C        0000    0.0000         0.00         0.00         0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                               50 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated     4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

33684      Repair heart septum defect           C            C        0000    0.0000         0.00         0.00         0.00
33688      Repair heart septum defect           C            C        0000    0.0000         0.00         0.00         0.00
33690      Reinforce pulmonary artery           C            C        0000    0.0000         0.00         0.00         0.00
33692      Repair of heart defects              C            C        0000    0.0000         0.00         0.00         0.00
33694      Repair of heart defects              C            C        0000    0.0000         0.00         0.00         0.00
33697      Repair of heart defects              C            C        0000    0.0000         0.00         0.00         0.00
33702      Repair of heart defects              C            C        0000    0.0000         0.00         0.00         0.00
33710      Repair of heart defects              C            C        0000    0.0000         0.00         0.00         0.00
33720      Repair of heart defect               C            C        0000    0.0000         0.00         0.00         0.00
33722      Repair of heart defect               C            C        0000    0.0000         0.00         0.00         0.00
33730      Repair heart-vein defect(s)          C            C        0000    0.0000         0.00         0.00         0.00
33732      Repair heart-vein defect             C            C        0000    0.0000         0.00         0.00         0.00
33735      Revision of heart chamber            C            C        0000    0.0000         0.00         0.00         0.00
33736      Revision of heart chamber            C            C        0000    0.0000         0.00         0.00         0.00
33737      Revision of heart chamber            C            C        0000    0.0000         0.00         0.00         0.00
33750      Major vessel shunt                   C            C        0000    0.0000         0.00         0.00         0.00
33755      Major vessel shunt                   C            C        0000    0.0000         0.00         0.00         0.00
33762      Major vessel shunt                   C            C        0000    0.0000         0.00         0.00         0.00
33764      Major vessel shunt & graft           C            C        0000    0.0000         0.00         0.00         0.00
33766      Major vessel shunt                   C            C        0000    0.0000         0.00         0.00         0.00
33767      Major vessel shunt                   C            C        0000    0.0000         0.00         0.00         0.00
33768      Cavopulmonary shunting               C            C        0000    0.0000         0.00         0.00         0.00
33770      Repair great vessels defect          C            C        0000    0.0000         0.00         0.00         0.00
33771      Repair great vessels defect          C            C        0000    0.0000         0.00         0.00         0.00
33774      Repair great vessels defect          C            C        0000    0.0000         0.00         0.00         0.00
33775      Repair great vessels defect          C            C        0000    0.0000         0.00         0.00         0.00
33776      Repair great vessels defect          C            C        0000    0.0000         0.00         0.00         0.00
33777      Repair great vessels defect          C            C        0000    0.0000         0.00         0.00         0.00
33778      Repair great vessels defect          C            C        0000    0.0000         0.00         0.00         0.00
33779      Repair great vessels defect          C            C        0000    0.0000         0.00         0.00         0.00
33780      Repair great vessels defect          C            C        0000    0.0000         0.00         0.00         0.00
33781      Repair great vessels defect          C            C        0000    0.0000         0.00         0.00         0.00
33786      Repair arterial trunk                C            C        0000    0.0000         0.00         0.00         0.00
33788      Revision of pulmonary artery         C            C        0000    0.0000         0.00         0.00         0.00
33800      Aortic suspension                    C            C        0000    0.0000         0.00         0.00         0.00
33802      Repair vessel defect                 C            C        0000    0.0000         0.00         0.00         0.00
33803      Repair vessel defect                 C            C        0000    0.0000         0.00         0.00         0.00
33813      Repair septal defect                 C            C        0000    0.0000         0.00         0.00         0.00
33814      Repair septal defect                 C            C        0000    0.0000         0.00         0.00         0.00
33820      Revise major vessel                  C            C        0000    0.0000         0.00         0.00         0.00
33822      Revise major vessel                  C            C        0000    0.0000         0.00         0.00         0.00
33824      Revise major vessel                  C            C        0000    0.0000         0.00         0.00         0.00
33840      Remove aorta constriction            C            C        0000    0.0000         0.00         0.00         0.00
33845      Remove aorta constriction            C            C        0000    0.0000         0.00         0.00         0.00
33851      Remove aorta constriction            C            C        0000    0.0000         0.00         0.00         0.00
33852      Repair septal defect                 C            C        0000    0.0000         0.00         0.00         0.00
33853      Repair septal defect                 C            C        0000    0.0000         0.00         0.00         0.00
33860      Ascending aortic graft               C            C        0000    0.0000         0.00         0.00         0.00
33861      Ascending aortic graft               C            C        0000    0.0000         0.00         0.00         0.00
33863      Ascending aortic graft               C            C        0000    0.0000         0.00         0.00         0.00
33870      Transverse aortic arch graft         C            C        0000    0.0000         0.00         0.00         0.00
33875      Thoracic aortic graft                C            C        0000    0.0000         0.00         0.00         0.00
33877      Thoracoabdominal graft               C            C        0000    0.0000         0.00         0.00         0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                               51 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

33880      Endovasc taa repr incl subcl         C            C        0000     0.0000        0.00         0.00           0.00
33881      Endovasc taa repr w/o subcl          C            C        0000     0.0000        0.00         0.00           0.00
33883      Insert endovasc prosth, taa          C            C        0000     0.0000        0.00         0.00           0.00
33884      Endovasc prosth, taa, add-on         C            C        0000     0.0000        0.00         0.00           0.00
33886      Endovasc prosth, delayed             C            C        0000     0.0000        0.00         0.00           0.00
33889      Artery transpose/endovas taa         C            C        0000     0.0000        0.00         0.00           0.00
33891      Car-car bp grft/endovas taa          C            C        0000     0.0000        0.00         0.00           0.00
33910      Remove lung artery emboli            C            C        0000     0.0000        0.00         0.00           0.00
33915      Remove lung artery emboli            C            C        0000     0.0000        0.00         0.00           0.00
33916      Surgery of great vessel              C            C        0000     0.0000        0.00         0.00           0.00
33917      Repair pulmonary artery              C            C        0000     0.0000        0.00         0.00           0.00
33920      Repair pulmonary atresia             C            C        0000     0.0000        0.00         0.00           0.00
33922      Transect pulmonary artery            C            C        0000     0.0000        0.00         0.00           0.00
33924      Remove pulmonary shunt               C            C        0000     0.0000        0.00         0.00           0.00
33925      Rpr pul art unifocal w/o cpb         C            C        0000     0.0000        0.00         0.00           0.00
33926      Repr pul art, unifocal w/cpb         C            C        0000     0.0000        0.00         0.00           0.00
33930      Removal of donor heart/lung          C            C        0000     0.0000        0.00         0.00           0.00
33933      Prepare donor heart/lung             C            C        0000     0.0000        0.00         0.00           0.00
33935      Transplantation, heart/lung          C            C        0000     0.0000        0.00         0.00           0.00
33940      Removal of donor heart               C            C        0000     0.0000        0.00         0.00           0.00
33944      Prepare donor heart                  C            C        0000     0.0000        0.00         0.00           0.00
33945      Transplantation of heart             C            C        0000     0.0000        0.00         0.00           0.00
33960      External circulation assist          C            C        0000     0.0000        0.00         0.00           0.00
33961      External circulation assist          C            C        0000     0.0000        0.00         0.00           0.00
33967      Insert ia percut device              C            C        0000     0.0000        0.00         0.00           0.00
33968      Remove aortic assist device          C            C        0000     0.0000        0.00         0.00           0.00
33970      Aortic circulation assist            C            C        0000     0.0000        0.00         0.00           0.00
33971      Aortic circulation assist            C            C        0000     0.0000        0.00         0.00           0.00
33973      Insert balloon device                C            C        0000     0.0000        0.00         0.00           0.00
33974      Remove intra-aortic balloon          C            C        0000     0.0000        0.00         0.00           0.00
33975      Implant ventricular device           C            C        0000     0.0000        0.00         0.00           0.00
33976      Implant ventricular device           C            C        0000     0.0000        0.00         0.00           0.00
33977      Remove ventricular device            C            C        0000     0.0000        0.00         0.00           0.00
33978      Remove ventricular device            C            C        0000     0.0000        0.00         0.00           0.00
33979      Insert intracorporeal device         C            C        0000     0.0000        0.00         0.00           0.00
33980      Remove intracorporeal device         C            C        0000     0.0000        0.00         0.00           0.00
33999      Cardiac surgery procedure            T            1        0000     0.0000        0.00         0.00           0.00
34001      Removal of artery clot               C            C        0000     0.0000        0.00         0.00           0.00
34051      Removal of artery clot               C            C        0000     0.0000        0.00         0.00           0.00
34101      Removal of artery clot               T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
34111      Removal of arm artery clot           T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
34151      Removal of artery clot               C            C        0000     0.0000        0.00         0.00           0.00
34201      Removal of artery clot               T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
34203      Removal of leg artery clot           T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
34401      Removal of vein clot                 C            C        0000     0.0000        0.00         0.00           0.00
34421      Removal of vein clot                 T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
34451      Removal of vein clot                 C            C        0000     0.0000        0.00         0.00           0.00
34471      Removal of vein clot                 T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
34490      Removal of vein clot                 T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
34501      Repair valve, femoral vein           T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
34502      Reconstruct vena cava                C            C        0000     0.0000        0.00         0.00           0.00
34510      Transposition of vein valve          T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
34520      Cross-over vein graft                T            T        0088    36.5126      1,616.78     3,715.16       4,257.37

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 52 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

34530      Leg vein fusion                      T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
34800      Endovas aaa repr w/sm tube           C            C        0000     0.0000        0.00         0.00           0.00
34802      Endovas aaa repr w/2-p part          C            C        0000     0.0000        0.00         0.00           0.00
34803      Endovas aaa repr w/3-p part          C            C        0000     0.0000        0.00         0.00           0.00
34804      Endovas aaa repr w/1-p part          C            C        0000     0.0000        0.00         0.00           0.00
34805      Endovas aaa repr w/long tube         C            C        0000     0.0000        0.00         0.00           0.00
34808      Endovas iliac a device addon         C            C        0000     0.0000        0.00         0.00           0.00
34812      Xpose for endoprosth, femorl         C            C        0000     0.0000        0.00         0.00           0.00
34813      Femoral endovas graft add-on         C            C        0000     0.0000        0.00         0.00           0.00
34820      Xpose for endoprosth, iliac          C            C        0000     0.0000        0.00         0.00           0.00
34825      Endovasc extend prosth, init         C            C        0000     0.0000        0.00         0.00           0.00
34826      Endovasc exten prosth, add’l         C            C        0000     0.0000        0.00         0.00           0.00
34830      Open aortic tube prosth repr         C            C        0000     0.0000        0.00         0.00           0.00
34831      Open aortoiliac prosth repr          C            C        0000     0.0000        0.00         0.00           0.00
34832      Open aortofemor prosth repr          C            C        0000     0.0000        0.00         0.00           0.00
34833      Xpose for endoprosth, iliac          C            C        0000     0.0000        0.00         0.00           0.00
34834      Xpose, endoprosth, brachial          C            C        0000     0.0000        0.00         0.00           0.00
34900      Endovasc iliac repr w/graft          C            C        0000     0.0000        0.00         0.00           0.00
35001      Repair defect of artery              C            C        0000     0.0000        0.00         0.00           0.00
35002      Repair artery rupture, neck          C            C        0000     0.0000        0.00         0.00           0.00
35005      Repair defect of artery              C            C        0000     0.0000        0.00         0.00           0.00
35011      Repair defect of artery              T            T        0653    36.9427      1,635.82     3,758.92       4,307.52
35013      Repair artery rupture, arm           C            C        0000     0.0000        0.00         0.00           0.00
35021      Repair defect of artery              C            C        0000     0.0000        0.00         0.00           0.00
35022      Repair artery rupture, chest         C            C        0000     0.0000        0.00         0.00           0.00
35045      Repair defect of arm artery          C            C        0000     0.0000        0.00         0.00           0.00
35081      Repair defect of artery              C            C        0000     0.0000        0.00         0.00           0.00
35082      Repair artery rupture, aorta         C            C        0000     0.0000        0.00         0.00           0.00
35091      Repair defect of artery              C            C        0000     0.0000        0.00         0.00           0.00
35092      Repair artery rupture, aorta         C            C        0000     0.0000        0.00         0.00           0.00
35102      Repair defect of artery              C            C        0000     0.0000        0.00         0.00           0.00
35103      Repair artery rupture, groin         C            C        0000     0.0000        0.00         0.00           0.00
35111      Repair defect of artery              C            C        0000     0.0000        0.00         0.00           0.00
35112      Repair artery rupture,spleen         C            C        0000     0.0000        0.00         0.00           0.00
35121      Repair defect of artery              C            C        0000     0.0000        0.00         0.00           0.00
35122      Repair artery rupture, belly         C            C        0000     0.0000        0.00         0.00           0.00
35131      Repair defect of artery              C            C        0000     0.0000        0.00         0.00           0.00
35132      Repair artery rupture, groin         C            C        0000     0.0000        0.00         0.00           0.00
35141      Repair defect of artery              C            C        0000     0.0000        0.00         0.00           0.00
35142      Repair artery rupture, thigh         C            C        0000     0.0000        0.00         0.00           0.00
35151      Repair defect of artery              C            C        0000     0.0000        0.00         0.00           0.00
35152      Repair artery rupture, knee          C            C        0000     0.0000        0.00         0.00           0.00
35180      Repair blood vessel lesion           T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35182      Repair blood vessel lesion           C            C        0000     0.0000        0.00         0.00           0.00
35184      Repair blood vessel lesion           T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35188      Repair blood vessel lesion           T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
35189      Repair blood vessel lesion           C            C        0000     0.0000        0.00         0.00           0.00
35190      Repair blood vessel lesion           T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35201      Repair blood vessel lesion           T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35206      Repair blood vessel lesion           T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35207      Repair blood vessel lesion           T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
35211      Repair blood vessel lesion           C            C        0000     0.0000        0.00         0.00           0.00
35216      Repair blood vessel lesion           C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 53 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

35221      Repair blood vessel lesion           C            C        0000     0.0000        0.00         0.00           0.00
35226      Repair blood vessel lesion           T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35231      Repair blood vessel lesion           T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35236      Repair blood vessel lesion           T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35241      Repair blood vessel lesion           C            C        0000     0.0000        0.00         0.00           0.00
35246      Repair blood vessel lesion           C            C        0000     0.0000        0.00         0.00           0.00
35251      Repair blood vessel lesion           C            C        0000     0.0000        0.00         0.00           0.00
35256      Repair blood vessel lesion           T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35261      Repair blood vessel lesion           T            T        0653    36.9427      1,635.82     3,758.92       4,307.52
35266      Repair blood vessel lesion           T            T        0653    36.9427      1,635.82     3,758.92       4,307.52
35271      Repair blood vessel lesion           C            C        0000     0.0000        0.00         0.00           0.00
35276      Repair blood vessel lesion           C            C        0000     0.0000        0.00         0.00           0.00
35281      Repair blood vessel lesion           C            C        0000     0.0000        0.00         0.00           0.00
35286      Repair blood vessel lesion           T            T        0653    36.9427      1,635.82     3,758.92       4,307.52
35301      Rechanneling of artery               C            C        0000     0.0000        0.00         0.00           0.00
35311      Rechanneling of artery               C            C        0000     0.0000        0.00         0.00           0.00
35321      Rechanneling of artery               T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35331      Rechanneling of artery               C            C        0000     0.0000        0.00         0.00           0.00
35341      Rechanneling of artery               C            C        0000     0.0000        0.00         0.00           0.00
35351      Rechanneling of artery               C            C        0000     0.0000        0.00         0.00           0.00
35355      Rechanneling of artery               C            C        0000     0.0000        0.00         0.00           0.00
35361      Rechanneling of artery               C            C        0000     0.0000        0.00         0.00           0.00
35363      Rechanneling of artery               C            C        0000     0.0000        0.00         0.00           0.00
35371      Rechanneling of artery               C            C        0000     0.0000        0.00         0.00           0.00
35372      Rechanneling of artery               C            C        0000     0.0000        0.00         0.00           0.00
35381      Rechanneling of artery               C            C        0000     0.0000        0.00         0.00           0.00
35390      Reoperation, carotid add-on          C            C        0000     0.0000        0.00         0.00           0.00
35400      Angioscopy                           C            C        0000     0.0000        0.00         0.00           0.00
35450      Repair arterial blockage             C            C        0000     0.0000        0.00         0.00           0.00
35452      Repair arterial blockage             C            C        0000     0.0000        0.00         0.00           0.00
35454      Repair arterial blockage             C            C        0000     0.0000        0.00         0.00           0.00
35456      Repair arterial blockage             C            C        0000     0.0000        0.00         0.00           0.00
35458      Repair arterial blockage             T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35459      Repair arterial blockage             T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35460      Repair venous blockage               T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35470      Repair arterial blockage             T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35471      Repair arterial blockage             T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35472      Repair arterial blockage             T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35473      Repair arterial blockage             T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35474      Repair arterial blockage             T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35475      Repair arterial blockage             T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35476      Repair venous blockage               T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35480      Atherectomy, open                    C            C        0000     0.0000        0.00         0.00           0.00
35481      Atherectomy, open                    C            C        0000     0.0000        0.00         0.00           0.00
35482      Atherectomy, open                    C            C        0000     0.0000        0.00         0.00           0.00
35483      Atherectomy, open                    C            C        0000     0.0000        0.00         0.00           0.00
35484      Atherectomy, open                    T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35485      Atherectomy, open                    T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35490      Atherectomy, percutaneous            T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35491      Atherectomy, percutaneous            T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35492      Atherectomy, percutaneous            T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35493      Atherectomy, percutaneous            T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35494      Atherectomy, percutaneous            T            T        0081    42.2664      1,871.56     4,300.61       4,928.26

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 54 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

35495      Atherectomy, percutaneous            T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35500      Harvest vein for bypass              T            T        0081    42.2664      1,871.56     4,300.61       4,928.26
35501      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35506      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35507      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35508      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35509      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35510      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35511      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35512      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35515      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35516      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35518      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35521      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35522      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35525      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35526      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35531      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35533      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35536      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35541      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35546      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35548      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35549      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35551      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35556      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35558      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35560      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35563      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35565      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35566      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35571      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35572      Harvest femoropopliteal vein         N            N        0000     0.0000        0.00         0.00           0.00
35583      Vein bypass graft                    C            C        0000     0.0000        0.00         0.00           0.00
35585      Vein bypass graft                    C            C        0000     0.0000        0.00         0.00           0.00
35587      Vein bypass graft                    C            C        0000     0.0000        0.00         0.00           0.00
35600      Harvest artery for cabg              C            C        0000     0.0000        0.00         0.00           0.00
35601      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35606      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35612      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35616      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35621      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35623      Bypass graft, not vein               C            C        0000     0.0000        0.00         0.00           0.00
35626      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35631      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35636      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35641      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35642      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35645      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35646      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35647      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35650      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35651      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 55 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

35654      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35656      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35661      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35663      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35665      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35666      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35671      Artery bypass graft                  C            C        0000     0.0000        0.00         0.00           0.00
35681      Composite bypass graft               C            C        0000     0.0000        0.00         0.00           0.00
35682      Composite bypass graft               C            C        0000     0.0000        0.00         0.00           0.00
35683      Composite bypass graft               C            C        0000     0.0000        0.00         0.00           0.00
35685      Bypass graft patency/patch           T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35686      Bypass graft/av fist patency         T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35691      Arterial transposition               C            C        0000     0.0000        0.00         0.00           0.00
35693      Arterial transposition               C            C        0000     0.0000        0.00         0.00           0.00
35694      Arterial transposition               C            C        0000     0.0000        0.00         0.00           0.00
35695      Arterial transposition               C            C        0000     0.0000        0.00         0.00           0.00
35697      Reimplant artery each                C            C        0000     0.0000        0.00         0.00           0.00
35700      Reoperation, bypass graft            C            C        0000     0.0000        0.00         0.00           0.00
35701      Exploration, carotid artery          C            C        0000     0.0000        0.00         0.00           0.00
35721      Exploration, femoral artery          C            C        0000     0.0000        0.00         0.00           0.00
35741      Exploration popliteal artery         C            C        0000     0.0000        0.00         0.00           0.00
35761      Exploration of artery/vein           T            T        0115    36.9806      1,637.50     3,762.78       4,311.94
35800      Explore neck vessels                 C            C        0000     0.0000        0.00         0.00           0.00
35820      Explore chest vessels                C            C        0000     0.0000        0.00         0.00           0.00
35840      Explore abdominal vessels            C            C        0000     0.0000        0.00         0.00           0.00
35860      Explore limb vessels                 T            T        0093    23.3101      1,032.17     2,371.80       2,717.96
35870      Repair vessel graft defect           C            C        0000     0.0000        0.00         0.00           0.00
35875      Removal of clot in graft             T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
35876      Removal of clot in graft             T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
35879      Revise graft w/vein                  T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
35881      Revise graft w/vein                  T            T        0088    36.5126      1,616.78     3,715.16       4,257.37
35901      Excision, graft, neck                C            C        0000     0.0000        0.00         0.00           0.00
35903      Excision, graft, extremity           T            T        0115    36.9806      1,637.50     3,762.78       4,311.94
35905      Excision, graft, thorax              C            C        0000     0.0000        0.00         0.00           0.00
35907      Excision, graft, abdomen             C            C        0000     0.0000        0.00         0.00           0.00
36000      Place needle in vein                 N            N        0000     0.0000        0.00         0.00           0.00
36002      Pseudoaneurysm injection trt         S            S        0267     2.5543       113.10       259.90         297.83
36005      Injection ext venography             N            N        0000     0.0000        0.00         0.00           0.00
36010      Place catheter in vein               N            N        0000     0.0000        0.00         0.00           0.00
36011      Place catheter in vein               N            N        0000     0.0000        0.00         0.00           0.00
36012      Place catheter in vein               N            N        0000     0.0000        0.00         0.00           0.00
36013      Place catheter in artery             N            N        0000     0.0000        0.00         0.00           0.00
36014      Place catheter in artery             N            N        0000     0.0000        0.00         0.00           0.00
36015      Place catheter in artery             N            N        0000     0.0000        0.00         0.00           0.00
36100      Establish access to artery           N            N        0000     0.0000        0.00         0.00           0.00
36120      Establish access to artery           N            N        0000     0.0000        0.00         0.00           0.00
36140      Establish access to artery           N            N        0000     0.0000        0.00         0.00           0.00
36145      Artery to vein shunt                 N            N        0000     0.0000        0.00         0.00           0.00
36160      Establish access to aorta            N            N        0000     0.0000        0.00         0.00           0.00
36200      Place catheter in aorta              N            N        0000     0.0000        0.00         0.00           0.00
36215      Place catheter in artery             N            N        0000     0.0000        0.00         0.00           0.00
36216      Place catheter in artery             N            N        0000     0.0000        0.00         0.00           0.00
36217      Place catheter in artery             N            N        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 56 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

36218      Place catheter in artery             N            N        0000     0.0000         0.00        0.00           0.00
36245      Place catheter in artery             N            N        0000     0.0000         0.00        0.00           0.00
36246      Place catheter in artery             N            N        0000     0.0000         0.00        0.00           0.00
36247      Place catheter in artery             N            N        0000     0.0000         0.00        0.00           0.00
36248      Place catheter in artery             N            N        0000     0.0000         0.00        0.00           0.00
36260      Insertion of infusion pump           T            T        0623    27.1472       1,202.08    2,762.23       3,165.36
36261      Revision of infusion pump            T            T        0623    27.1472       1,202.08    2,762.23       3,165.36
36262      Removal of infusion pump             T            T        0622    21.2464        940.79     2,161.82       2,477.33
36299      Vessel injection procedure           N            1        0000     0.0000         0.00        0.00           0.00
36400      Bl draw < 3 yrs fem/jugular          N            N        0000     0.0000         0.00        0.00           0.00
36405      Bl draw < 3 yrs scalp vein           N            N        0000     0.0000         0.00        0.00           0.00
36406      Bl draw < 3 yrs other vein           N            N        0000     0.0000         0.00        0.00           0.00
36410      Non-routine bl draw > 3 yrs          N            N        0000     0.0000         0.00        0.00           0.00
36415      Routine venipuncture                 A            3        0000     0.0000         M01         M01            M01
36416      Capillary blood draw                 N            N        0000     0.0000         0.00        0.00           0.00
36420      Vein access cutdown < 1 yr           T            T        0035     0.0834         3.69        8.49           9.72
36425      Vein access cutdown > 1 yr           T            T        0035     0.0834         3.69        8.49           9.72
36430      Blood transfusion service            S            S        0110     3.6419        161.26      370.56         424.65
36440      Bl push transfuse, 2 yr or <         S            S        0110     3.6419        161.26      370.56         424.65
36450      Bl exchange/transfuse, nb            S            S        0110     3.6419        161.26      370.56         424.65
36455      Bl exchange/transfuse non-nb         S            S        0110     3.6419        161.26      370.56         424.65
36460      Transfusion service, fetal           S            S        0110     3.6419        161.26      370.56         424.65
36468      Injection(s), spider veins           T            1        0000     0.0000         0.00        0.00           0.00
36469      Injection(s), spider veins           T            1        0000     0.0000         0.00        0.00           0.00
36470      Injection therapy of vein            T            1        0000     0.0000         0.00        0.00           0.00
36471      Injection therapy of veins           T            1        0000     0.0000         0.00        0.00           0.00
36475      Endovenous rf, 1st vein              T            T        0091    28.8805       1,278.83    2,938.59       3,367.47
36476      Endovenous rf, vein add-on           T            T        0091    28.8805       1,278.83    2,938.59       3,367.47
36478      Endovenous laser, 1st vein           T            T        0091    28.8805       1,278.83    2,938.59       3,367.47
36479      Endovenous laser vein addon          T            T        0091    28.8805       1,278.83    2,938.59       3,367.47
36481      Insertion of catheter, vein          N            N        0000     0.0000         0.00        0.00           0.00
36500      Insertion of catheter, vein          N            N        0000     0.0000         0.00        0.00           0.00
36510      Insertion of catheter, vein          N            N        0000     0.0000         0.00        0.00           0.00
36511      Apheresis wbc                        S            S        0111    12.0768        534.76     1,228.81       1,408.15
36512      Apheresis rbc                        S            S        0111    12.0768        534.76     1,228.81       1,408.15
36513      Apheresis platelets                  S            S        0111    12.0768        534.76     1,228.81       1,408.15
36514      Apheresis plasma                     S            S        0111    12.0768        534.76     1,228.81       1,408.15
36515      Apheresis, adsorp/reinfuse           S            S        0112    26.3750       1,167.89    2,683.66       3,075.33
36516      Apheresis, selective                 S            S        0112    26.3750       1,167.89    2,683.66       3,075.33
36522      Photopheresis                        S            S        0112    26.3750       1,167.89    2,683.66       3,075.33
36540      Collect blood venous device          N            N        0000     0.0000         0.00        0.00           0.00
36550      Declot vascular device               T            T        0676     2.2742        100.70      231.40         265.17
36555      Insert non-tunnel cv cath            T            T        0621     8.2313        364.48      837.53         959.77
36556      Insert non-tunnel cv cath            T            T        0621     8.2313        364.48      837.53         959.77
36557      Insert tunneled cv cath              T            T        0622    21.2464        940.79     2,161.82       2,477.33
36558      Insert tunneled cv cath              T            T        0622    21.2464        940.79     2,161.82       2,477.33
36560      Insert tunneled cv cath              T            T        0623    27.1472       1,202.08    2,762.23       3,165.36
36561      Insert tunneled cv cath              T            T        0623    27.1472       1,202.08    2,762.23       3,165.36
36563      Insert tunneled cv cath              T            T        0623    27.1472       1,202.08    2,762.23       3,165.36
36565      Insert tunneled cv cath              T            T        0623    27.1472       1,202.08    2,762.23       3,165.36
36566      Insert tunneled cv cath              T            T        1564    79.8172   *   3,534.31    8,121.40       9,306.69
36568      Insert picc cath                     T            T        0621     8.2313        364.48      837.53         959.77
36569      Insert picc cath                     T            T        0621     8.2313        364.48      837.53         959.77

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 57 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 58 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 59 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

38206      Harvest auto stem cells              S            S        0111    12.0768       534.76      1,228.81       1,408.15
38207      Cryopreserve stem cells              E            3        0000     0.0000        M01          M01            M01
38208      Thaw preserved stem cells            E            3        0000     0.0000        M01          M01            M01
38209      Wash harvest stem cells              E            1        0000     0.0000        0.00         0.00           0.00
38210      T-cell depletion of harvest          E            1        0000     0.0000        0.00         0.00           0.00
38211      Tumor cell deplete of harvst         E            1        0000     0.0000        0.00         0.00           0.00
38212      Rbc depletion of harvest             E            1        0000     0.0000        0.00         0.00           0.00
38213      Platelet deplete of harvest          E            1        0000     0.0000        0.00         0.00           0.00
38214      Volume deplete of harvest            E            1        0000     0.0000        0.00         0.00           0.00
38215      Harvest stem cell concentrte         E            1        0000     0.0000        0.00         0.00           0.00
38220      Bone marrow aspiration               T            T        0003     2.6756       118.48       272.24         311.97
38221      Bone marrow biopsy                   T            T        0003     2.6756       118.48       272.24         311.97
38230      Bone marrow collection               S            S        0123    24.4820      1,084.06     2,491.04       2,854.60
38240      Bone marrow/stem transplant          S            S        0123    24.4820      1,084.06     2,491.04       2,854.60
38241      Bone marrow/stem transplant          S            S        0123    24.4820      1,084.06     2,491.04       2,854.60
38242      Lymphocyte infuse transplant         S            S        0111    12.0768       534.76      1,228.81       1,408.15
38300      Drainage, lymph node lesion          T            T        0007    11.6717       516.82      1,187.60       1,360.92
38305      Drainage, lymph node lesion          T            T        0008    16.2953       721.56      1,658.05       1,900.03
38308      Incision of lymph channels           T            T        0113    21.4112       948.09      2,178.59       2,496.55
38380      Thoracic duct procedure              C            C        0000     0.0000        0.00         0.00           0.00
38381      Thoracic duct procedure              C            C        0000     0.0000        0.00         0.00           0.00
38382      Thoracic duct procedure              C            C        0000     0.0000        0.00         0.00           0.00
38500      Biopsy/removal, lymph nodes          T            T        0113    21.4112       948.09      2,178.59       2,496.55
38505      Needle biopsy, lymph nodes           T            T        0005     3.5834       158.67       364.61         417.82
38510      Biopsy/removal, lymph nodes          T            T        0113    21.4112       948.09      2,178.59       2,496.55
38520      Biopsy/removal, lymph nodes          T            T        0113    21.4112       948.09      2,178.59       2,496.55
38525      Biopsy/removal, lymph nodes          T            T        0113    21.4112       948.09      2,178.59       2,496.55
38530      Biopsy/removal, lymph nodes          T            T        0113    21.4112       948.09      2,178.59       2,496.55
38542      Explore deep node(s), neck           T            T        0114    40.4596      1,791.55     4,116.76       4,717.59
38550      Removal, neck/armpit lesion          T            T        0113    21.4112       948.09      2,178.59       2,496.55
38555      Removal, neck/armpit lesion          T            T        0113    21.4112       948.09      2,178.59       2,496.55
38562      Removal, pelvic lymph nodes          C            C        0000     0.0000        0.00         0.00           0.00
38564      Removal, abdomen lymph nodes         C            C        0000     0.0000        0.00         0.00           0.00
38570      Laparoscopy, lymph node biop         T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
38571      Laparoscopy, lymphadenectomy         T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
38572      Laparoscopy, lymphadenectomy         T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
38589      Laparoscope proc, lymphatic          T            1        0000     0.0000        0.00         0.00           0.00
38700      Removal of lymph nodes, neck         T            T        0113    21.4112       948.09      2,178.59       2,496.55
38720      Removal of lymph nodes, neck         T            T        0113    21.4112       948.09      2,178.59       2,496.55
38724      Removal of lymph nodes, neck         C            C        0000     0.0000        0.00         0.00           0.00
38740      Remove armpit lymph nodes            T            T        0114    40.4596      1,791.55     4,116.76       4,717.59
38745      Remove armpit lymph nodes            T            T        0114    40.4596      1,791.55     4,116.76       4,717.59
38746      Remove thoracic lymph nodes          C            C        0000     0.0000        0.00         0.00           0.00
38747      Remove abdominal lymph nodes         C            C        0000     0.0000        0.00         0.00           0.00
38760      Remove groin lymph nodes             T            T        0113    21.4112       948.09      2,178.59       2,496.55
38765      Remove groin lymph nodes             C            C        0000     0.0000        0.00         0.00           0.00
38770      Remove pelvis lymph nodes            C            C        0000     0.0000        0.00         0.00           0.00
38780      Remove abdomen lymph nodes           C            C        0000     0.0000        0.00         0.00           0.00
38790      Inject for lymphatic x-ray           N            N        0000     0.0000        0.00         0.00           0.00
38792      Identify sentinel node               N            N        0000     0.0000        0.00         0.00           0.00
38794      Access thoracic lymph duct           N            N        0000     0.0000        0.00         0.00           0.00
38999      Blood/lymph system procedure         S            1        0000     0.0000        0.00         0.00           0.00
39000      Exploration of chest                 C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 60 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

39010      Exploration of chest                 C            C        0000     0.0000        0.00         0.00           0.00
39200      Removal chest lesion                 C            C        0000     0.0000        0.00         0.00           0.00
39220      Removal chest lesion                 C            C        0000     0.0000        0.00         0.00           0.00
39400      Visualization of chest               T            T        0069    30.9541      1,370.65     3,149.58       3,609.25
39499      Chest procedure                      C            1        0000     0.0000        0.00         0.00           0.00
39501      Repair diaphragm laceration          C            C        0000     0.0000        0.00         0.00           0.00
39502      Repair paraesophageal hernia         C            C        0000     0.0000        0.00         0.00           0.00
39503      Repair of diaphragm hernia           C            C        0000     0.0000        0.00         0.00           0.00
39520      Repair of diaphragm hernia           C            C        0000     0.0000        0.00         0.00           0.00
39530      Repair of diaphragm hernia           C            C        0000     0.0000        0.00         0.00           0.00
39531      Repair of diaphragm hernia           C            C        0000     0.0000        0.00         0.00           0.00
39540      Repair of diaphragm hernia           C            C        0000     0.0000        0.00         0.00           0.00
39541      Repair of diaphragm hernia           C            C        0000     0.0000        0.00         0.00           0.00
39545      Revision of diaphragm                C            C        0000     0.0000        0.00         0.00           0.00
39560      Resect diaphragm, simple             C            C        0000     0.0000        0.00         0.00           0.00
39561      Resect diaphragm, complex            C            C        0000     0.0000        0.00         0.00           0.00
39599      Diaphragm surgery procedure          C            1        0000     0.0000        0.00         0.00           0.00
40490      Biopsy of lip                        T            T        0251     2.0789        92.05       211.53         242.40
40500      Partial excision of lip              T            T        0253    16.0740       711.76      1,635.53       1,874.23
40510      Partial excision of lip              T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
40520      Partial excision of lip              T            T        0253    16.0740       711.76      1,635.53       1,874.23
40525      Reconstruct lip with flap            T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
40527      Reconstruct lip with flap            T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
40530      Partial removal of lip               T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
40650      Repair lip                           T            T        0252     8.1033       358.81       824.51         944.84
40652      Repair lip                           T            T        0252     8.1033       358.81       824.51         944.84
40654      Repair lip                           T            T        0252     8.1033       358.81       824.51         944.84
40700      Repair cleft lip/nasal               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
40701      Repair cleft lip/nasal               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
40702      Repair cleft lip/nasal               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
40720      Repair cleft lip/nasal               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
40761      Repair cleft lip/nasal               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
40799      Lip surgery procedure                T            1        0000     0.0000        0.00         0.00           0.00
40800      Drainage of mouth lesion             T            T        0251     2.0789        92.05       211.53         242.40
40801      Drainage of mouth lesion             T            T        0252     8.1033       358.81       824.51         944.84
40804      Removal, foreign body, mouth         X            X        0340     0.6137        27.17        62.44          71.56
40805      Removal, foreign body, mouth         T            T        0252     8.1033       358.81       824.51         944.84
40806      Incision of lip fold                 T            T        0251     2.0789        92.05       211.53         242.40
40808      Biopsy of mouth lesion               T            T        0251     2.0789        92.05       211.53         242.40
40810      Excision of mouth lesion             T            T        0253    16.0740       711.76      1,635.53       1,874.23
40812      Excise/repair mouth lesion           T            T        0253    16.0740       711.76      1,635.53       1,874.23
40814      Excise/repair mouth lesion           T            T        0253    16.0740       711.76      1,635.53       1,874.23
40816      Excision of mouth lesion             T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
40818      Excise oral mucosa for graft         T            T        0251     2.0789        92.05       211.53         242.40
40819      Excise lip or cheek fold             T            T        0252     8.1033       358.81       824.51         944.84
40820      Treatment of mouth lesion            T            T        0253    16.0740       711.76      1,635.53       1,874.23
40830      Repair mouth laceration              T            T        0251     2.0789        92.05       211.53         242.40
40831      Repair mouth laceration              T            T        0252     8.1033       358.81       824.51         944.84
40840      Reconstruction of mouth              T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
40842      Reconstruction of mouth              T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
40843      Reconstruction of mouth              T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
40844      Reconstruction of mouth              T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
40845      Reconstruction of mouth              T            T        0256    37.0000      1,638.36     3,764.75       4,314.20

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 61 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

40899      Mouth surgery procedure              T            1        0000     0.0000        0.00         0.00           0.00
41000      Drainage of mouth lesion             T            T        0253    16.0740       711.76      1,635.53       1,874.23
41005      Drainage of mouth lesion             T            T        0251     2.0789        92.05       211.53         242.40
41006      Drainage of mouth lesion             T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
41007      Drainage of mouth lesion             T            T        0253    16.0740       711.76      1,635.53       1,874.23
41008      Drainage of mouth lesion             T            T        0253    16.0740       711.76      1,635.53       1,874.23
41009      Drainage of mouth lesion             T            T        0251     2.0789        92.05       211.53         242.40
41010      Incision of tongue fold              T            T        0252     8.1033       358.81       824.51         944.84
41015      Drainage of mouth lesion             T            T        0251     2.0789        92.05       211.53         242.40
41016      Drainage of mouth lesion             T            T        0252     8.1033       358.81       824.51         944.84
41017      Drainage of mouth lesion             T            T        0252     8.1033       358.81       824.51         944.84
41018      Drainage of mouth lesion             T            T        0252     8.1033       358.81       824.51         944.84
41100      Biopsy of tongue                     T            T        0252     8.1033       358.81       824.51         944.84
41105      Biopsy of tongue                     T            T        0253    16.0740       711.76      1,635.53       1,874.23
41108      Biopsy of floor of mouth             T            T        0252     8.1033       358.81       824.51         944.84
41110      Excision of tongue lesion            T            T        0253    16.0740       711.76      1,635.53       1,874.23
41112      Excision of tongue lesion            T            T        0253    16.0740       711.76      1,635.53       1,874.23
41113      Excision of tongue lesion            T            T        0253    16.0740       711.76      1,635.53       1,874.23
41114      Excision of tongue lesion            T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
41115      Excision of tongue fold              T            T        0252     8.1033       358.81       824.51         944.84
41116      Excision of mouth lesion             T            T        0253    16.0740       711.76      1,635.53       1,874.23
41120      Partial removal of tongue            T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
41130      Partial removal of tongue            C            C        0000     0.0000        0.00         0.00           0.00
41135      Tongue and neck surgery              C            C        0000     0.0000        0.00         0.00           0.00
41140      Removal of tongue                    C            C        0000     0.0000        0.00         0.00           0.00
41145      Tongue removal, neck surgery         C            C        0000     0.0000        0.00         0.00           0.00
41150      Tongue, mouth, jaw surgery           C            C        0000     0.0000        0.00         0.00           0.00
41153      Tongue, mouth, neck surgery          C            C        0000     0.0000        0.00         0.00           0.00
41155      Tongue, jaw, & neck surgery          C            C        0000     0.0000        0.00         0.00           0.00
41250      Repair tongue laceration             T            T        0251     2.0789        92.05       211.53         242.40
41251      Repair tongue laceration             T            T        0251     2.0789        92.05       211.53         242.40
41252      Repair tongue laceration             T            T        0252     8.1033       358.81       824.51         944.84
41500      Fixation of tongue                   T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
41510      Tongue to lip surgery                T            T        0253    16.0740       711.76      1,635.53       1,874.23
41520      Reconstruction, tongue fold          T            T        0252     8.1033       358.81       824.51         944.84
41599      Tongue and mouth surgery             T            1        0000     0.0000        0.00         0.00           0.00
41800      Drainage of gum lesion               T            T        0251     2.0789        92.05       211.53         242.40
41805      Removal foreign body, gum            T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
41806      Removal foreign body,jawbone         T            T        0253    16.0740       711.76      1,635.53       1,874.23
41820      Excision, gum, each quadrant         T            T        0252     8.1033       358.81       824.51         944.84
41821      Excision of gum flap                 T            T        0252     8.1033       358.81       824.51         944.84
41822      Excision of gum lesion               T            T        0253    16.0740       711.76      1,635.53       1,874.23
41823      Excision of gum lesion               T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
41825      Excision of gum lesion               T            T        0253    16.0740       711.76      1,635.53       1,874.23
41826      Excision of gum lesion               T            T        0253    16.0740       711.76      1,635.53       1,874.23
41827      Excision of gum lesion               T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
41828      Excision of gum lesion               T            T        0253    16.0740       711.76      1,635.53       1,874.23
41830      Removal of gum tissue                T            T        0253    16.0740       711.76      1,635.53       1,874.23
41850      Treatment of gum lesion              T            T        0253    16.0740       711.76      1,635.53       1,874.23
41870      Gum graft                            T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
41872      Repair gum                           T            T        0253    16.0740       711.76      1,635.53       1,874.23
41874      Repair tooth socket                  T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
41899      Dental surgery procedure             T            2        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 62 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

42000      Drainage mouth roof lesion           T            T        0251     2.0789        92.05       211.53         242.40
42100      Biopsy roof of mouth                 T            T        0252     8.1033       358.81       824.51         944.84
42104      Excision lesion, mouth roof          T            T        0253    16.0740       711.76      1,635.53       1,874.23
42106      Excision lesion, mouth roof          T            T        0253    16.0740       711.76      1,635.53       1,874.23
42107      Excision lesion, mouth roof          T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
42120      Remove palate/lesion                 T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42140      Excision of uvula                    T            T        0252     8.1033       358.81       824.51         944.84
42145      Repair palate, pharynx/uvula         T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
42160      Treatment mouth roof lesion          T            T        0253    16.0740       711.76      1,635.53       1,874.23
42180      Repair palate                        T            T        0251     2.0789        92.05       211.53         242.40
42182      Repair palate                        T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42200      Reconstruct cleft palate             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42205      Reconstruct cleft palate             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42210      Reconstruct cleft palate             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42215      Reconstruct cleft palate             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42220      Reconstruct cleft palate             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42225      Reconstruct cleft palate             T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42226      Lengthening of palate                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42227      Lengthening of palate                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42235      Repair palate                        T            T        0253    16.0740       711.76      1,635.53       1,874.23
42260      Repair nose to lip fistula           T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
42280      Preparation, palate mold             T            T        0251     2.0789        92.05       211.53         242.40
42281      Insertion, palate prosthesis         T            T        0253    16.0740       711.76      1,635.53       1,874.23
42299      Palate/uvula surgery                 T            1        0000     0.0000        0.00         0.00           0.00
42300      Drainage of salivary gland           T            T        0253    16.0740       711.76      1,635.53       1,874.23
42305      Drainage of salivary gland           T            T        0253    16.0740       711.76      1,635.53       1,874.23
42310      Drainage of salivary gland           T            T        0251     2.0789        92.05       211.53         242.40
42320      Drainage of salivary gland           T            T        0251     2.0789        92.05       211.53         242.40
42330      Removal of salivary stone            T            T        0253    16.0740       711.76      1,635.53       1,874.23
42335      Removal of salivary stone            T            T        0253    16.0740       711.76      1,635.53       1,874.23
42340      Removal of salivary stone            T            T        0253    16.0740       711.76      1,635.53       1,874.23
42400      Biopsy of salivary gland             T            T        0005     3.5834       158.67       364.61         417.82
42405      Biopsy of salivary gland             T            T        0253    16.0740       711.76      1,635.53       1,874.23
42408      Excision of salivary cyst            T            T        0253    16.0740       711.76      1,635.53       1,874.23
42409      Drainage of salivary cyst            T            T        0253    16.0740       711.76      1,635.53       1,874.23
42410      Excise parotid gland/lesion          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42415      Excise parotid gland/lesion          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42420      Excise parotid gland/lesion          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42425      Excise parotid gland/lesion          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42426      Excise parotid gland/lesion          C            C        0000     0.0000        0.00         0.00           0.00
42440      Excise submaxillary gland            T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42450      Excise sublingual gland              T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
42500      Repair salivary duct                 T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
42505      Repair salivary duct                 T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42507      Parotid duct diversion               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42508      Parotid duct diversion               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42509      Parotid duct diversion               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42510      Parotid duct diversion               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42550      Injection for salivary x-ray         N            N        0000     0.0000        0.00         0.00           0.00
42600      Closure of salivary fistula          T            T        0253    16.0740       711.76      1,635.53       1,874.23
42650      Dilation of salivary duct            T            T        0252     8.1033       358.81       824.51         944.84
42660      Dilation of salivary duct            T            T        0251     2.0789        92.05       211.53         242.40
42665      Ligation of salivary duct            T            T        0254    23.3114      1,032.23     2,371.93       2,718.11

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 63 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

42699      Salivary surgery procedure           T            1        0000     0.0000        0.00         0.00           0.00
42700      Drainage of tonsil abscess           T            T        0251     2.0789        92.05       211.53         242.40
42720      Drainage of throat abscess           T            T        0253    16.0740       711.76      1,635.53       1,874.23
42725      Drainage of throat abscess           T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42800      Biopsy of throat                     T            T        0253    16.0740       711.76      1,635.53       1,874.23
42802      Biopsy of throat                     T            T        0253    16.0740       711.76      1,635.53       1,874.23
42804      Biopsy of upper nose/throat          T            T        0253    16.0740       711.76      1,635.53       1,874.23
42806      Biopsy of upper nose/throat          T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
42808      Excise pharynx lesion                T            T        0253    16.0740       711.76      1,635.53       1,874.23
42809      Remove pharynx foreign body          X            X        0340     0.6137        27.17        62.44          71.56
42810      Excision of neck cyst                T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
42815      Excision of neck cyst                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42820      Remove tonsils and adenoids          T            T        0258    21.8761       968.67      2,225.89       2,550.75
42821      Remove tonsils and adenoids          T            T        0258    21.8761       968.67      2,225.89       2,550.75
42825      Removal of tonsils                   T            T        0258    21.8761       968.67      2,225.89       2,550.75
42826      Removal of tonsils                   T            T        0258    21.8761       968.67      2,225.89       2,550.75
42830      Removal of adenoids                  T            T        0258    21.8761       968.67      2,225.89       2,550.75
42831      Removal of adenoids                  T            T        0258    21.8761       968.67      2,225.89       2,550.75
42835      Removal of adenoids                  T            T        0258    21.8761       968.67      2,225.89       2,550.75
42836      Removal of adenoids                  T            T        0258    21.8761       968.67      2,225.89       2,550.75
42842      Extensive surgery of throat          T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
42844      Extensive surgery of throat          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42845      Extensive surgery of throat          C            C        0000     0.0000        0.00         0.00           0.00
42860      Excision of tonsil tags              T            T        0258    21.8761       968.67      2,225.89       2,550.75
42870      Excision of lingual tonsil           T            T        0258    21.8761       968.67      2,225.89       2,550.75
42890      Partial removal of pharynx           T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42892      Revision of pharyngeal walls         T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42894      Revision of pharyngeal walls         C            C        0000     0.0000        0.00         0.00           0.00
42900      Repair throat wound                  T            T        0252     8.1033       358.81       824.51         944.84
42950      Reconstruction of throat             T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
42953      Repair throat, esophagus             C            C        0000     0.0000        0.00         0.00           0.00
42955      Surgical opening of throat           T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
42960      Control throat bleeding              T            T        0250     1.2241        54.20       124.55         142.73
42961      Control throat bleeding              C            C        0000     0.0000        0.00         0.00           0.00
42962      Control throat bleeding              T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
42970      Control nose/throat bleeding         T            T        0250     1.2241        54.20       124.55         142.73
42971      Control nose/throat bleeding         C            C        0000     0.0000        0.00         0.00           0.00
42972      Control nose/throat bleeding         T            T        0253    16.0740       711.76      1,635.53       1,874.23
42999      Throat surgery procedure             T            1        0000     0.0000        0.00         0.00           0.00
43020      Incision of esophagus                T            T        0252     8.1033       358.81       824.51         944.84
43030      Throat muscle surgery                T            T        0253    16.0740       711.76      1,635.53       1,874.23
43045      Incision of esophagus                C            C        0000     0.0000        0.00         0.00           0.00
43100      Excision of esophagus lesion         C            C        0000     0.0000        0.00         0.00           0.00
43101      Excision of esophagus lesion         C            C        0000     0.0000        0.00         0.00           0.00
43107      Removal of esophagus                 C            C        0000     0.0000        0.00         0.00           0.00
43108      Removal of esophagus                 C            C        0000     0.0000        0.00         0.00           0.00
43112      Removal of esophagus                 C            C        0000     0.0000        0.00         0.00           0.00
43113      Removal of esophagus                 C            C        0000     0.0000        0.00         0.00           0.00
43116      Partial removal of esophagus         C            C        0000     0.0000        0.00         0.00           0.00
43117      Partial removal of esophagus         C            C        0000     0.0000        0.00         0.00           0.00
43118      Partial removal of esophagus         C            C        0000     0.0000        0.00         0.00           0.00
43121      Partial removal of esophagus         C            C        0000     0.0000        0.00         0.00           0.00
43122      Partial removal of esophagus         C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 64 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

43123      Partial removal of esophagus         C            C        0000     0.0000        0.00         0.00           0.00
43124      Removal of esophagus                 C            C        0000     0.0000        0.00         0.00           0.00
43130      Removal of esophagus pouch           T            T        0254    23.3114      1,032.23     2,371.93       2,718.11
43135      Removal of esophagus pouch           C            C        0000     0.0000        0.00         0.00           0.00
43200      Esophagus endoscopy                  T            T        0141     8.0662       357.17       820.74         940.52
43201      Esoph scope w/submucous inj          T            T        0141     8.0662       357.17       820.74         940.52
43202      Esophagus endoscopy, biopsy          T            T        0141     8.0662       357.17       820.74         940.52
43204      Esoph scope w/sclerosis inj          T            T        0141     8.0662       357.17       820.74         940.52
43205      Esophagus endoscopy/ligation         T            T        0141     8.0662       357.17       820.74         940.52
43215      Esophagus endoscopy                  T            T        0141     8.0662       357.17       820.74         940.52
43216      Esophagus endoscopy/lesion           T            T        0141     8.0662       357.17       820.74         940.52
43217      Esophagus endoscopy                  T            T        0141     8.0662       357.17       820.74         940.52
43219      Esophagus endoscopy                  T            T        0384    26.8955      1,190.93     2,736.62       3,136.02
43220      Esoph endoscopy, dilation            T            T        0141     8.0662       357.17       820.74         940.52
43226      Esoph endoscopy, dilation            T            T        0141     8.0662       357.17       820.74         940.52
43227      Esoph endoscopy, repair              T            T        0141     8.0662       357.17       820.74         940.52
43228      Esoph endoscopy, ablation            T            T        0422    24.0525      1,065.04     2,447.34       2,804.52
43231      Esoph endoscopy w/us exam            T            T        0141     8.0662       357.17       820.74         940.52
43232      Esoph endoscopy w/us fn bx           T            T        0141     8.0662       357.17       820.74         940.52
43234      Upper GI endoscopy, exam             T            T        0141     8.0662       357.17       820.74         940.52
43235      Uppr gi endoscopy, diagnosis         T            T        0141     8.0662       357.17       820.74         940.52
43236      Uppr gi scope w/submuc inj           T            T        0141     8.0662       357.17       820.74         940.52
43237      Endoscopic us exam, esoph            T            T        0141     8.0662       357.17       820.74         940.52
43238      Uppr gi endoscopy w/us fn bx         T            T        0141     8.0662       357.17       820.74         940.52
43239      Upper GI endoscopy, biopsy           T            T        0141     8.0662       357.17       820.74         940.52
43240      Esoph endoscope w/drain cyst         T            T        0141     8.0662       357.17       820.74         940.52
43241      Upper GI endoscopy with tube         T            T        0141     8.0662       357.17       820.74         940.52
43242      Uppr gi endoscopy w/us fn bx         T            T        0141     8.0662       357.17       820.74         940.52
43243      Upper gi endoscopy & inject          T            T        0141     8.0662       357.17       820.74         940.52
43244      Upper GI endoscopy/ligation          T            T        0141     8.0662       357.17       820.74         940.52
43245      Uppr gi scope dilate strictr         T            T        0141     8.0662       357.17       820.74         940.52
43246      Place gastrostomy tube               T            T        0141     8.0662       357.17       820.74         940.52
43247      Operative upper GI endoscopy         T            T        0141     8.0662       357.17       820.74         940.52
43248      Uppr gi endoscopy/guide wire         T            T        0141     8.0662       357.17       820.74         940.52
43249      Esoph endoscopy, dilation            T            T        0141     8.0662       357.17       820.74         940.52
43250      Upper GI endoscopy/tumor             T            T        0141     8.0662       357.17       820.74         940.52
43251      Operative upper GI endoscopy         T            T        0141     8.0662       357.17       820.74         940.52
43255      Operative upper GI endoscopy         T            T        0141     8.0662       357.17       820.74         940.52
43256      Uppr gi endoscopy w/stent            T            T        0384    26.8955      1,190.93     2,736.62       3,136.02
43257      Uppr gi scope w/thrml txmnt          T            T        0422    24.0525      1,065.04     2,447.34       2,804.52
43258      Operative upper GI endoscopy         T            T        0141     8.0662       357.17       820.74         940.52
43259      Endoscopic ultrasound exam           T            T        0141     8.0662       357.17       820.74         940.52
43260      Endo cholangiopancreatograph         T            T        0151    18.6171       824.37      1,894.29       2,170.75
43261      Endo cholangiopancreatograph         T            T        0151    18.6171       824.37      1,894.29       2,170.75
43262      Endo cholangiopancreatograph         T            T        0151    18.6171       824.37      1,894.29       2,170.75
43263      Endo cholangiopancreatograph         T            T        0151    18.6171       824.37      1,894.29       2,170.75
43264      Endo cholangiopancreatograph         T            T        0151    18.6171       824.37      1,894.29       2,170.75
43265      Endo cholangiopancreatograph         T            T        0151    18.6171       824.37      1,894.29       2,170.75
43267      Endo cholangiopancreatograph         T            T        0151    18.6171       824.37      1,894.29       2,170.75
43268      Endo cholangiopancreatograph         T            T        0384    26.8955      1,190.93     2,736.62       3,136.02
43269      Endo cholangiopancreatograph         T            T        0384    26.8955      1,190.93     2,736.62       3,136.02
43271      Endo cholangiopancreatograph         T            T        0151    18.6171       824.37      1,894.29       2,170.75
43272      Endo cholangiopancreatograph         T            T        0151    18.6171       824.37      1,894.29       2,170.75

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 65 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

43280      Laparoscopy, fundoplasty             T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
43289      Laparoscope proc, esoph              T            1        0000     0.0000        0.00         0.00           0.00
43300      Repair of esophagus                  C            C        0000     0.0000        0.00         0.00           0.00
43305      Repair esophagus and fistula         C            C        0000     0.0000        0.00         0.00           0.00
43310      Repair of esophagus                  C            C        0000     0.0000        0.00         0.00           0.00
43312      Repair esophagus and fistula         C            C        0000     0.0000        0.00         0.00           0.00
43313      Esophagoplasty congenital            C            C        0000     0.0000        0.00         0.00           0.00
43314      Tracheo-esophagoplasty cong          C            C        0000     0.0000        0.00         0.00           0.00
43320      Fuse esophagus & stomach             C            C        0000     0.0000        0.00         0.00           0.00
43324      Revise esophagus & stomach           C            C        0000     0.0000        0.00         0.00           0.00
43325      Revise esophagus & stomach           C            C        0000     0.0000        0.00         0.00           0.00
43326      Revise esophagus & stomach           C            C        0000     0.0000        0.00         0.00           0.00
43330      Repair of esophagus                  C            C        0000     0.0000        0.00         0.00           0.00
43331      Repair of esophagus                  C            C        0000     0.0000        0.00         0.00           0.00
43340      Fuse esophagus & intestine           C            C        0000     0.0000        0.00         0.00           0.00
43341      Fuse esophagus & intestine           C            C        0000     0.0000        0.00         0.00           0.00
43350      Surgical opening, esophagus          C            C        0000     0.0000        0.00         0.00           0.00
43351      Surgical opening, esophagus          C            C        0000     0.0000        0.00         0.00           0.00
43352      Surgical opening, esophagus          C            C        0000     0.0000        0.00         0.00           0.00
43360      Gastrointestinal repair              C            C        0000     0.0000        0.00         0.00           0.00
43361      Gastrointestinal repair              C            C        0000     0.0000        0.00         0.00           0.00
43400      Ligate esophagus veins               C            C        0000     0.0000        0.00         0.00           0.00
43401      Esophagus surgery for veins          C            C        0000     0.0000        0.00         0.00           0.00
43405      Ligate/staple esophagus              C            C        0000     0.0000        0.00         0.00           0.00
43410      Repair esophagus wound               C            C        0000     0.0000        0.00         0.00           0.00
43415      Repair esophagus wound               C            C        0000     0.0000        0.00         0.00           0.00
43420      Repair esophagus opening             C            C        0000     0.0000        0.00         0.00           0.00
43425      Repair esophagus opening             C            C        0000     0.0000        0.00         0.00           0.00
43450      Dilate esophagus                     T            T        0140     5.2970       234.55       538.97         617.63
43453      Dilate esophagus                     T            T        0140     5.2970       234.55       538.97         617.63
43456      Dilate esophagus                     T            T        0140     5.2970       234.55       538.97         617.63
43458      Dilate esophagus                     T            T        0140     5.2970       234.55       538.97         617.63
43460      Pressure treatment esophagus         C            C        0000     0.0000        0.00         0.00           0.00
43496      Free jejunum flap, microvasc         C            C        0000     0.0000        0.00         0.00           0.00
43499      Esophagus surgery procedure          T            1        0000     0.0000        0.00         0.00           0.00
43500      Surgical opening of stomach          C            C        0000     0.0000        0.00         0.00           0.00
43501      Surgical repair of stomach           C            C        0000     0.0000        0.00         0.00           0.00
43502      Surgical repair of stomach           C            C        0000     0.0000        0.00         0.00           0.00
43510      Surgical opening of stomach          T            T        0141     8.0662       357.17       820.74         940.52
43520      Incision of pyloric muscle           C            C        0000     0.0000        0.00         0.00           0.00
43600      Biopsy of stomach                    T            T        0141     8.0662       357.17       820.74         940.52
43605      Biopsy of stomach                    C            C        0000     0.0000        0.00         0.00           0.00
43610      Excision of stomach lesion           C            C        0000     0.0000        0.00         0.00           0.00
43611      Excision of stomach lesion           C            C        0000     0.0000        0.00         0.00           0.00
43620      Removal of stomach                   C            C        0000     0.0000        0.00         0.00           0.00
43621      Removal of stomach                   C            C        0000     0.0000        0.00         0.00           0.00
43622      Removal of stomach                   C            C        0000     0.0000        0.00         0.00           0.00
43631      Removal of stomach, partial          C            C        0000     0.0000        0.00         0.00           0.00
43632      Removal of stomach, partial          C            C        0000     0.0000        0.00         0.00           0.00
43633      Removal of stomach, partial          C            C        0000     0.0000        0.00         0.00           0.00
43634      Removal of stomach, partial          C            C        0000     0.0000        0.00         0.00           0.00
43635      Removal of stomach, partial          C            C        0000     0.0000        0.00         0.00           0.00
43640      Vagotomy & pylorus repair            C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 66 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

43641      Vagotomy & pylorus repair            C            C        0000     0.0000        0.00         0.00           0.00
43644      Lap gastric bypass/roux-en-y         C            C        0000     0.0000        0.00         0.00           0.00
43645      Lap gastr bypass incl smll i         C            C        0000     0.0000        0.00         0.00           0.00
43651      Laparoscopy, vagus nerve             T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
43652      Laparoscopy, vagus nerve             T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
43653      Laparoscopy, gastrostomy             T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
43659      Laparoscope proc, stom               T            1        0000     0.0000        0.00         0.00           0.00
43750      Place gastrostomy tube               T            T        0141     8.0662       357.17       820.74         940.52
43752      Nasal/orogastric w/stent             X            X        0272     1.3291        58.85       135.24         154.97
43760      Change gastrostomy tube              T            T        0121     2.2374        99.07       227.66         260.88
43761      Reposition gastrostomy tube          T            T        0122     6.9179       306.32       703.90         806.63
43770      Lap, place gastr adjust band         C            C        0000     0.0000        0.00         0.00           0.00
43771      Lap, revise adjust gast band         C            C        0000     0.0000        0.00         0.00           0.00
43772      Lap, remove adjust gast band         C            C        0000     0.0000        0.00         0.00           0.00
43773      Lap, change adjust gast band         C            C        0000     0.0000        0.00         0.00           0.00
43774      Lap remov adj gast band/port         C            C        0000     0.0000        0.00         0.00           0.00
43800      Reconstruction of pylorus            C            C        0000     0.0000        0.00         0.00           0.00
43810      Fusion of stomach and bowel          C            C        0000     0.0000        0.00         0.00           0.00
43820      Fusion of stomach and bowel          C            C        0000     0.0000        0.00         0.00           0.00
43825      Fusion of stomach and bowel          C            C        0000     0.0000        0.00         0.00           0.00
43830      Place gastrostomy tube               T            T        0422    24.0525      1,065.04     2,447.34       2,804.52
43831      Place gastrostomy tube               T            T        0141     8.0662       357.17       820.74         940.52
43832      Place gastrostomy tube               C            C        0000     0.0000        0.00         0.00           0.00
43840      Repair of stomach lesion             C            C        0000     0.0000        0.00         0.00           0.00
43842      V-band gastroplasty                  C            C        0000     0.0000        0.00         0.00           0.00
43843      Gastroplasty w/o v-band              C            C        0000     0.0000        0.00         0.00           0.00
43845      Gastroplasty duodenal switch         C            C        0000     0.0000        0.00         0.00           0.00
43846      Gastric bypass for obesity           C            C        0000     0.0000        0.00         0.00           0.00
43847      Gastric bypass incl small i          C            C        0000     0.0000        0.00         0.00           0.00
43848      Revision gastroplasty                C            C        0000     0.0000        0.00         0.00           0.00
43850      Revise stomach-bowel fusion          C            C        0000     0.0000        0.00         0.00           0.00
43855      Revise stomach-bowel fusion          C            C        0000     0.0000        0.00         0.00           0.00
43860      Revise stomach-bowel fusion          C            C        0000     0.0000        0.00         0.00           0.00
43865      Revise stomach-bowel fusion          C            C        0000     0.0000        0.00         0.00           0.00
43870      Repair stomach opening               T            T        0141     8.0662       357.17       820.74         940.52
43880      Repair stomach-bowel fistula         C            C        0000     0.0000        0.00         0.00           0.00
43886      Revise gastric port, open            T            T        0025     5.3051       234.91       539.79         618.57
43887      Remove gastric port, open            T            T        0025     5.3051       234.91       539.79         618.57
43888      Change gastric port, open            T            T        0686    13.4973       597.66      1,373.35       1,573.79
43999      Stomach surgery procedure            T            1        0000     0.0000        0.00         0.00           0.00
44005      Freeing of bowel adhesion            C            C        0000     0.0000        0.00         0.00           0.00
44010      Incision of small bowel              C            C        0000     0.0000        0.00         0.00           0.00
44015      Insert needle cath bowel             C            C        0000     0.0000        0.00         0.00           0.00
44020      Explore small intestine              C            C        0000     0.0000        0.00         0.00           0.00
44021      Decompress small bowel               C            C        0000     0.0000        0.00         0.00           0.00
44025      Incision of large bowel              C            C        0000     0.0000        0.00         0.00           0.00
44050      Reduce bowel obstruction             C            C        0000     0.0000        0.00         0.00           0.00
44055      Correct malrotation of bowel         C            C        0000     0.0000        0.00         0.00           0.00
44100      Biopsy of bowel                      T            T        0141     8.0662       357.17       820.74         940.52
44110      Excise intestine lesion(s)           C            C        0000     0.0000        0.00         0.00           0.00
44111      Excision of bowel lesion(s)          C            C        0000     0.0000        0.00         0.00           0.00
44120      Removal of small intestine           C            C        0000     0.0000        0.00         0.00           0.00
44121      Removal of small intestine           C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 67 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

44125      Removal of small intestine           C            C        0000     0.0000        0.00         0.00           0.00
44126      Enterectomy w/o taper, cong          C            C        0000     0.0000        0.00         0.00           0.00
44127      Enterectomy w/taper, cong            C            C        0000     0.0000        0.00         0.00           0.00
44128      Enterectomy cong, add-on             C            C        0000     0.0000        0.00         0.00           0.00
44130      Bowel to bowel fusion                C            C        0000     0.0000        0.00         0.00           0.00
44132      Enterectomy, cadaver donor           C            1        0000     0.0000        0.00         0.00           0.00
44133      Enterectomy, live donor              C            1        0000     0.0000        0.00         0.00           0.00
44135      Intestine transplnt, cadaver         C            1        0000     0.0000        0.00         0.00           0.00
44136      Intestine transplant, live           C            1        0000     0.0000        0.00         0.00           0.00
44137      Remove intestinal allograft          C            1        0000     0.0000        0.00         0.00           0.00
44139      Mobilization of colon                C            C        0000     0.0000        0.00         0.00           0.00
44140      Partial removal of colon             C            C        0000     0.0000        0.00         0.00           0.00
44141      Partial removal of colon             C            C        0000     0.0000        0.00         0.00           0.00
44143      Partial removal of colon             C            C        0000     0.0000        0.00         0.00           0.00
44144      Partial removal of colon             C            C        0000     0.0000        0.00         0.00           0.00
44145      Partial removal of colon             C            C        0000     0.0000        0.00         0.00           0.00
44146      Partial removal of colon             C            C        0000     0.0000        0.00         0.00           0.00
44147      Partial removal of colon             C            C        0000     0.0000        0.00         0.00           0.00
44150      Removal of colon                     C            C        0000     0.0000        0.00         0.00           0.00
44151      Removal of colon/ileostomy           C            C        0000     0.0000        0.00         0.00           0.00
44152      Removal of colon/ileostomy           C            C        0000     0.0000        0.00         0.00           0.00
44153      Removal of colon/ileostomy           C            C        0000     0.0000        0.00         0.00           0.00
44155      Removal of colon/ileostomy           C            C        0000     0.0000        0.00         0.00           0.00
44156      Removal of colon/ileostomy           C            C        0000     0.0000        0.00         0.00           0.00
44160      Removal of colon                     C            C        0000     0.0000        0.00         0.00           0.00
44180      Lap, enterolysis                     T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
44186      Lap, jejunostomy                     T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
44187      Lap, ileo/jejuno-stomy               C            C        0000     0.0000        0.00         0.00           0.00
44188      Lap, colostomy                       C            C        0000     0.0000        0.00         0.00           0.00
44202      Lap resect s/intestine singl         C            C        0000     0.0000        0.00         0.00           0.00
44203      Lap resect s/intestine, addl         C            C        0000     0.0000        0.00         0.00           0.00
44204      Laparo partial colectomy             C            C        0000     0.0000        0.00         0.00           0.00
44205      Lap colectomy part w/ileum           C            C        0000     0.0000        0.00         0.00           0.00
44206      Lap part colectomy w/stoma           T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
44207      L colectomy/coloproctostomy          T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
44208      L colectomy/coloproctostomy          T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
44210      Laparo total proctocolectomy         C            C        0000     0.0000        0.00         0.00           0.00
44211      Laparo total proctocolectomy         C            C        0000     0.0000        0.00         0.00           0.00
44212      Laparo total proctocolectomy         C            C        0000     0.0000        0.00         0.00           0.00
44213      Lap, mobil splenic fl add-on         T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
44227      Lap, close enterostomy               C            C        0000     0.0000        0.00         0.00           0.00
44238      Laparoscope proc, intestine          T            1        0000     0.0000        0.00         0.00           0.00
44300      Open bowel to skin                   C            C        0000     0.0000        0.00         0.00           0.00
44310      Ileostomy/jejunostomy                C            C        0000     0.0000        0.00         0.00           0.00
44312      Revision of ileostomy                T            T        0027    18.1956       805.70      1,851.40       2,121.61
44314      Revision of ileostomy                C            C        0000     0.0000        0.00         0.00           0.00
44316      Devise bowel pouch                   C            C        0000     0.0000        0.00         0.00           0.00
44320      Colostomy                            C            C        0000     0.0000        0.00         0.00           0.00
44322      Colostomy with biopsies              C            C        0000     0.0000        0.00         0.00           0.00
44340      Revision of colostomy                T            T        0027    18.1956       805.70      1,851.40       2,121.61
44345      Revision of colostomy                C            C        0000     0.0000        0.00         0.00           0.00
44346      Revision of colostomy                C            C        0000     0.0000        0.00         0.00           0.00
44360      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 68 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

44361      Small bowel endoscopy/biopsy         T            T        0142     9.0564       401.02       921.49        1,055.98
44363      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98
44364      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98
44365      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98
44366      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98
44369      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98
44370      Small bowel endoscopy/stent          T            T        0384    26.8955      1,190.93     2,736.62       3,136.02
44372      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98
44373      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98
44376      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98
44377      Small bowel endoscopy/biopsy         T            T        0142     9.0564       401.02       921.49        1,055.98
44378      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98
44379      S bowel endoscope w/stent            T            T        0384    26.8955      1,190.93     2,736.62       3,136.02
44380      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98
44382      Small bowel endoscopy                T            T        0142     9.0564       401.02       921.49        1,055.98
44383      Ileoscopy w/stent                    T            T        0384    26.8955      1,190.93     2,736.62       3,136.02
44385      Endoscopy of bowel pouch             T            T        0143     8.5588       378.98       870.86         997.96
44386      Endoscopy, bowel pouch/biop          T            T        0143     8.5588       378.98       870.86         997.96
44388      Colonoscopy                          T            T        0143     8.5588       378.98       870.86         997.96
44389      Colonoscopy with biopsy              T            T        0143     8.5588       378.98       870.86         997.96
44390      Colonoscopy for foreign body         T            T        0143     8.5588       378.98       870.86         997.96
44391      Colonoscopy for bleeding             T            T        0143     8.5588       378.98       870.86         997.96
44392      Colonoscopy & polypectomy            T            T        0143     8.5588       378.98       870.86         997.96
44393      Colonoscopy, lesion removal          T            T        0143     8.5588       378.98       870.86         997.96
44394      Colonoscopy w/snare                  T            T        0143     8.5588       378.98       870.86         997.96
44397      Colonoscopy w/stent                  T            T        0384    26.8955      1,190.93     2,736.62       3,136.02
44500      Intro, gastrointestinal tube         T            T        0121     2.2374        99.07       227.66         260.88
44602      Suture, small intestine              C            C        0000     0.0000        0.00         0.00           0.00
44603      Suture, small intestine              C            C        0000     0.0000        0.00         0.00           0.00
44604      Suture, large intestine              C            C        0000     0.0000        0.00         0.00           0.00
44605      Repair of bowel lesion               C            C        0000     0.0000        0.00         0.00           0.00
44615      Intestinal stricturoplasty           C            C        0000     0.0000        0.00         0.00           0.00
44620      Repair bowel opening                 C            C        0000     0.0000        0.00         0.00           0.00
44625      Repair bowel opening                 C            C        0000     0.0000        0.00         0.00           0.00
44626      Repair bowel opening                 C            C        0000     0.0000        0.00         0.00           0.00
44640      Repair bowel-skin fistula            C            C        0000     0.0000        0.00         0.00           0.00
44650      Repair bowel fistula                 C            C        0000     0.0000        0.00         0.00           0.00
44660      Repair bowel-bladder fistula         C            C        0000     0.0000        0.00         0.00           0.00
44661      Repair bowel-bladder fistula         C            C        0000     0.0000        0.00         0.00           0.00
44680      Surgical revision, intestine         C            C        0000     0.0000        0.00         0.00           0.00
44700      Suspend bowel w/prosthesis           C            C        0000     0.0000        0.00         0.00           0.00
44701      Intraop colon lavage add-on          N            N        0000     0.0000        0.00         0.00           0.00
44715      Prepare donor intestine              C            1        0000     0.0000        0.00         0.00           0.00
44720      Prep donor intestine/venous          C            1        0000     0.0000        0.00         0.00           0.00
44721      Prep donor intestine/artery          C            1        0000     0.0000        0.00         0.00           0.00
44799      Unlisted procedure intestine         T            1        0000     0.0000        0.00         0.00           0.00
44800      Excision of bowel pouch              C            C        0000     0.0000        0.00         0.00           0.00
44820      Excision of mesentery lesion         C            C        0000     0.0000        0.00         0.00           0.00
44850      Repair of mesentery                  C            C        0000     0.0000        0.00         0.00           0.00
44899      Bowel surgery procedure              C            1        0000     0.0000        0.00         0.00           0.00
44900      Drain app abscess, open              C            C        0000     0.0000        0.00         0.00           0.00
44901      Drain app abscess, percut            T            T        0037     9.6103       425.54       977.85        1,120.56
44950      Appendectomy                         C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 69 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 70 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

45379      Colonoscopy w/fb removal             T            T        0143     8.5588       378.98       870.86         997.96
45380      Colonoscopy and biopsy               T            T        0143     8.5588       378.98       870.86         997.96
45381      Colonoscopy, submucous inj           T            T        0143     8.5588       378.98       870.86         997.96
45382      Colonoscopy/control bleeding         T            T        0143     8.5588       378.98       870.86         997.96
45383      Lesion removal colonoscopy           T            T        0143     8.5588       378.98       870.86         997.96
45384      Lesion remove colonoscopy            T            T        0143     8.5588       378.98       870.86         997.96
45385      Lesion removal colonoscopy           T            T        0143     8.5588       378.98       870.86         997.96
45386      Colonoscopy dilate stricture         T            T        0143     8.5588       378.98       870.86         997.96
45387      Colonoscopy w/stent                  T            T        0384    26.8955      1,190.93     2,736.62       3,136.02
45391      Colonoscopy w/endoscope us           T            T        0143     8.5588       378.98       870.86         997.96
45392      Colonoscopy w/endoscopic fnb         T            T        0143     8.5588       378.98       870.86         997.96
45395      Lap, removal of rectum               C            C        0000     0.0000        0.00         0.00           0.00
45397      Lap, remove rectum w/pouch           C            C        0000     0.0000        0.00         0.00           0.00
45400      Laparoscopic proctopexy              C            C        0000     0.0000        0.00         0.00           0.00
45402      Lap proctopexy w/sig resect          C            C        0000     0.0000        0.00         0.00           0.00
45499      Laparoscope proc, rectum             T            1        0000     0.0000        0.00         0.00           0.00
45500      Repair of rectum                     T            T        0149    18.0878       800.93      1,840.43       2,109.04
45505      Repair of rectum                     T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
45520      Treatment of rectal prolapse         T            T        0098     1.1444        50.67       116.44         133.44
45540      Correct rectal prolapse              C            C        0000     0.0000        0.00         0.00           0.00
45541      Correct rectal prolapse              T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
45550      Repair rectum/remove sigmoid         C            C        0000     0.0000        0.00         0.00           0.00
45560      Repair of rectocele                  T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
45562      Exploration/repair of rectum         C            C        0000     0.0000        0.00         0.00           0.00
45563      Exploration/repair of rectum         C            C        0000     0.0000        0.00         0.00           0.00
45800      Repair rect/bladder fistula          C            C        0000     0.0000        0.00         0.00           0.00
45805      Repair fistula w/colostomy           C            C        0000     0.0000        0.00         0.00           0.00
45820      Repair rectourethral fistula         C            C        0000     0.0000        0.00         0.00           0.00
45825      Repair fistula w/colostomy           C            C        0000     0.0000        0.00         0.00           0.00
45900      Reduction of rectal prolapse         T            T        0148     3.5047       155.19       356.60         408.65
45905      Dilation of anal sphincter           T            T        0149    18.0878       800.93      1,840.43       2,109.04
45910      Dilation of rectal narrowing         T            T        0149    18.0878       800.93      1,840.43       2,109.04
45915      Remove rectal obstruction            T            T        0148     3.5047       155.19       356.60         408.65
45990      Surg dx exam, anorectal              T            T        0148     3.5047       155.19       356.60         408.65
45999      Rectum surgery procedure             T            1        0000     0.0000        0.00         0.00           0.00
46020      Placement of seton                   T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46030      Removal of rectal marker             T            T        0148     3.5047       155.19       356.60         408.65
46040      Incision of rectal abscess           T            T        0149    18.0878       800.93      1,840.43       2,109.04
46045      Incision of rectal abscess           T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46050      Incision of anal abscess             T            T        0148     3.5047       155.19       356.60         408.65
46060      Incision of rectal abscess           T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46070      Incision of anal septum              T            T        0155    15.9499       706.26      1,622.90       1,859.76
46080      Incision of anal sphincter           T            T        0149    18.0878       800.93      1,840.43       2,109.04
46083      Incise external hemorrhoid           T            T        0148     3.5047       155.19       356.60         408.65
46200      Removal of anal fissure              T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46210      Removal of anal crypt                T            T        0149    18.0878       800.93      1,840.43       2,109.04
46211      Removal of anal crypts               T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46220      Removal of anal tag                  T            T        0149    18.0878       800.93      1,840.43       2,109.04
46221      Ligation of hemorrhoid(s)            T            T        0148     3.5047       155.19       356.60         408.65
46230      Removal of anal tags                 T            T        0149    18.0878       800.93      1,840.43       2,109.04
46250      Hemorrhoidectomy                     T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46255      Hemorrhoidectomy                     T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46257      Remove hemorrhoids & fissure         T            T        0150    23.8736      1,057.12     2,429.14       2,783.66

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 71 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

46258      Remove hemorrhoids & fistula         T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46260      Hemorrhoidectomy                     T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46261      Remove hemorrhoids & fissure         T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46262      Remove hemorrhoids & fistula         T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46270      Removal of anal fistula              T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46275      Removal of anal fistula              T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46280      Removal of anal fistula              T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46285      Removal of anal fistula              T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46288      Repair anal fistula                  T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46320      Removal of hemorrhoid clot           T            T        0148     3.5047       155.19       356.60         408.65
46500      Injection into hemorrhoid(s)         T            T        0155    15.9499       706.26      1,622.90       1,859.76
46505      Chemodenervation anal musc           T            T        0148     3.5047       155.19       356.60         408.65
46600      Diagnostic anoscopy                  X            X        0340     0.6137        27.17        62.44          71.56
46604      Anoscopy and dilation                T            T        0147     7.9652       352.70       810.46         928.74
46606      Anoscopy and biopsy                  T            T        0146     4.7086       208.50       479.10         549.02
46608      Anoscopy, remove for body            T            T        0147     7.9652       352.70       810.46         928.74
46610      Anoscopy, remove lesion              T            T        0428    20.0871       889.46      2,043.86       2,342.16
46611      Anoscopy                             T            T        0147     7.9652       352.70       810.46         928.74
46612      Anoscopy, remove lesions             T            T        0428    20.0871       889.46      2,043.86       2,342.16
46614      Anoscopy, control bleeding           T            T        0146     4.7086       208.50       479.10         549.02
46615      Anoscopy                             T            T        0428    20.0871       889.46      2,043.86       2,342.16
46700      Repair of anal stricture             T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46705      Repair of anal stricture             C            C        0000     0.0000        0.00         0.00           0.00
46706      Repr of anal fistula w/glue          T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46710      Repr per/vag pouch sngl proc         C            C        0000     0.0000        0.00         0.00           0.00
46712      Repr per/vag pouch dbl proc          C            C        0000     0.0000        0.00         0.00           0.00
46715      Rep perf anoper fistu                C            C        0000     0.0000        0.00         0.00           0.00
46716      Rep perf anoper/vestib fistu         C            C        0000     0.0000        0.00         0.00           0.00
46730      Construction of absent anus          C            C        0000     0.0000        0.00         0.00           0.00
46735      Construction of absent anus          C            C        0000     0.0000        0.00         0.00           0.00
46740      Construction of absent anus          C            C        0000     0.0000        0.00         0.00           0.00
46742      Repair of imperforated anus          C            C        0000     0.0000        0.00         0.00           0.00
46744      Repair of cloacal anomaly            C            C        0000     0.0000        0.00         0.00           0.00
46746      Repair of cloacal anomaly            C            C        0000     0.0000        0.00         0.00           0.00
46748      Repair of cloacal anomaly            C            C        0000     0.0000        0.00         0.00           0.00
46750      Repair of anal sphincter             T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46751      Repair of anal sphincter             C            C        0000     0.0000        0.00         0.00           0.00
46753      Reconstruction of anus               T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46754      Removal of suture from anus          T            T        0149    18.0878       800.93      1,840.43       2,109.04
46760      Repair of anal sphincter             T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46761      Repair of anal sphincter             T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46762      Implant artificial sphincter         T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46900      Destruction, anal lesion(s)          T            T        0016     2.5080       111.05       255.19         292.43
46910      Destruction, anal lesion(s)          T            T        0017    17.9937       796.76      1,830.86       2,098.07
46916      Cryosurgery, anal lesion(s)          T            T        0013     1.0603        46.95       107.89         123.63
46917      Laser surgery, anal lesions          T            T        0695    20.2372       896.10      2,059.14       2,359.66
46922      Excision of anal lesion(s)           T            T        0695    20.2372       896.10      2,059.14       2,359.66
46924      Destruction, anal lesion(s)          T            T        0695    20.2372       896.10      2,059.14       2,359.66
46934      Destruction of hemorrhoids           T            T        0155    15.9499       706.26      1,622.90       1,859.76
46935      Destruction of hemorrhoids           T            T        0155    15.9499       706.26      1,622.90       1,859.76
46936      Destruction of hemorrhoids           T            T        0149    18.0878       800.93      1,840.43       2,109.04
46937      Cryotherapy of rectal lesion         T            T        0149    18.0878       800.93      1,840.43       2,109.04
46938      Cryotherapy of rectal lesion         T            T        0150    23.8736      1,057.12     2,429.14       2,783.66

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 72 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

46940      Treatment of anal fissure            T            T        0149    18.0878       800.93      1,840.43       2,109.04
46942      Treatment of anal fissure            T            T        0148     3.5047       155.19       356.60         408.65
46945      Ligation of hemorrhoids              T            T        0155    15.9499       706.26      1,622.90       1,859.76
46946      Ligation of hemorrhoids              T            T        0155    15.9499       706.26      1,622.90       1,859.76
46947      Hemorrhoidopexy by stapling          T            T        0150    23.8736      1,057.12     2,429.14       2,783.66
46999      Anus surgery procedure               T            1        0000     0.0000        0.00         0.00           0.00
47000      Needle biopsy of liver               T            T        0685     6.0034       265.83       610.85         700.00
47001      Needle biopsy, liver add-on          N            N        0000     0.0000        0.00         0.00           0.00
47010      Open drainage, liver lesion          C            C        0000     0.0000        0.00         0.00           0.00
47011      Percut drain, liver lesion           T            T        0037     9.6103       425.54       977.85        1,120.56
47015      Inject/aspirate liver cyst           C            C        0000     0.0000        0.00         0.00           0.00
47100      Wedge biopsy of liver                C            C        0000     0.0000        0.00         0.00           0.00
47120      Partial removal of liver             C            C        0000     0.0000        0.00         0.00           0.00
47122      Extensive removal of liver           C            C        0000     0.0000        0.00         0.00           0.00
47125      Partial removal of liver             C            C        0000     0.0000        0.00         0.00           0.00
47130      Partial removal of liver             C            C        0000     0.0000        0.00         0.00           0.00
47133      Removal of donor liver               C            C        0000     0.0000        0.00         0.00           0.00
47135      Transplantation of liver             C            C        0000     0.0000        0.00         0.00           0.00
47136      Transplantation of liver             C            C        0000     0.0000        0.00         0.00           0.00
47140      Partial removal, donor liver         C            C        0000     0.0000        0.00         0.00           0.00
47141      Partial removal, donor liver         C            C        0000     0.0000        0.00         0.00           0.00
47142      Partial removal, donor liver         C            C        0000     0.0000        0.00         0.00           0.00
47143      Prep donor liver, whole              C            C        0000     0.0000        0.00         0.00           0.00
47144      Prep donor liver, 3-segment          C            C        0000     0.0000        0.00         0.00           0.00
47145      Prep donor liver, lobe split         C            C        0000     0.0000        0.00         0.00           0.00
47146      Prep donor liver/venous              C            C        0000     0.0000        0.00         0.00           0.00
47147      Prep donor liver/arterial            C            C        0000     0.0000        0.00         0.00           0.00
47300      Surgery for liver lesion             C            C        0000     0.0000        0.00         0.00           0.00
47350      Repair liver wound                   C            C        0000     0.0000        0.00         0.00           0.00
47360      Repair liver wound                   C            C        0000     0.0000        0.00         0.00           0.00
47361      Repair liver wound                   C            C        0000     0.0000        0.00         0.00           0.00
47362      Repair liver wound                   C            C        0000     0.0000        0.00         0.00           0.00
47370      Laparo ablate liver tumor rf         T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
47371      Laparo ablate liver cryosurg         T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
47379      Laparoscope procedure, liver         T            1        0000     0.0000        0.00         0.00           0.00
47380      Open ablate liver tumor rf           C            C        0000     0.0000        0.00         0.00           0.00
47381      Open ablate liver tumor cryo         C            C        0000     0.0000        0.00         0.00           0.00
47382      Percut ablate liver rf               T            T        0423    39.5881      1,752.96     4,028.09       4,615.97
47399      Liver surgery procedure              T            1        0000     0.0000        0.00         0.00           0.00
47400      Incision of liver duct               C            C        0000     0.0000        0.00         0.00           0.00
47420      Incision of bile duct                C            C        0000     0.0000        0.00         0.00           0.00
47425      Incision of bile duct                C            C        0000     0.0000        0.00         0.00           0.00
47460      Incise bile duct sphincter           C            C        0000     0.0000        0.00         0.00           0.00
47480      Incision of gallbladder              C            C        0000     0.0000        0.00         0.00           0.00
47490      Incision of gallbladder              T            T        0152    18.2391       807.63      1,855.83       2,126.68
47500      Injection for liver x-rays           N            N        0000     0.0000        0.00         0.00           0.00
47505      Injection for liver x-rays           N            N        0000     0.0000        0.00         0.00           0.00
47510      Insert catheter, bile duct           T            T        0152    18.2391       807.63      1,855.83       2,126.68
47511      Insert bile duct drain               T            T        0152    18.2391       807.63      1,855.83       2,126.68
47525      Change bile duct catheter            T            T        0427    10.0109       443.28      1,018.61       1,167.27
47530      Revise/reinsert bile tube            T            T        0427    10.0109       443.28      1,018.61       1,167.27
47550      Bile duct endoscopy add-on           C            C        0000     0.0000        0.00         0.00           0.00
47552      Biliary endoscopy thru skin          T            T        0152    18.2391       807.63      1,855.83       2,126.68

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 73 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

47553      Biliary endoscopy thru skin          T            T        0152    18.2391       807.63      1,855.83       2,126.68
47554      Biliary endoscopy thru skin          T            T        0152    18.2391       807.63      1,855.83       2,126.68
47555      Biliary endoscopy thru skin          T            T        0152    18.2391       807.63      1,855.83       2,126.68
47556      Biliary endoscopy thru skin          T            T        0152    18.2391       807.63      1,855.83       2,126.68
47560      Laparoscopy w/cholangio              T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
47561      Laparo w/cholangio/biopsy            T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
47562      Laparoscopic cholecystectomy         T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
47563      Laparo cholecystectomy/graph         T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
47564      Laparo cholecystectomy/explr         T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
47570      Laparo cholecystoenterostomy         C            C        0000     0.0000        0.00         0.00           0.00
47579      Laparoscope proc, biliary            T            1        0000     0.0000        0.00         0.00           0.00
47600      Removal of gallbladder               C            C        0000     0.0000        0.00         0.00           0.00
47605      Removal of gallbladder               C            C        0000     0.0000        0.00         0.00           0.00
47610      Removal of gallbladder               C            C        0000     0.0000        0.00         0.00           0.00
47612      Removal of gallbladder               C            C        0000     0.0000        0.00         0.00           0.00
47620      Removal of gallbladder               C            C        0000     0.0000        0.00         0.00           0.00
47630      Remove bile duct stone               T            T        0152    18.2391       807.63      1,855.83       2,126.68
47700      Exploration of bile ducts            C            C        0000     0.0000        0.00         0.00           0.00
47701      Bile duct revision                   C            C        0000     0.0000        0.00         0.00           0.00
47711      Excision of bile duct tumor          C            C        0000     0.0000        0.00         0.00           0.00
47712      Excision of bile duct tumor          C            C        0000     0.0000        0.00         0.00           0.00
47715      Excision of bile duct cyst           C            C        0000     0.0000        0.00         0.00           0.00
47716      Fusion of bile duct cyst             C            C        0000     0.0000        0.00         0.00           0.00
47720      Fuse gallbladder & bowel             C            C        0000     0.0000        0.00         0.00           0.00
47721      Fuse upper gi structures             C            C        0000     0.0000        0.00         0.00           0.00
47740      Fuse gallbladder & bowel             C            C        0000     0.0000        0.00         0.00           0.00
47741      Fuse gallbladder & bowel             C            C        0000     0.0000        0.00         0.00           0.00
47760      Fuse bile ducts and bowel            C            C        0000     0.0000        0.00         0.00           0.00
47765      Fuse liver ducts & bowel             C            C        0000     0.0000        0.00         0.00           0.00
47780      Fuse bile ducts and bowel            C            C        0000     0.0000        0.00         0.00           0.00
47785      Fuse bile ducts and bowel            C            C        0000     0.0000        0.00         0.00           0.00
47800      Reconstruction of bile ducts         C            C        0000     0.0000        0.00         0.00           0.00
47801      Placement, bile duct support         C            C        0000     0.0000        0.00         0.00           0.00
47802      Fuse liver duct & intestine          C            C        0000     0.0000        0.00         0.00           0.00
47900      Suture bile duct injury              C            C        0000     0.0000        0.00         0.00           0.00
47999      Bile tract surgery procedure         T            1        0000     0.0000        0.00         0.00           0.00
48000      Drainage of abdomen                  C            C        0000     0.0000        0.00         0.00           0.00
48001      Placement of drain, pancreas         C            C        0000     0.0000        0.00         0.00           0.00
48005      Resect/debride pancreas              C            C        0000     0.0000        0.00         0.00           0.00
48020      Removal of pancreatic stone          C            C        0000     0.0000        0.00         0.00           0.00
48100      Biopsy of pancreas, open             C            C        0000     0.0000        0.00         0.00           0.00
48102      Needle biopsy, pancreas              T            T        0685     6.0034       265.83       610.85         700.00
48120      Removal of pancreas lesion           C            C        0000     0.0000        0.00         0.00           0.00
48140      Partial removal of pancreas          C            C        0000     0.0000        0.00         0.00           0.00
48145      Partial removal of pancreas          C            C        0000     0.0000        0.00         0.00           0.00
48146      Pancreatectomy                       C            C        0000     0.0000        0.00         0.00           0.00
48148      Removal of pancreatic duct           C            C        0000     0.0000        0.00         0.00           0.00
48150      Partial removal of pancreas          C            C        0000     0.0000        0.00         0.00           0.00
48152      Pancreatectomy                       C            C        0000     0.0000        0.00         0.00           0.00
48153      Pancreatectomy                       C            C        0000     0.0000        0.00         0.00           0.00
48154      Pancreatectomy                       C            C        0000     0.0000        0.00         0.00           0.00
48155      Removal of pancreas                  C            C        0000     0.0000        0.00         0.00           0.00
48160      Pancreas removal/transplant          E            3        0000     0.0000        M01          M01            M01

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 74 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

48180      Fuse pancreas and bowel              C            C        0000     0.0000        0.00         0.00           0.00
48400      Injection, intraop add-on            C            C        0000     0.0000        0.00         0.00           0.00
48500      Surgery of pancreatic cyst           C            C        0000     0.0000        0.00         0.00           0.00
48510      Drain pancreatic pseudocyst          C            C        0000     0.0000        0.00         0.00           0.00
48511      Drain pancreatic pseudocyst          T            T        0037     9.6103       425.54       977.85        1,120.56
48520      Fuse pancreas cyst and bowel         C            C        0000     0.0000        0.00         0.00           0.00
48540      Fuse pancreas cyst and bowel         C            C        0000     0.0000        0.00         0.00           0.00
48545      Pancreatorrhaphy                     C            C        0000     0.0000        0.00         0.00           0.00
48547      Duodenal exclusion                   C            C        0000     0.0000        0.00         0.00           0.00
48550      Donor pancreatectomy                 E            3        0000     0.0000        M01          M01            M01
48551      Prep donor pancreas                  C            C        0000     0.0000        0.00         0.00           0.00
48552      Prep donor pancreas/venous           C            C        0000     0.0000        0.00         0.00           0.00
48554      Transpl allograft pancreas           C            C        0000     0.0000        0.00         0.00           0.00
48556      Removal, allograft pancreas          C            C        0000     0.0000        0.00         0.00           0.00
48999      Pancreas surgery procedure           T            1        0000     0.0000        0.00         0.00           0.00
49000      Exploration of abdomen               C            C        0000     0.0000        0.00         0.00           0.00
49002      Reopening of abdomen                 C            C        0000     0.0000        0.00         0.00           0.00
49010      Exploration behind abdomen           C            C        0000     0.0000        0.00         0.00           0.00
49020      Drain abdominal abscess              C            C        0000     0.0000        0.00         0.00           0.00
49021      Drain abdominal abscess              T            T        0037     9.6103       425.54       977.85        1,120.56
49040      Drain, open, abdom abscess           C            C        0000     0.0000        0.00         0.00           0.00
49041      Drain, percut, abdom abscess         T            T        0037     9.6103       425.54       977.85        1,120.56
49060      Drain, open, retrop abscess          C            C        0000     0.0000        0.00         0.00           0.00
49061      Drain, percut, retroper absc         T            T        0037     9.6103       425.54       977.85        1,120.56
49062      Drain to peritoneal cavity           C            C        0000     0.0000        0.00         0.00           0.00
49080      Puncture, peritoneal cavity          T            T        0070     3.2141       142.32       327.03         374.76
49081      Removal of abdominal fluid           T            T        0070     3.2141       142.32       327.03         374.76
49085      Remove abdomen foreign body          T            T        0153    22.4936       996.02      2,288.72       2,622.75
49180      Biopsy, abdominal mass               T            T        0685     6.0034       265.83       610.85         700.00
49200      Removal of abdominal lesion          T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
49201      Remove abdom lesion, complex         C            C        0000     0.0000        0.00         0.00           0.00
49215      Excise sacral spine tumor            C            C        0000     0.0000        0.00         0.00           0.00
49220      Multiple surgery, abdomen            C            C        0000     0.0000        0.00         0.00           0.00
49250      Excision of umbilicus                T            T        0153    22.4936       996.02      2,288.72       2,622.75
49255      Removal of omentum                   C            C        0000     0.0000        0.00         0.00           0.00
49320      Diag laparo separate proc            T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
49321      Laparoscopy, biopsy                  T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
49322      Laparoscopy, aspiration              T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
49323      Laparo drain lymphocele              T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
49329      Laparo proc, abdm/per/oment          T            1        0000     0.0000        0.00         0.00           0.00
49400      Air injection into abdomen           N            N        0000     0.0000        0.00         0.00           0.00
49419      Insrt abdom cath for chemotx         T            T        0115    36.9806      1,637.50     3,762.78       4,311.94
49420      Insert abdom drain, temp             T            T        0652    29.3648      1,300.27     2,987.87       3,423.94
49421      Insert abdom drain, perm             T            T        0652    29.3648      1,300.27     2,987.87       3,423.94
49422      Remove perm cannula/catheter         T            T        0105    21.9865       973.56      2,237.13       2,563.63
49423      Exchange drainage catheter           T            T        0427    10.0109       443.28      1,018.61       1,167.27
49424      Assess cyst, contrast inject         N            N        0000     0.0000        0.00         0.00           0.00
49425      Insert abdomen-venous drain          C            C        0000     0.0000        0.00         0.00           0.00
49426      Revise abdomen-venous shunt          T            T        0153    22.4936       996.02      2,288.72       2,622.75
49427      Injection, abdominal shunt           N            N        0000     0.0000        0.00         0.00           0.00
49428      Ligation of shunt                    C            C        0000     0.0000        0.00         0.00           0.00
49429      Removal of shunt                     T            T        0105    21.9865       973.56      2,237.13       2,563.63
49491      Rpr hern preemie reduc               T            T        0154    28.6432      1,268.32     2,914.45       3,339.80

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 75 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

49492      Rpr ing hern premie, blocked         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49495      Rpr ing hernia baby, reduc           T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49496      Rpr ing hernia baby, blocked         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49500      Rpr ing hernia, init, reduce         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49501      Rpr ing hernia, init blocked         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49505      Prp i/hern init reduc >5 yr          T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49507      Prp i/hern init block >5 yr          T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49520      Rerepair ing hernia, reduce          T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49521      Rerepair ing hernia, blocked         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49525      Repair ing hernia, sliding           T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49540      Repair lumbar hernia                 T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49550      Rpr rem hernia, init, reduce         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49553      Rpr fem hernia, init blocked         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49555      Rerepair fem hernia, reduce          T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49557      Rerepair fem hernia, blocked         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49560      Rpr ventral hern init, reduc         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49561      Rpr ventral hern init, block         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49565      Rerepair ventrl hern, reduce         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49566      Rerepair ventrl hern, block          T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49568      Hernia repair w/mesh                 T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49570      Rpr epigastric hern, reduce          T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49572      Rpr epigastric hern, blocked         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49580      Rpr umbil hern, reduc < 5 yr         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49582      Rpr umbil hern, block < 5 yr         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49585      Rpr umbil hern, reduc > 5 yr         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49587      Rpr umbil hern, block > 5 yr         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49590      Repair spigelian hernia              T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49600      Repair umbilical lesion              T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
49605      Repair umbilical lesion              C            C        0000     0.0000        0.00         0.00           0.00
49606      Repair umbilical lesion              C            C        0000     0.0000        0.00         0.00           0.00
49610      Repair umbilical lesion              C            C        0000     0.0000        0.00         0.00           0.00
49611      Repair umbilical lesion              C            C        0000     0.0000        0.00         0.00           0.00
49650      Laparo hernia repair initial         T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
49651      Laparo hernia repair recur           T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
49659      Laparo proc, hernia repair           T            1        0000     0.0000        0.00         0.00           0.00
49900      Repair of abdominal wall             C            C        0000     0.0000        0.00         0.00           0.00
49904      Omental flap, extra-abdom            C            C        0000     0.0000        0.00         0.00           0.00
49905      Omental flap, intra-abdom            C            C        0000     0.0000        0.00         0.00           0.00
49906      Free omental flap, microvasc         C            C        0000     0.0000        0.00         0.00           0.00
49999      Abdomen surgery procedure            T            1        0000     0.0000        0.00         0.00           0.00
50010      Exploration of kidney                C            C        0000     0.0000        0.00         0.00           0.00
50020      Renal abscess, open drain            T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
50021      Renal abscess, percut drain          T            T        0037     9.6103       425.54       977.85        1,120.56
50040      Drainage of kidney                   C            C        0000     0.0000        0.00         0.00           0.00
50045      Exploration of kidney                C            C        0000     0.0000        0.00         0.00           0.00
50060      Removal of kidney stone              C            C        0000     0.0000        0.00         0.00           0.00
50065      Incision of kidney                   C            C        0000     0.0000        0.00         0.00           0.00
50070      Incision of kidney                   C            C        0000     0.0000        0.00         0.00           0.00
50075      Removal of kidney stone              C            C        0000     0.0000        0.00         0.00           0.00
50080      Removal of kidney stone              T            T        0429    42.0802      1,863.31     4,281.66       4,906.55
50081      Removal of kidney stone              T            T        0429    42.0802      1,863.31     4,281.66       4,906.55
50100      Revise kidney blood vessels          C            C        0000     0.0000        0.00         0.00           0.00
50120      Exploration of kidney                C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 76 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

50125      Explore and drain kidney             C            C        0000     0.0000        0.00         0.00           0.00
50130      Removal of kidney stone              C            C        0000     0.0000        0.00         0.00           0.00
50135      Exploration of kidney                C            C        0000     0.0000        0.00         0.00           0.00
50200      Biopsy of kidney                     T            T        0685     6.0034       265.83       610.85         700.00
50205      Biopsy of kidney                     C            C        0000     0.0000        0.00         0.00           0.00
50220      Remove kidney, open                  C            C        0000     0.0000        0.00         0.00           0.00
50225      Removal kidney open, complex         C            C        0000     0.0000        0.00         0.00           0.00
50230      Removal kidney open, radical         C            C        0000     0.0000        0.00         0.00           0.00
50234      Removal of kidney & ureter           C            C        0000     0.0000        0.00         0.00           0.00
50236      Removal of kidney & ureter           C            C        0000     0.0000        0.00         0.00           0.00
50240      Partial removal of kidney            C            C        0000     0.0000        0.00         0.00           0.00
50250      Cryoablate renal mass open           C            C        0000     0.0000        0.00         0.00           0.00
50280      Removal of kidney lesion             C            C        0000     0.0000        0.00         0.00           0.00
50290      Removal of kidney lesion             C            C        0000     0.0000        0.00         0.00           0.00
50300      Remove cadaver donor kidney          C            C        0000     0.0000        0.00         0.00           0.00
50320      Remove kidney, living donor          C            C        0000     0.0000        0.00         0.00           0.00
50323      Prep cadaver renal allograft         C            C        0000     0.0000        0.00         0.00           0.00
50325      Prep donor renal graft               C            C        0000     0.0000        0.00         0.00           0.00
50327      Prep renal graft/venous              C            C        0000     0.0000        0.00         0.00           0.00
50328      Prep renal graft/arterial            C            C        0000     0.0000        0.00         0.00           0.00
50329      Prep renal graft/ureteral            C            C        0000     0.0000        0.00         0.00           0.00
50340      Removal of kidney                    C            C        0000     0.0000        0.00         0.00           0.00
50360      Transplantation of kidney            C            C        0000     0.0000        0.00         0.00           0.00
50365      Transplantation of kidney            C            C        0000     0.0000        0.00         0.00           0.00
50370      Remove transplanted kidney           C            C        0000     0.0000        0.00         0.00           0.00
50380      Reimplantation of kidney             C            C        0000     0.0000        0.00         0.00           0.00
50382      Change ureter stent, percut          T            T        0161    18.5804       822.74      1,890.56       2,166.47
50384      Remove ureter stent, percut          T            T        0161    18.5804       822.74      1,890.56       2,166.47
50387      Change ext/int ureter stent          T            T        0122     6.9179       306.32       703.90         806.63
50389      Remove renal tube w/fluoro           T            T        0156     2.6123       115.67       265.80         304.59
50390      Drainage of kidney lesion            T            T        0685     6.0034       265.83       610.85         700.00
50391      Instll rx agnt into rnal tub         T            T        0156     2.6123       115.67       265.80         304.59
50392      Insert kidney drain                  T            T        0161    18.5804       822.74      1,890.56       2,166.47
50393      Insert ureteral tube                 T            T        0161    18.5804       822.74      1,890.56       2,166.47
50394      Injection for kidney x-ray           N            N        0000     0.0000        0.00         0.00           0.00
50395      Create passage to kidney             T            T        0161    18.5804       822.74      1,890.56       2,166.47
50396      Measure kidney pressure              T            T        0164     1.1600        51.36       118.03         135.26
50398      Change kidney tube                   T            T        0122     6.9179       306.32       703.90         806.63
50400      Revision of kidney/ureter            C            C        0000     0.0000        0.00         0.00           0.00
50405      Revision of kidney/ureter            C            C        0000     0.0000        0.00         0.00           0.00
50500      Repair of kidney wound               C            C        0000     0.0000        0.00         0.00           0.00
50520      Close kidney-skin fistula            C            C        0000     0.0000        0.00         0.00           0.00
50525      Repair renal-abdomen fistula         C            C        0000     0.0000        0.00         0.00           0.00
50526      Repair renal-abdomen fistula         C            C        0000     0.0000        0.00         0.00           0.00
50540      Revision of horseshoe kidney         C            C        0000     0.0000        0.00         0.00           0.00
50541      Laparo ablate renal cyst             T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
50542      Laparo ablate renal mass             T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
50543      Laparo partial nephrectomy           T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
50544      Laparoscopy, pyeloplasty             T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
50545      Laparo radical nephrectomy           C            C        0000     0.0000        0.00         0.00           0.00
50546      Laparoscopic nephrectomy             C            C        0000     0.0000        0.00         0.00           0.00
50547      Laparo removal donor kidney          C            C        0000     0.0000        0.00         0.00           0.00
50548      Laparo remove w/ureter               C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 77 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

50549      Laparoscope proc, renal              T            1        0000     0.0000        0.00         0.00           0.00
50551      Kidney endoscopy                     T            T        0160     6.9387       307.25       706.01         809.05
50553      Kidney endoscopy                     T            T        0161    18.5804       822.74      1,890.56       2,166.47
50555      Kidney endoscopy & biopsy            T            T        0160     6.9387       307.25       706.01         809.05
50557      Kidney endoscopy & treatment         T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
50561      Kidney endoscopy & treatment         T            T        0161    18.5804       822.74      1,890.56       2,166.47
50562      Renal scope w/tumor resect           T            T        0160     6.9387       307.25       706.01         809.05
50570      Kidney endoscopy                     T            T        0160     6.9387       307.25       706.01         809.05
50572      Kidney endoscopy                     T            T        0160     6.9387       307.25       706.01         809.05
50574      Kidney endoscopy & biopsy            T            T        0160     6.9387       307.25       706.01         809.05
50575      Kidney endoscopy                     T            T        0163    33.5963      1,487.64     3,418.42       3,917.33
50576      Kidney endoscopy & treatment         T            T        0161    18.5804       822.74      1,890.56       2,166.47
50580      Kidney endoscopy & treatment         C            C        0000     0.0000        0.00         0.00           0.00
50590      Fragmenting of kidney stone          T            T        0169    42.4073      1,877.80     4,314.94       4,944.69
50592      Perc rf ablate renal tumor           T            T        0423    39.5881      1,752.96     4,028.09       4,615.97
50600      Exploration of ureter                C            C        0000     0.0000        0.00         0.00           0.00
50605      Insert ureteral support              C            C        0000     0.0000        0.00         0.00           0.00
50610      Removal of ureter stone              C            C        0000     0.0000        0.00         0.00           0.00
50620      Removal of ureter stone              C            C        0000     0.0000        0.00         0.00           0.00
50630      Removal of ureter stone              C            C        0000     0.0000        0.00         0.00           0.00
50650      Removal of ureter                    C            C        0000     0.0000        0.00         0.00           0.00
50660      Removal of ureter                    C            C        0000     0.0000        0.00         0.00           0.00
50684      Injection for ureter x-ray           N            N        0000     0.0000        0.00         0.00           0.00
50686      Measure ureter pressure              T            T        0164     1.1600        51.36       118.03         135.26
50688      Change of ureter tube                T            T        0122     6.9179       306.32       703.90         806.63
50690      Injection for ureter x-ray           N            N        0000     0.0000        0.00         0.00           0.00
50700      Revision of ureter                   C            C        0000     0.0000        0.00         0.00           0.00
50715      Release of ureter                    C            C        0000     0.0000        0.00         0.00           0.00
50722      Release of ureter                    C            C        0000     0.0000        0.00         0.00           0.00
50725      Release/revise ureter                C            C        0000     0.0000        0.00         0.00           0.00
50727      Revise ureter                        C            C        0000     0.0000        0.00         0.00           0.00
50728      Revise ureter                        C            C        0000     0.0000        0.00         0.00           0.00
50740      Fusion of ureter & kidney            C            C        0000     0.0000        0.00         0.00           0.00
50750      Fusion of ureter & kidney            C            C        0000     0.0000        0.00         0.00           0.00
50760      Fusion of ureters                    C            C        0000     0.0000        0.00         0.00           0.00
50770      Splicing of ureters                  C            C        0000     0.0000        0.00         0.00           0.00
50780      Reimplant ureter in bladder          C            C        0000     0.0000        0.00         0.00           0.00
50782      Reimplant ureter in bladder          C            C        0000     0.0000        0.00         0.00           0.00
50783      Reimplant ureter in bladder          C            C        0000     0.0000        0.00         0.00           0.00
50785      Reimplant ureter in bladder          C            C        0000     0.0000        0.00         0.00           0.00
50800      Implant ureter in bowel              C            C        0000     0.0000        0.00         0.00           0.00
50810      Fusion of ureter & bowel             C            C        0000     0.0000        0.00         0.00           0.00
50815      Urine shunt to intestine             C            C        0000     0.0000        0.00         0.00           0.00
50820      Construct bowel bladder              C            C        0000     0.0000        0.00         0.00           0.00
50825      Construct bowel bladder              C            C        0000     0.0000        0.00         0.00           0.00
50830      Revise urine flow                    C            C        0000     0.0000        0.00         0.00           0.00
50840      Replace ureter by bowel              C            C        0000     0.0000        0.00         0.00           0.00
50845      Appendico-vesicostomy                C            C        0000     0.0000        0.00         0.00           0.00
50860      Transplant ureter to skin            C            C        0000     0.0000        0.00         0.00           0.00
50900      Repair of ureter                     C            C        0000     0.0000        0.00         0.00           0.00
50920      Closure ureter/skin fistula          C            C        0000     0.0000        0.00         0.00           0.00
50930      Closure ureter/bowel fistula         C            C        0000     0.0000        0.00         0.00           0.00
50940      Release of ureter                    C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 78 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

50945      Laparoscopy ureterolithotomy         T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
50947      Laparo new ureter/bladder            T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
50948      Laparo new ureter/bladder            T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
50949      Laparoscope proc, ureter             T            1        0000     0.0000        0.00         0.00           0.00
50951      Endoscopy of ureter                  T            T        0160     6.9387       307.25       706.01         809.05
50953      Endoscopy of ureter                  T            T        0160     6.9387       307.25       706.01         809.05
50955      Ureter endoscopy & biopsy            T            T        0161    18.5804       822.74      1,890.56       2,166.47
50957      Ureter endoscopy & treatment         T            T        0161    18.5804       822.74      1,890.56       2,166.47
50961      Ureter endoscopy & treatment         T            T        0161    18.5804       822.74      1,890.56       2,166.47
50970      Ureter endoscopy                     T            T        0160     6.9387       307.25       706.01         809.05
50972      Ureter endoscopy & catheter          T            T        0160     6.9387       307.25       706.01         809.05
50974      Ureter endoscopy & biopsy            T            T        0161    18.5804       822.74      1,890.56       2,166.47
50976      Ureter endoscopy & treatment         T            T        0161    18.5804       822.74      1,890.56       2,166.47
50980      Ureter endoscopy & treatment         T            T        0161    18.5804       822.74      1,890.56       2,166.47
51000      Drainage of bladder                  T            T        0164     1.1600        51.36       118.03         135.26
51005      Drainage of bladder                  T            T        0164     1.1600        51.36       118.03         135.26
51010      Drainage of bladder                  T            T        0165    16.5343       732.14      1,682.37       1,927.90
51020      Incise & treat bladder               T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
51030      Incise & treat bladder               T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
51040      Incise & drain bladder               T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
51045      Incise bladder/drain ureter          T            T        0160     6.9387       307.25       706.01         809.05
51050      Removal of bladder stone             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
51060      Removal of ureter stone              C            C        0000     0.0000        0.00         0.00           0.00
51065      Remove ureter calculus               T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
51080      Drainage of bladder abscess          T            T        0008    16.2953       721.56      1,658.05       1,900.03
51500      Removal of bladder cyst              T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
51520      Removal of bladder lesion            T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
51525      Removal of bladder lesion            C            C        0000     0.0000        0.00         0.00           0.00
51530      Removal of bladder lesion            C            C        0000     0.0000        0.00         0.00           0.00
51535      Repair of ureter lesion              C            C        0000     0.0000        0.00         0.00           0.00
51550      Partial removal of bladder           C            C        0000     0.0000        0.00         0.00           0.00
51555      Partial removal of bladder           C            C        0000     0.0000        0.00         0.00           0.00
51565      Revise bladder & ureter(s)           C            C        0000     0.0000        0.00         0.00           0.00
51570      Removal of bladder                   C            C        0000     0.0000        0.00         0.00           0.00
51575      Removal of bladder & nodes           C            C        0000     0.0000        0.00         0.00           0.00
51580      Remove bladder/revise tract          C            C        0000     0.0000        0.00         0.00           0.00
51585      Removal of bladder & nodes           C            C        0000     0.0000        0.00         0.00           0.00
51590      Remove bladder/revise tract          C            C        0000     0.0000        0.00         0.00           0.00
51595      Remove bladder/revise tract          C            C        0000     0.0000        0.00         0.00           0.00
51596      Remove bladder/create pouch          C            C        0000     0.0000        0.00         0.00           0.00
51597      Removal of pelvic structures         C            C        0000     0.0000        0.00         0.00           0.00
51600      Injection for bladder x-ray          N            N        0000     0.0000        0.00         0.00           0.00
51605      Preparation for bladder xray         N            N        0000     0.0000        0.00         0.00           0.00
51610      Injection for bladder x-ray          N            N        0000     0.0000        0.00         0.00           0.00
51700      Irrigation of bladder                T            T        0164     1.1600        51.36       118.03         135.26
51701      Insert bladder catheter              X            X        0340     0.6137        27.17        62.44          71.56
51702      Insert temp bladder cath             X            X        0340     0.6137        27.17        62.44          71.56
51703      Insert bladder cath, complex         T            T        0164     1.1600        51.36       118.03         135.26
51705      Change of bladder tube               T            T        0121     2.2374        99.07       227.66         260.88
51710      Change of bladder tube               T            T        0122     6.9179       306.32       703.90         806.63
51715      Endoscopic injection/implant         T            T        0168    28.1985      1,248.63     2,869.20       3,287.95
51720      Treatment of bladder lesion          T            T        0156     2.6123       115.67       265.80         304.59
51725      Simple cystometrogram                T            T        0156     2.6123       115.67       265.80         304.59

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 79 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

51726      Complex cystometrogram               T            T        0156     2.6123       115.67       265.80         304.59
51736      Urine flow measurement               T            T        0164     1.1600        51.36       118.03         135.26
51741      Electro-uroflowmetry, first          T            T        0164     1.1600        51.36       118.03         135.26
51772      Urethra pressure profile             T            T        0156     2.6123       115.67       265.80         304.59
51784      Anal/urinary muscle study            T            T        0164     1.1600        51.36       118.03         135.26
51785      Anal/urinary muscle study            T            T        0164     1.1600        51.36       118.03         135.26
51792      Urinary reflex study                 T            T        0164     1.1600        51.36       118.03         135.26
51795      Urine voiding pressure study         T            T        0164     1.1600        51.36       118.03         135.26
51797      Intraabdominal pressure test         T            T        0164     1.1600        51.36       118.03         135.26
51798      Us urine capacity measure            X            X        0340     0.6137        27.17        62.44          71.56
51800      Revision of bladder/urethra          C            C        0000     0.0000        0.00         0.00           0.00
51820      Revision of urinary tract            C            C        0000     0.0000        0.00         0.00           0.00
51840      Attach bladder/urethra               C            C        0000     0.0000        0.00         0.00           0.00
51841      Attach bladder/urethra               C            C        0000     0.0000        0.00         0.00           0.00
51845      Repair bladder neck                  C            C        0000     0.0000        0.00         0.00           0.00
51860      Repair of bladder wound              C            C        0000     0.0000        0.00         0.00           0.00
51865      Repair of bladder wound              C            C        0000     0.0000        0.00         0.00           0.00
51880      Repair of bladder opening            T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
51900      Repair bladder/vagina lesion         C            C        0000     0.0000        0.00         0.00           0.00
51920      Close bladder-uterus fistula         C            C        0000     0.0000        0.00         0.00           0.00
51925      Hysterectomy/bladder repair          C            C        0000     0.0000        0.00         0.00           0.00
51940      Correction of bladder defect         C            C        0000     0.0000        0.00         0.00           0.00
51960      Revision of bladder & bowel          C            C        0000     0.0000        0.00         0.00           0.00
51980      Construct bladder opening            C            C        0000     0.0000        0.00         0.00           0.00
51990      Laparo urethral suspension           T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
51992      Laparo sling operation               T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
51999      Laparoscope proc, bladder            T            1        0000     0.0000        0.00         0.00           0.00
52000      Cystoscopy                           T            T        0160     6.9387       307.25       706.01         809.05
52001      Cystoscopy, removal of clots         T            T        0160     6.9387       307.25       706.01         809.05
52005      Cystoscopy & ureter catheter         T            T        0161    18.5804       822.74      1,890.56       2,166.47
52007      Cystoscopy and biopsy                T            T        0161    18.5804       822.74      1,890.56       2,166.47
52010      Cystoscopy & duct catheter           T            T        0160     6.9387       307.25       706.01         809.05
52204      Cystoscopy                           T            T        0161    18.5804       822.74      1,890.56       2,166.47
52214      Cystoscopy and treatment             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52224      Cystoscopy and treatment             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52234      Cystoscopy and treatment             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52235      Cystoscopy and treatment             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52240      Cystoscopy and treatment             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52250      Cystoscopy and radiotracer           T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52260      Cystoscopy and treatment             T            T        0161    18.5804       822.74      1,890.56       2,166.47
52265      Cystoscopy and treatment             T            T        0160     6.9387       307.25       706.01         809.05
52270      Cystoscopy & revise urethra          T            T        0161    18.5804       822.74      1,890.56       2,166.47
52275      Cystoscopy & revise urethra          T            T        0161    18.5804       822.74      1,890.56       2,166.47
52276      Cystoscopy and treatment             T            T        0161    18.5804       822.74      1,890.56       2,166.47
52277      Cystoscopy and treatment             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52281      Cystoscopy and treatment             T            T        0161    18.5804       822.74      1,890.56       2,166.47
52282      Cystoscopy, implant stent            T            T        0163    33.5963      1,487.64     3,418.42       3,917.33
52283      Cystoscopy and treatment             T            T        0161    18.5804       822.74      1,890.56       2,166.47
52285      Cystoscopy and treatment             T            T        0161    18.5804       822.74      1,890.56       2,166.47
52290      Cystoscopy and treatment             T            T        0161    18.5804       822.74      1,890.56       2,166.47
52300      Cystoscopy and treatment             T            T        0161    18.5804       822.74      1,890.56       2,166.47
52301      Cystoscopy and treatment             T            T        0161    18.5804       822.74      1,890.56       2,166.47
52305      Cystoscopy and treatment             T            T        0161    18.5804       822.74      1,890.56       2,166.47

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 80 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

52310      Cystoscopy and treatment             T            T        0160     6.9387       307.25       706.01         809.05
52315      Cystoscopy and treatment             T            T        0161    18.5804       822.74      1,890.56       2,166.47
52317      Remove bladder stone                 T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52318      Remove bladder stone                 T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52320      Cystoscopy and treatment             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52325      Cystoscopy, stone removal            T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52327      Cystoscopy, inject material          T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52330      Cystoscopy and treatment             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52332      Cystoscopy and treatment             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52334      Create passage to kidney             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52341      Cysto w/ureter stricture tx          T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52342      Cysto w/up stricture tx              T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52343      Cysto w/renal stricture tx           T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52344      Cysto/uretero, stricture tx          T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52345      Cysto/uretero w/up stricture         T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52346      Cystouretero w/renal strict          T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52351      Cystouretero & or pyeloscope         T            T        0161    18.5804       822.74      1,890.56       2,166.47
52352      Cystouretero w/stone remove          T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52353      Cystouretero w/lithotripsy           T            T        0163    33.5963      1,487.64     3,418.42       3,917.33
52354      Cystouretero w/biopsy                T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52355      Cystouretero w/excise tumor          T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52400      Cystouretero w/congen repr           T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52402      Cystourethro cut ejacul duct         T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52450      Incision of prostate                 T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52500      Revision of bladder neck             T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52510      Dilation prostatic urethra           T            T        0161    18.5804       822.74      1,890.56       2,166.47
52601      Prostatectomy (TURP)                 T            T        0163    33.5963      1,487.64     3,418.42       3,917.33
52606      Control postop bleeding              T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52612      Prostatectomy, first stage           T            T        0163    33.5963      1,487.64     3,418.42       3,917.33
52614      Prostatectomy, second stage          T            T        0163    33.5963      1,487.64     3,418.42       3,917.33
52620      Remove residual prostate             T            T        0163    33.5963      1,487.64     3,418.42       3,917.33
52630      Remove prostate regrowth             T            T        0163    33.5963      1,487.64     3,418.42       3,917.33
52640      Relieve bladder contracture          T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
52647      Laser surgery of prostate            T            T        0429    42.0802      1,863.31     4,281.66       4,906.55
52648      Laser surgery of prostate            T            T        0429    42.0802      1,863.31     4,281.66       4,906.55
52700      Drainage of prostate abscess         T            T        0162    23.3383      1,033.42     2,374.67       2,721.25
53000      Incision of urethra                  T            T        0166    17.7635       786.57      1,807.44       2,071.22
53010      Incision of urethra                  T            T        0166    17.7635       786.57      1,807.44       2,071.22
53020      Incision of urethra                  T            T        0166    17.7635       786.57      1,807.44       2,071.22
53025      Incision of urethra                  T            T        0166    17.7635       786.57      1,807.44       2,071.22
53040      Drainage of urethra abscess          T            T        0166    17.7635       786.57      1,807.44       2,071.22
53060      Drainage of urethra abscess          T            T        0166    17.7635       786.57      1,807.44       2,071.22
53080      Drainage of urinary leakage          T            T        0166    17.7635       786.57      1,807.44       2,071.22
53085      Drainage of urinary leakage          T            T        0166    17.7635       786.57      1,807.44       2,071.22
53200      Biopsy of urethra                    T            T        0166    17.7635       786.57      1,807.44       2,071.22
53210      Removal of urethra                   T            T        0168    28.1985      1,248.63     2,869.20       3,287.95
53215      Removal of urethra                   T            T        0166    17.7635       786.57      1,807.44       2,071.22
53220      Treatment of urethra lesion          T            T        0168    28.1985      1,248.63     2,869.20       3,287.95
53230      Removal of urethra lesion            T            T        0168    28.1985      1,248.63     2,869.20       3,287.95
53235      Removal of urethra lesion            T            T        0166    17.7635       786.57      1,807.44       2,071.22
53240      Surgery for urethra pouch            T            T        0168    28.1985      1,248.63     2,869.20       3,287.95
53250      Removal of urethra gland             T            T        0166    17.7635       786.57      1,807.44       2,071.22
53260      Treatment of urethra lesion          T            T        0166    17.7635       786.57      1,807.44       2,071.22

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 81 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                             82 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

54115      Treatment of penis lesion            T            T        0008    16.2953       721.56      1,658.05       1,900.03
54120      Partial removal of penis             T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54125      Removal of penis                     C            C        0000     0.0000        0.00         0.00           0.00
54130      Remove penis & nodes                 C            C        0000     0.0000        0.00         0.00           0.00
54135      Remove penis & nodes                 C            C        0000     0.0000        0.00         0.00           0.00
54150      Circumcision                         T            T        0180    19.7721       875.51      2,011.81       2,305.43
54152      Circumcision                         T            T        0180    19.7721       875.51      2,011.81       2,305.43
54160      Circumcision                         T            T        0180    19.7721       875.51      2,011.81       2,305.43
54161      Circumcision                         T            T        0180    19.7721       875.51      2,011.81       2,305.43
54162      Lysis penil circumic lesion          T            T        0180    19.7721       875.51      2,011.81       2,305.43
54163      Repair of circumcision               T            T        0180    19.7721       875.51      2,011.81       2,305.43
54164      Frenulotomy of penis                 T            T        0180    19.7721       875.51      2,011.81       2,305.43
54200      Treatment of penis lesion            T            T        0156     2.6123       115.67       265.80         304.59
54205      Treatment of penis lesion            T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54220      Treatment of penis lesion            T            T        0156     2.6123       115.67       265.80         304.59
54230      Prepare penis study                  N            N        0000     0.0000        0.00         0.00           0.00
54231      Dynamic cavernosometry               T            T        0165    16.5343       732.14      1,682.37       1,927.90
54235      Penile injection                     T            T        0164     1.1600        51.36       118.03         135.26
54240      Penis study                          T            1        0000     0.0000        0.00         0.00           0.00
54250      Penis study                          T            1        0000     0.0000        0.00         0.00           0.00
54300      Revision of penis                    T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54304      Revision of penis                    T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54308      Reconstruction of urethra            T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54312      Reconstruction of urethra            T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54316      Reconstruction of urethra            T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54318      Reconstruction of urethra            T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54322      Reconstruction of urethra            T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54324      Reconstruction of urethra            T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54326      Reconstruction of urethra            T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54328      Revise penis/urethra                 T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54332      Revise penis/urethra                 C            C        0000     0.0000        0.00         0.00           0.00
54336      Revise penis/urethra                 C            C        0000     0.0000        0.00         0.00           0.00
54340      Secondary urethral surgery           T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54344      Secondary urethral surgery           T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54348      Secondary urethral surgery           T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54352      Reconstruct urethra/penis            T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54360      Penis plastic surgery                T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54380      Repair penis                         T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54385      Repair penis                         T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54390      Repair penis and bladder             C            C        0000     0.0000        0.00         0.00           0.00
54400      Insert semi-rigid prosthesis         S            1        0000     0.0000        0.00         0.00           0.00
54401      Insert self-contd prosthesis         S            1        0000     0.0000        0.00         0.00           0.00
54405      Insert multi-comp penis pros         S            1        0000     0.0000        0.00         0.00           0.00
54406      Remove muti-comp penis pros          T            1        0000     0.0000        0.00         0.00           0.00
54408      Repair multi-comp penis pros         T            1        0000     0.0000        0.00         0.00           0.00
54410      Remove/replace penis prosth          S            1        0000     0.0000        0.00         0.00           0.00
54411      Remov/replc penis pros, comp         C            1        0000     0.0000        0.00         0.00           0.00
54415      Remove self-contd penis pros         T            1        0000     0.0000        0.00         0.00           0.00
54416      Remv/repl penis contain pros         S            1        0000     0.0000        0.00         0.00           0.00
54417      Remv/replc penis pros, compl         C            1        0000     0.0000        0.00         0.00           0.00
54420      Revision of penis                    T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54430      Revision of penis                    C            C        0000     0.0000        0.00         0.00           0.00
54435      Revision of penis                    T            T        0181    30.9472      1,370.34     3,148.88       3,608.44

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 83 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

54440      Repair of penis                      T            T        0181    30.9472      1,370.34     3,148.88       3,608.44
54450      Preputial stretching                 T            T        0156     2.6123       115.67       265.80         304.59
54500      Biopsy of testis                     T            T        0037     9.6103       425.54       977.85        1,120.56
54505      Biopsy of testis                     T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54512      Excise lesion testis                 T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54520      Removal of testis                    T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54522      Orchiectomy, partial                 T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54530      Removal of testis                    T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
54535      Extensive testis surgery             C            C        0000     0.0000        0.00         0.00           0.00
54550      Exploration for testis               T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
54560      Exploration for testis               T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54600      Reduce testis torsion                T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54620      Suspension of testis                 T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54640      Suspension of testis                 T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
54650      Orchiopexy (Fowler-Stephens)         C            C        0000     0.0000        0.00         0.00           0.00
54660      Revision of testis                   T            1        0000     0.0000        0.00         0.00           0.00
54670      Repair testis injury                 T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54680      Relocation of testis(es)             T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54690      Laparoscopy, orchiectomy             T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
54692      Laparoscopy, orchiopexy              T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
54699      Laparoscope proc, testis             T            1        0000     0.0000        0.00         0.00           0.00
54700      Drainage of scrotum                  T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54800      Biopsy of epididymis                 T            T        0004     1.7771        78.69       180.82         207.21
54820      Exploration of epididymis            T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54830      Remove epididymis lesion             T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54840      Remove epididymis lesion             T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54860      Removal of epididymis                T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54861      Removal of epididymis                T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54900      Fusion of spermatic ducts            T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
54901      Fusion of spermatic ducts            T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55000      Drainage of hydrocele                T            T        0004     1.7771        78.69       180.82         207.21
55040      Removal of hydrocele                 T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
55041      Removal of hydroceles                T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
55060      Repair of hydrocele                  T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55100      Drainage of scrotum abscess          T            T        0008    16.2953       721.56      1,658.05       1,900.03
55110      Explore scrotum                      T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55120      Removal of scrotum lesion            T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55150      Removal of scrotum                   T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55175      Revision of scrotum                  T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55180      Revision of scrotum                  T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55200      Incision of sperm duct               T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55250      Removal of sperm duct(s)             T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55300      Prepare, sperm duct x-ray            N            N        0000     0.0000        0.00         0.00           0.00
55400      Repair of sperm duct                 T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55450      Ligation of sperm duct               T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55500      Removal of hydrocele                 T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55520      Removal of sperm cord lesion         T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55530      Revise spermatic cord veins          T            T        0183    23.3500      1,033.94     2,375.86       2,722.61
55535      Revise spermatic cord veins          T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
55540      Revise hernia & sperm veins          T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
55550      Laparo ligate spermatic vein         T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
55559      Laparo proc, spermatic cord          T            1        0000     0.0000        0.00         0.00           0.00
55600      Incise sperm duct pouch              T            T        0183    23.3500      1,033.94     2,375.86       2,722.61

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 84 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

55605      Incise sperm duct pouch              C            C        0000    0.0000         0.00         0.00         0.00
55650      Remove sperm duct pouch              C            C        0000    0.0000         0.00         0.00         0.00
55680      Remove sperm pouch lesion            T            T        0183   23.3500       1,033.94     2,375.86     2,722.61
55700      Biopsy of prostate                   T            T        0184    4.4432        196.74       452.10       518.08
55705      Biopsy of prostate                   T            T        0184    4.4432        196.74       452.10       518.08
55720      Drainage of prostate abscess         T            T        0162   23.3383       1,033.42     2,374.67     2,721.25
55725      Drainage of prostate abscess         T            T        0162   23.3383       1,033.42     2,374.67     2,721.25
55801      Removal of prostate                  C            C        0000    0.0000         0.00         0.00         0.00
55810      Extensive prostate surgery           C            C        0000    0.0000         0.00         0.00         0.00
55812      Extensive prostate surgery           C            C        0000    0.0000         0.00         0.00         0.00
55815      Extensive prostate surgery           C            C        0000    0.0000         0.00         0.00         0.00
55821      Removal of prostate                  C            C        0000    0.0000         0.00         0.00         0.00
55831      Removal of prostate                  C            C        0000    0.0000         0.00         0.00         0.00
55840      Extensive prostate surgery           C            C        0000    0.0000         0.00         0.00         0.00
55842      Extensive prostate surgery           C            C        0000    0.0000         0.00         0.00         0.00
55845      Extensive prostate surgery           C            C        0000    0.0000         0.00         0.00         0.00
55859      Percut/needle insert, pros           T            T        0163   33.5963       1,487.64     3,418.42     3,917.33
55860      Surgical exposure, prostate          T            T        0165   16.5343        732.14      1,682.37     1,927.90
55862      Extensive prostate surgery           C            C        0000    0.0000         0.00         0.00         0.00
55865      Extensive prostate surgery           C            C        0000    0.0000         0.00         0.00         0.00
55866      Laparo radical prostatectomy         C            C        0000    0.0000         0.00         0.00         0.00
55870      Electroejaculation                   T            1        0000    0.0000         0.00         0.00         0.00
55873      Cryoablate prostate                  T            T        0674   111.3747      4,931.67    11,332.38    12,986.29
55899      Genital surgery procedure            T            1        0000    0.0000         0.00         0.00         0.00
55970      Sex transformation, M to F           E            1        0000    0.0000         0.00         0.00         0.00
55980      Sex transformation, F to M           E            1        0000    0.0000         0.00         0.00         0.00
56405      I & D of vulva/perineum              T            T        0189    2.3805        105.41       242.22       277.57
56420      Drainage of gland abscess            T            T        0189    2.3805        105.41       242.22       277.57
56440      Surgery for vulva lesion             T            T        0194   20.6573        914.71      2,101.88     2,408.64
56441      Lysis of labial lesion(s)            T            T        0193   14.6385        648.19      1,489.47     1,706.85
56501      Destroy, vulva lesions, sim          T            T        0017   17.9937        796.76      1,830.86     2,098.07
56515      Destroy vulva lesion/s compl         T            T        0695   20.2372        896.10      2,059.14     2,359.66
56605      Biopsy of vulva/perineum             T            T        0019    4.1481        183.68       422.07       483.67
56606      Biopsy of vulva/perineum             T            T        0019    4.1481        183.68       422.07       483.67
56620      Partial removal of vulva             T            T        0195   26.7972       1,186.58     2,726.62     3,124.55
56625      Complete removal of vulva            T            T        0195   26.7972       1,186.58     2,726.62     3,124.55
56630      Extensive vulva surgery              C            C        0000    0.0000         0.00         0.00         0.00
56631      Extensive vulva surgery              C            C        0000    0.0000         0.00         0.00         0.00
56632      Extensive vulva surgery              C            C        0000    0.0000         0.00         0.00         0.00
56633      Extensive vulva surgery              C            C        0000    0.0000         0.00         0.00         0.00
56634      Extensive vulva surgery              C            C        0000    0.0000         0.00         0.00         0.00
56637      Extensive vulva surgery              C            C        0000    0.0000         0.00         0.00         0.00
56640      Extensive vulva surgery              C            C        0000    0.0000         0.00         0.00         0.00
56700      Partial removal of hymen             T            T        0194   20.6573        914.71      2,101.88     2,408.64
56720      Incision of hymen                    T            T        0193   14.6385        648.19      1,489.47     1,706.85
56740      Remove vagina gland lesion           T            T        0194   20.6573        914.71      2,101.88     2,408.64
56800      Repair of vagina                     T            T        0194   20.6573        914.71      2,101.88     2,408.64
56805      Repair clitoris                      T            T        0193   14.6385        648.19      1,489.47     1,706.85
56810      Repair of perineum                   T            T        0194   20.6573        914.71      2,101.88     2,408.64
56820      Exam of vulva w/scope                T            T        0188    1.2615         55.86       128.36       147.09
56821      Exam/biopsy of vulva w/scope         T            T        0189    2.3805        105.41       242.22       277.57
57000      Exploration of vagina                T            T        0193   14.6385        648.19      1,489.47     1,706.85
57010      Drainage of pelvic abscess           T            T        0193   14.6385        648.19      1,489.47     1,706.85

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                             85 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

57020      Drainage of pelvic fluid             T            T        0192     4.1597       184.19       423.25         485.02
57022      I & d vaginal hematoma, pp           T            T        0007    11.6717       516.82      1,187.60       1,360.92
57023      I & d vag hematoma, non-ob           T            T        0008    16.2953       721.56      1,658.05       1,900.03
57061      Destroy vag lesions, simple          T            T        0194    20.6573       914.71      2,101.88       2,408.64
57065      Destroy vag lesions, complex         T            T        0194    20.6573       914.71      2,101.88       2,408.64
57100      Biopsy of vagina                     T            T        0192     4.1597       184.19       423.25         485.02
57105      Biopsy of vagina                     T            T        0194    20.6573       914.71      2,101.88       2,408.64
57106      Remove vagina wall, partial          T            T        0194    20.6573       914.71      2,101.88       2,408.64
57107      Remove vagina tissue, part           T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57109      Vaginectomy partial w/nodes          T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57110      Remove vagina wall, complete         C            C        0000     0.0000        0.00         0.00           0.00
57111      Remove vagina tissue, compl          C            C        0000     0.0000        0.00         0.00           0.00
57112      Vaginectomy w/nodes, compl           C            C        0000     0.0000        0.00         0.00           0.00
57120      Closure of vagina                    T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57130      Remove vagina lesion                 T            T        0194    20.6573       914.71      2,101.88       2,408.64
57135      Remove vagina lesion                 T            T        0194    20.6573       914.71      2,101.88       2,408.64
57150      Treat vagina infection               T            T        0191     0.1702        7.54         17.32          19.85
57155      Insert uteri tandems/ovoids          T            T        0192     4.1597       184.19       423.25         485.02
57160      Insert pessary/other device          T            T        0188     1.2615        55.86       128.36         147.09
57170      Fitting of diaphragm/cap             T            T        0191     0.1702        7.54         17.32          19.85
57180      Treat vaginal bleeding               T            T        0189     2.3805       105.41       242.22         277.57
57200      Repair of vagina                     T            T        0194    20.6573       914.71      2,101.88       2,408.64
57210      Repair vagina/perineum               T            T        0194    20.6573       914.71      2,101.88       2,408.64
57220      Revision of urethra                  T            T        0202    41.2319      1,825.75     4,195.35       4,807.64
57230      Repair of urethral lesion            T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57240      Repair bladder & vagina              T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57250      Repair rectum & vagina               T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57260      Repair of vagina                     T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57265      Extensive repair of vagina           T            T        0202    41.2319      1,825.75     4,195.35       4,807.64
57267      Insert mesh/pelvic flr addon         T            T        0154    28.6432      1,268.32     2,914.45       3,339.80
57268      Repair of bowel bulge                T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57270      Repair of bowel pouch                C            C        0000     0.0000        0.00         0.00           0.00
57280      Suspension of vagina                 C            C        0000     0.0000        0.00         0.00           0.00
57282      Colpopexy, extraperitoneal           C            C        0000     0.0000        0.00         0.00           0.00
57283      Colpopexy, intraperitoneal           C            C        0000     0.0000        0.00         0.00           0.00
57284      Repair paravaginal defect            T            T        0202    41.2319      1,825.75     4,195.35       4,807.64
57287      Revise/remove sling repair           T            T        0202    41.2319      1,825.75     4,195.35       4,807.64
57288      Repair bladder defect                T            T        0202    41.2319      1,825.75     4,195.35       4,807.64
57289      Repair bladder & vagina              T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57291      Construction of vagina               T            1        0000     0.0000        0.00         0.00           0.00
57292      Construct vagina with graft          C            1        0000     0.0000        0.00         0.00           0.00
57295      Change vaginal graft                 T            1        0000     0.0000        0.00         0.00           0.00
57300      Repair rectum-vagina fistula         T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57305      Repair rectum-vagina fistula         C            C        0000     0.0000        0.00         0.00           0.00
57307      Fistula repair & colostomy           C            C        0000     0.0000        0.00         0.00           0.00
57308      Fistula repair, transperine          C            C        0000     0.0000        0.00         0.00           0.00
57310      Repair urethrovaginal lesion         T            T        0202    41.2319      1,825.75     4,195.35       4,807.64
57311      Repair urethrovaginal lesion         C            C        0000     0.0000        0.00         0.00           0.00
57320      Repair bladder-vagina lesion         T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57330      Repair bladder-vagina lesion         T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57335      Repair vagina                        C            C        0000     0.0000        0.00         0.00           0.00
57400      Dilation of vagina                   T            T        0194    20.6573       914.71      2,101.88       2,408.64
57410      Pelvic examination                   T            T        0193    14.6385       648.19      1,489.47       1,706.85

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 86 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

57415      Remove vaginal foreign body          T            T        0194    20.6573       914.71      2,101.88       2,408.64
57420      Exam of vagina w/scope               T            T        0189     2.3805       105.41       242.22         277.57
57421      Exam/biopsy of vag w/scope           T            T        0189     2.3805       105.41       242.22         277.57
57425      Laparoscopy, surg, colpopexy         T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
57452      Exam of cervix w/scope               T            T        0189     2.3805       105.41       242.22         277.57
57454      Bx/curett of cervix w/scope          T            T        0189     2.3805       105.41       242.22         277.57
57455      Biopsy of cervix w/scope             T            T        0189     2.3805       105.41       242.22         277.57
57456      Endocerv curettage w/scope           T            T        0189     2.3805       105.41       242.22         277.57
57460      Bx of cervix w/scope, leep           T            T        0193    14.6385       648.19      1,489.47       1,706.85
57461      Conz of cervix w/scope, leep         T            T        0194    20.6573       914.71      2,101.88       2,408.64
57500      Biopsy of cervix                     T            T        0192     4.1597       184.19       423.25         485.02
57505      Endocervical curettage               T            T        0189     2.3805       105.41       242.22         277.57
57510      Cauterization of cervix              T            T        0193    14.6385       648.19      1,489.47       1,706.85
57511      Cryocautery of cervix                T            T        0189     2.3805       105.41       242.22         277.57
57513      Laser surgery of cervix              T            T        0193    14.6385       648.19      1,489.47       1,706.85
57520      Conization of cervix                 T            T        0194    20.6573       914.71      2,101.88       2,408.64
57522      Conization of cervix                 T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57530      Removal of cervix                    T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57531      Removal of cervix, radical           C            C        0000     0.0000        0.00         0.00           0.00
57540      Removal of residual cervix           C            C        0000     0.0000        0.00         0.00           0.00
57545      Remove cervix/repair pelvis          C            C        0000     0.0000        0.00         0.00           0.00
57550      Removal of residual cervix           T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57555      Remove cervix/repair vagina          T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
57556      Remove cervix, repair bowel          T            T        0202    41.2319      1,825.75     4,195.35       4,807.64
57700      Revision of cervix                   T            T        0194    20.6573       914.71      2,101.88       2,408.64
57720      Revision of cervix                   T            T        0194    20.6573       914.71      2,101.88       2,408.64
57800      Dilation of cervical canal           T            T        0193    14.6385       648.19      1,489.47       1,706.85
57820      D & c of residual cervix             T            T        0196    17.0012       752.81      1,729.87       1,982.34
58100      Biopsy of uterus lining              T            T        0188     1.2615        55.86       128.36         147.09
58110      Bx done w/colposcopy add-on          T            T        0188     1.2615        55.86       128.36         147.09
58120      Dilation and curettage               T            T        0196    17.0012       752.81      1,729.87       1,982.34
58140      Myomectomy abdom method              C            C        0000     0.0000        0.00         0.00           0.00
58145      Myomectomy vag method                T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
58146      Myomectomy abdom complex             C            C        0000     0.0000        0.00         0.00           0.00
58150      Total hysterectomy                   C            C        0000     0.0000        0.00         0.00           0.00
58152      Total hysterectomy                   C            C        0000     0.0000        0.00         0.00           0.00
58180      Partial hysterectomy                 C            C        0000     0.0000        0.00         0.00           0.00
58200      Extensive hysterectomy               C            C        0000     0.0000        0.00         0.00           0.00
58210      Extensive hysterectomy               C            C        0000     0.0000        0.00         0.00           0.00
58240      Removal of pelvis contents           C            C        0000     0.0000        0.00         0.00           0.00
58260      Vaginal hysterectomy                 C            C        0000     0.0000        0.00         0.00           0.00
58262      Vag hyst including t/o               C            C        0000     0.0000        0.00         0.00           0.00
58263      Vag hyst w/t/o & vag repair          C            C        0000     0.0000        0.00         0.00           0.00
58267      Vag hyst w/urinary repair            C            C        0000     0.0000        0.00         0.00           0.00
58270      Vag hyst w/enterocele repair         C            C        0000     0.0000        0.00         0.00           0.00
58275      Hysterectomy/revise vagina           C            C        0000     0.0000        0.00         0.00           0.00
58280      Hysterectomy/revise vagina           C            C        0000     0.0000        0.00         0.00           0.00
58285      Extensive hysterectomy               C            C        0000     0.0000        0.00         0.00           0.00
58290      Vag hyst complex                     C            C        0000     0.0000        0.00         0.00           0.00
58291      Vag hyst incl t/o, complex           C            C        0000     0.0000        0.00         0.00           0.00
58292      Vag hyst t/o & repair, compl         C            C        0000     0.0000        0.00         0.00           0.00
58293      Vag hyst w/uro repair, compl         C            C        0000     0.0000        0.00         0.00           0.00
58294      Vag hyst w/enterocele, compl         C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 87 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

58300      Insert intrauterine device           E            3        0000     0.0000        M01          M01            M01
58301      Remove intrauterine device           T            T        0189     2.3805       105.41       242.22         277.57
58321      Artificial insemination              T            1        0000     0.0000        0.00         0.00           0.00
58322      Artificial insemination              T            1        0000     0.0000        0.00         0.00           0.00
58323      Sperm washing                        T            1        0000     0.0000        0.00         0.00           0.00
58340      Catheter for hysterography           N            1        0000     0.0000        0.00         0.00           0.00
58345      Reopen fallopian tube                T            1        0000     0.0000        0.00         0.00           0.00
58346      Insert heyman uteri capsule          T            1        0000     0.0000        0.00         0.00           0.00
58350      Reopen fallopian tube                T            1        0000     0.0000        0.00         0.00           0.00
58353      Endometr ablate, thermal             T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
58356      Endometrial cryoablation             T            T        0202    41.2319      1,825.75     4,195.35       4,807.64
58400      Suspension of uterus                 C            C        0000     0.0000        0.00         0.00           0.00
58410      Suspension of uterus                 C            C        0000     0.0000        0.00         0.00           0.00
58520      Repair of ruptured uterus            C            C        0000     0.0000        0.00         0.00           0.00
58540      Revision of uterus                   C            C        0000     0.0000        0.00         0.00           0.00
58545      Laparoscopic myomectomy              T            T        0130    31.8753      1,411.44     3,243.31       3,716.66
58546      Laparo-myomectomy, complex           T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
58550      Laparo-asst vag hysterectomy         T            T        0132    63.6859      2,820.01     6,480.04       7,425.78
58552      Laparo-vag hyst incl t/o             T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
58553      Laparo-vag hyst, complex             T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
58554      Laparo-vag hyst w/t/o, compl         T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
58555      Hysteroscopy, dx, sep proc           T            T        0190    20.9198       926.33      2,128.59       2,439.25
58558      Hysteroscopy, biopsy                 T            T        0190    20.9198       926.33      2,128.59       2,439.25
58559      Hysteroscopy, lysis                  T            T        0190    20.9198       926.33      2,128.59       2,439.25
58560      Hysteroscopy, resect septum          T            T        0387    32.3170      1,431.00     3,288.25       3,768.16
58561      Hysteroscopy, remove myoma           T            T        0387    32.3170      1,431.00     3,288.25       3,768.16
58562      Hysteroscopy, remove fb              T            T        0190    20.9198       926.33      2,128.59       2,439.25
58563      Hysteroscopy, ablation               T            T        0387    32.3170      1,431.00     3,288.25       3,768.16
58565      Hysteroscopy, sterilization          T            T        0202    41.2319      1,825.75     4,195.35       4,807.64
58578      Laparo proc, uterus                  T            1        0000     0.0000        0.00         0.00           0.00
58579      Hysteroscope procedure               T            1        0000     0.0000        0.00         0.00           0.00
58600      Division of fallopian tube           T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
58605      Division of fallopian tube           C            C        0000     0.0000        0.00         0.00           0.00
58611      Ligate oviduct(s) add-on             C            C        0000     0.0000        0.00         0.00           0.00
58615      Occlude fallopian tube(s)            T            T        0194    20.6573       914.71      2,101.88       2,408.64
58660      Laparoscopy, lysis                   T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
58661      Laparoscopy, remove adnexa           T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
58662      Laparoscopy, excise lesions          T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
58670      Laparoscopy, tubal cautery           T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
58671      Laparoscopy, tubal block             T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
58672      Laparoscopy, fimbrioplasty           T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
58673      Laparoscopy, salpingostomy           T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
58679      Laparo proc, oviduct-ovary           T            1        0000     0.0000        0.00         0.00           0.00
58700      Removal of fallopian tube            C            C        0000     0.0000        0.00         0.00           0.00
58720      Removal of ovary/tube(s)             C            C        0000     0.0000        0.00         0.00           0.00
58740      Revise fallopian tube(s)             C            C        0000     0.0000        0.00         0.00           0.00
58750      Repair oviduct                       C            1        0000     0.0000        0.00         0.00           0.00
58752      Revise ovarian tube(s)               C            1        0000     0.0000        0.00         0.00           0.00
58760      Remove tubal obstruction             C            1        0000     0.0000        0.00         0.00           0.00
58770      Create new tubal opening             T            1        0000     0.0000        0.00         0.00           0.00
58800      Drainage of ovarian cyst(s)          T            T        0193    14.6385       648.19      1,489.47       1,706.85
58805      Drainage of ovarian cyst(s)          C            C        0000     0.0000        0.00         0.00           0.00
58820      Drain ovary abscess, open            T            T        0195    26.7972      1,186.58     2,726.62       3,124.55

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 88 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

58822      Drain ovary abscess, percut          C            C        0000     0.0000        0.00         0.00           0.00
58823      Drain pelvic abscess, percut         T            T        0193    14.6385       648.19      1,489.47       1,706.85
58825      Transposition, ovary(s)              C            C        0000     0.0000        0.00         0.00           0.00
58900      Biopsy of ovary(s)                   T            T        0193    14.6385       648.19      1,489.47       1,706.85
58920      Partial removal of ovary(s)          T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
58925      Removal of ovarian cyst(s)           T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
58940      Removal of ovary(s)                  C            C        0000     0.0000        0.00         0.00           0.00
58943      Removal of ovary(s)                  C            C        0000     0.0000        0.00         0.00           0.00
58950      Resect ovarian malignancy            C            C        0000     0.0000        0.00         0.00           0.00
58951      Resect ovarian malignancy            C            C        0000     0.0000        0.00         0.00           0.00
58952      Resect ovarian malignancy            C            C        0000     0.0000        0.00         0.00           0.00
58953      Tah, rad dissect for debulk          C            C        0000     0.0000        0.00         0.00           0.00
58954      Tah rad debulk/lymph remove          C            C        0000     0.0000        0.00         0.00           0.00
58956      Bso, omentectomy w/tah               C            C        0000     0.0000        0.00         0.00           0.00
58960      Exploration of abdomen               C            C        0000     0.0000        0.00         0.00           0.00
58970      Retrieval of oocyte                  T            1        0000     0.0000        0.00         0.00           0.00
58974      Transfer of embryo                   T            1        0000     0.0000        0.00         0.00           0.00
58976      Transfer of embryo                   T            1        0000     0.0000        0.00         0.00           0.00
58999      Genital surgery procedure            T            1        0000     0.0000        0.00         0.00           0.00
59000      Amniocentesis, diagnostic            T            T        0198     1.3622        60.32       138.60         158.83
59001      Amniocentesis, therapeutic           T            T        0192     4.1597       184.19       423.25         485.02
59012      Fetal cord puncture,prenatal         T            T        0198     1.3622        60.32       138.60         158.83
59015      Chorion biopsy                       T            T        0198     1.3622        60.32       138.60         158.83
59020      Fetal contract stress test           T            T        0192     4.1597       184.19       423.25         485.02
59025      Fetal non-stress test                T            T        0198     1.3622        60.32       138.60         158.83
59030      Fetal scalp blood sample             T            T        0198     1.3622        60.32       138.60         158.83
59050      Fetal monitor w/report               M            1        0000     0.0000        0.00         0.00           0.00
59051      Fetal monitor/interpret only         B            1        0000     0.0000        0.00         0.00           0.00
59070      Transabdom amnioinfus w/us           T            T        0198     1.3622        60.32       138.60         158.83
59072      Umbilical cord occlud w/us           T            T        0198     1.3622        60.32       138.60         158.83
59074      Fetal fluid drainage w/us            T            T        0198     1.3622        60.32       138.60         158.83
59076      Fetal shunt placement, w/us          T            T        0198     1.3622        60.32       138.60         158.83
59100      Remove uterus lesion                 T            T        0195    26.7972      1,186.58     2,726.62       3,124.55
59120      Treat ectopic pregnancy              C            C        0000     0.0000        0.00         0.00           0.00
59121      Treat ectopic pregnancy              C            C        0000     0.0000        0.00         0.00           0.00
59130      Treat ectopic pregnancy              C            C        0000     0.0000        0.00         0.00           0.00
59135      Treat ectopic pregnancy              C            C        0000     0.0000        0.00         0.00           0.00
59136      Treat ectopic pregnancy              C            C        0000     0.0000        0.00         0.00           0.00
59140      Treat ectopic pregnancy              C            C        0000     0.0000        0.00         0.00           0.00
59150      Treat ectopic pregnancy              T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
59151      Treat ectopic pregnancy              T            T        0131    43.0498      1,906.25     4,380.32       5,019.61
59160      D & c after delivery                 T            T        0196    17.0012       752.81      1,729.87       1,982.34
59200      Insert cervical dilator              T            T        0189     2.3805       105.41       242.22         277.57
59300      Episiotomy or vaginal repair         T            T        0193    14.6385       648.19      1,489.47       1,706.85
59320      Revision of cervix                   T            T        0194    20.6573       914.71      2,101.88       2,408.64
59325      Revision of cervix                   C            C        0000     0.0000        0.00         0.00           0.00
59350      Repair of uterus                     C            C        0000     0.0000        0.00         0.00           0.00
59400      Obstetrical care                     B            1        0000     0.0000        0.00         0.00           0.00
59409      Obstetrical care                     T            T        0194    20.6573       914.71      2,101.88       2,408.64
59410      Obstetrical care                     B            1        0000     0.0000        0.00         0.00           0.00
59412      Antepartum manipulation              T            T        0700     4.1398       183.31       421.22         482.70
59414      Deliver placenta                     T            T        0193    14.6385       648.19      1,489.47       1,706.85
59425      Antepartum care only                 B            1        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 89 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

59426      Antepartum care only                 B            1        0000     0.0000        0.00         0.00           0.00
59430      Care after delivery                  B            1        0000     0.0000        0.00         0.00           0.00
59510      Cesarean delivery                    B            1        0000     0.0000        0.00         0.00           0.00
59514      Cesarean delivery only               C            C        0000     0.0000        0.00         0.00           0.00
59515      Cesarean delivery                    E            1        0000     0.0000        0.00         0.00           0.00
59525      Remove uterus after cesarean         C            C        0000     0.0000        0.00         0.00           0.00
59610      Vbac delivery                        E            1        0000     0.0000        0.00         0.00           0.00
59612      Vbac delivery only                   T            T        0194    20.6573       914.71      2,101.88       2,408.64
59614      Vbac care after delivery             E            1        0000     0.0000        0.00         0.00           0.00
59618      Attempted vbac delivery              E            1        0000     0.0000        0.00         0.00           0.00
59620      Attempted vbac delivery only         C            C        0000     0.0000        0.00         0.00           0.00
59622      Attempted vbac after care            E            1        0000     0.0000        0.00         0.00           0.00
59812      Treatment of miscarriage             T            T        0201    17.4749       773.79      1,778.07       2,037.57
59820      Care of miscarriage                  T            T        0201    17.4749       773.79      1,778.07       2,037.57
59821      Treatment of miscarriage             T            T        0201    17.4749       773.79      1,778.07       2,037.57
59830      Treat uterus infection               C            C        0000     0.0000        0.00         0.00           0.00
59840      Abortion                             T            T        0200    18.9518       839.19      1,928.35       2,209.78
59841      Abortion                             T            T        0200    18.9518       839.19      1,928.35       2,209.78
59850      Abortion                             C            C        0000     0.0000        0.00         0.00           0.00
59851      Abortion                             C            C        0000     0.0000        0.00         0.00           0.00
59852      Abortion                             C            C        0000     0.0000        0.00         0.00           0.00
59855      Abortion                             C            C        0000     0.0000        0.00         0.00           0.00
59856      Abortion                             C            C        0000     0.0000        0.00         0.00           0.00
59857      Abortion                             C            C        0000     0.0000        0.00         0.00           0.00
59866      Abortion (mpr)                       T            T        0198     1.3622        60.32       138.60         158.83
59870      Evacuate mole of uterus              T            T        0201    17.4749       773.79      1,778.07       2,037.57
59871      Remove cerclage suture               T            T        0194    20.6573       914.71      2,101.88       2,408.64
59897      Fetal invas px w/us                  T            1        0000     0.0000        0.00         0.00           0.00
59898      Laparo proc, ob care/deliver         T            1        0000     0.0000        0.00         0.00           0.00
59899      Maternity care procedure             T            1        0000     0.0000        0.00         0.00           0.00
60000      Drain thyroid/tongue cyst            T            T        0252     8.1033       358.81       824.51         944.84
60001      Aspirate/inject thyriod cyst         T            T        0004     1.7771        78.69       180.82         207.21
60100      Biopsy of thyroid                    T            T        0004     1.7771        78.69       180.82         207.21
60200      Remove thyroid lesion                T            T        0114    40.4596      1,791.55     4,116.76       4,717.59
60210      Partial thyroid excision             T            T        0114    40.4596      1,791.55     4,116.76       4,717.59
60212      Partial thyroid excision             T            T        0114    40.4596      1,791.55     4,116.76       4,717.59
60220      Partial removal of thyroid           T            T        0114    40.4596      1,791.55     4,116.76       4,717.59
60225      Partial removal of thyroid           T            T        0114    40.4596      1,791.55     4,116.76       4,717.59
60240      Removal of thyroid                   T            T        0114    40.4596      1,791.55     4,116.76       4,717.59
60252      Removal of thyroid                   T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
60254      Extensive thyroid surgery            C            C        0000     0.0000        0.00         0.00           0.00
60260      Repeat thyroid surgery               T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
60270      Removal of thyroid                   C            C        0000     0.0000        0.00         0.00           0.00
60271      Removal of thyroid                   C            C        0000     0.0000        0.00         0.00           0.00
60280      Remove thyroid duct lesion           T            T        0114    40.4596      1,791.55     4,116.76       4,717.59
60281      Remove thyroid duct lesion           T            T        0114    40.4596      1,791.55     4,116.76       4,717.59
60500      Explore parathyroid glands           T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
60502      Re-explore parathyroids              C            C        0000     0.0000        0.00         0.00           0.00
60505      Explore parathyroid glands           C            C        0000     0.0000        0.00         0.00           0.00
60512      Autotransplant parathyroid           T            1        0000     0.0000        0.00         0.00           0.00
60520      Removal of thymus gland              C            C        0000     0.0000        0.00         0.00           0.00
60521      Removal of thymus gland              C            C        0000     0.0000        0.00         0.00           0.00
60522      Removal of thymus gland              C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 90 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

60540      Explore adrenal gland                C            C        0000     0.0000        0.00         0.00           0.00
60545      Explore adrenal gland                C            C        0000     0.0000        0.00         0.00           0.00
60600      Remove carotid body lesion           C            C        0000     0.0000        0.00         0.00           0.00
60605      Remove carotid body lesion           C            C        0000     0.0000        0.00         0.00           0.00
60650      Laparoscopy adrenalectomy            C            C        0000     0.0000        0.00         0.00           0.00
60659      Laparo proc, endocrine               T            1        0000     0.0000        0.00         0.00           0.00
60699      Endocrine surgery procedure          T            1        0000     0.0000        0.00         0.00           0.00
61000      Remove cranial cavity fluid          T            T        0212     2.7712       122.71       281.97         323.12
61001      Remove cranial cavity fluid          T            T        0212     2.7712       122.71       281.97         323.12
61020      Remove brain cavity fluid            T            T        0212     2.7712       122.71       281.97         323.12
61026      Injection into brain canal           T            T        0212     2.7712       122.71       281.97         323.12
61050      Remove brain canal fluid             T            T        0212     2.7712       122.71       281.97         323.12
61055      Injection into brain canal           T            T        0212     2.7712       122.71       281.97         323.12
61070      Brain canal shunt procedure          T            T        0212     2.7712       122.71       281.97         323.12
61105      Twist drill hole                     C            C        0000     0.0000        0.00         0.00           0.00
61107      Drill skull for implantation         C            C        0000     0.0000        0.00         0.00           0.00
61108      Drill skull for drainage             C            C        0000     0.0000        0.00         0.00           0.00
61120      Burr hole for puncture               C            C        0000     0.0000        0.00         0.00           0.00
61140      Pierce skull for biopsy              C            C        0000     0.0000        0.00         0.00           0.00
61150      Pierce skull for drainage            C            C        0000     0.0000        0.00         0.00           0.00
61151      Pierce skull for drainage            C            C        0000     0.0000        0.00         0.00           0.00
61154      Pierce skull & remove clot           C            C        0000     0.0000        0.00         0.00           0.00
61156      Pierce skull for drainage            C            C        0000     0.0000        0.00         0.00           0.00
61210      Pierce skull, implant device         C            C        0000     0.0000        0.00         0.00           0.00
61215      Insert brain-fluid device            T            T        0224    41.1421      1,821.77     4,186.21       4,797.17
61250      Pierce skull & explore               C            C        0000     0.0000        0.00         0.00           0.00
61253      Pierce skull & explore               C            C        0000     0.0000        0.00         0.00           0.00
61304      Open skull for exploration           C            C        0000     0.0000        0.00         0.00           0.00
61305      Open skull for exploration           C            C        0000     0.0000        0.00         0.00           0.00
61312      Open skull for drainage              C            C        0000     0.0000        0.00         0.00           0.00
61313      Open skull for drainage              C            C        0000     0.0000        0.00         0.00           0.00
61314      Open skull for drainage              C            C        0000     0.0000        0.00         0.00           0.00
61315      Open skull for drainage              C            C        0000     0.0000        0.00         0.00           0.00
61316      Implt cran bone flap to abdo         C            C        0000     0.0000        0.00         0.00           0.00
61320      Open skull for drainage              C            C        0000     0.0000        0.00         0.00           0.00
61321      Open skull for drainage              C            C        0000     0.0000        0.00         0.00           0.00
61322      Decompressive craniotomy             C            C        0000     0.0000        0.00         0.00           0.00
61323      Decompressive lobectomy              C            C        0000     0.0000        0.00         0.00           0.00
61330      Decompress eye socket                T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
61332      Explore/biopsy eye socket            C            C        0000     0.0000        0.00         0.00           0.00
61333      Explore orbit/remove lesion          C            C        0000     0.0000        0.00         0.00           0.00
61334      Explore orbit/remove object          T            T        0256    37.0000      1,638.36     3,764.75       4,314.20
61340      Subtemporal decompression            C            C        0000     0.0000        0.00         0.00           0.00
61343      Incise skull (press relief)          C            C        0000     0.0000        0.00         0.00           0.00
61345      Relieve cranial pressure             C            C        0000     0.0000        0.00         0.00           0.00
61440      Incise skull for surgery             C            C        0000     0.0000        0.00         0.00           0.00
61450      Incise skull for surgery             C            C        0000     0.0000        0.00         0.00           0.00
61458      Incise skull for brain wound         C            C        0000     0.0000        0.00         0.00           0.00
61460      Incise skull for surgery             C            C        0000     0.0000        0.00         0.00           0.00
61470      Incise skull for surgery             C            C        0000     0.0000        0.00         0.00           0.00
61480      Incise skull for surgery             C            C        0000     0.0000        0.00         0.00           0.00
61490      Incise skull for surgery             C            C        0000     0.0000        0.00         0.00           0.00
61500      Removal of skull lesion              C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 91 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated     4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

61501      Remove infected skull bone           C            C        0000    0.0000         0.00         0.00         0.00
61510      Removal of brain lesion              C            C        0000    0.0000         0.00         0.00         0.00
61512      Remove brain lining lesion           C            C        0000    0.0000         0.00         0.00         0.00
61514      Removal of brain abscess             C            C        0000    0.0000         0.00         0.00         0.00
61516      Removal of brain lesion              C            C        0000    0.0000         0.00         0.00         0.00
61517      Implt brain chemotx add-on           C            C        0000    0.0000         0.00         0.00         0.00
61518      Removal of brain lesion              C            C        0000    0.0000         0.00         0.00         0.00
61519      Remove brain lining lesion           C            C        0000    0.0000         0.00         0.00         0.00
61520      Removal of brain lesion              C            C        0000    0.0000         0.00         0.00         0.00
61521      Removal of brain lesion              C            C        0000    0.0000         0.00         0.00         0.00
61522      Removal of brain abscess             C            C        0000    0.0000         0.00         0.00         0.00
61524      Removal of brain lesion              C            C        0000    0.0000         0.00         0.00         0.00
61526      Removal of brain lesion              C            C        0000    0.0000         0.00         0.00         0.00
61530      Removal of brain lesion              C            C        0000    0.0000         0.00         0.00         0.00
61531      Implant brain electrodes             C            C        0000    0.0000         0.00         0.00         0.00
61533      Implant brain electrodes             C            C        0000    0.0000         0.00         0.00         0.00
61534      Removal of brain lesion              C            C        0000    0.0000         0.00         0.00         0.00
61535      Remove brain electrodes              C            C        0000    0.0000         0.00         0.00         0.00
61536      Removal of brain lesion              C            C        0000    0.0000         0.00         0.00         0.00
61537      Removal of brain tissue              C            C        0000    0.0000         0.00         0.00         0.00
61538      Removal of brain tissue              C            C        0000    0.0000         0.00         0.00         0.00
61539      Removal of brain tissue              C            C        0000    0.0000         0.00         0.00         0.00
61540      Removal of brain tissue              C            C        0000    0.0000         0.00         0.00         0.00
61541      Incision of brain tissue             C            C        0000    0.0000         0.00         0.00         0.00
61542      Removal of brain tissue              C            C        0000    0.0000         0.00         0.00         0.00
61543      Removal of brain tissue              C            C        0000    0.0000         0.00         0.00         0.00
61544      Remove & treat brain lesion          C            C        0000    0.0000         0.00         0.00         0.00
61545      Excision of brain tumor              C            C        0000    0.0000         0.00         0.00         0.00
61546      Removal of pituitary gland           C            C        0000    0.0000         0.00         0.00         0.00
61548      Removal of pituitary gland           C            C        0000    0.0000         0.00         0.00         0.00
61550      Release of skull seams               C            C        0000    0.0000         0.00         0.00         0.00
61552      Release of skull seams               C            C        0000    0.0000         0.00         0.00         0.00
61556      Incise skull/sutures                 C            C        0000    0.0000         0.00         0.00         0.00
61557      Incise skull/sutures                 C            C        0000    0.0000         0.00         0.00         0.00
61558      Excision of skull/sutures            C            C        0000    0.0000         0.00         0.00         0.00
61559      Excision of skull/sutures            C            C        0000    0.0000         0.00         0.00         0.00
61563      Excision of skull tumor              C            C        0000    0.0000         0.00         0.00         0.00
61564      Excision of skull tumor              C            C        0000    0.0000         0.00         0.00         0.00
61566      Removal of brain tissue              C            C        0000    0.0000         0.00         0.00         0.00
61567      Incision of brain tissue             C            C        0000    0.0000         0.00         0.00         0.00
61570      Remove foreign body, brain           C            C        0000    0.0000         0.00         0.00         0.00
61571      Incise skull for brain wound         C            C        0000    0.0000         0.00         0.00         0.00
61575      Skull base/brainstem surgery         C            C        0000    0.0000         0.00         0.00         0.00
61576      Skull base/brainstem surgery         C            C        0000    0.0000         0.00         0.00         0.00
61580      Craniofacial approach, skull         C            C        0000    0.0000         0.00         0.00         0.00
61581      Craniofacial approach, skull         C            C        0000    0.0000         0.00         0.00         0.00
61582      Craniofacial approach, skull         C            C        0000    0.0000         0.00         0.00         0.00
61583      Craniofacial approach, skull         C            C        0000    0.0000         0.00         0.00         0.00
61584      Orbitocranial approach/skull         C            C        0000    0.0000         0.00         0.00         0.00
61585      Orbitocranial approach/skull         C            C        0000    0.0000         0.00         0.00         0.00
61586      Resect nasopharynx, skull            C            C        0000    0.0000         0.00         0.00         0.00
61590      Infratemporal approach/skull         C            C        0000    0.0000         0.00         0.00         0.00
61591      Infratemporal approach/skull         C            C        0000    0.0000         0.00         0.00         0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                               92 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 93 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

61850      Implant neuroelectrodes              C            C        0000    0.0000         0.00         0.00         0.00
61860      Implant neuroelectrodes              C            C        0000    0.0000         0.00         0.00         0.00
61863      Implant neuroelectrode               C            C        0000    0.0000         0.00         0.00         0.00
61864      Implant neuroelectrde, add’l         C            C        0000    0.0000         0.00         0.00         0.00
61867      Implant neuroelectrode               C            C        0000    0.0000         0.00         0.00         0.00
61868      Implant neuroelectrde, add’l         C            C        0000    0.0000         0.00         0.00         0.00
61870      Implant neuroelectrodes              C            C        0000    0.0000         0.00         0.00         0.00
61875      Implant neuroelectrodes              C            C        0000    0.0000         0.00         0.00         0.00
61880      Revise/remove neuroelectrode         T            T        0687   19.1962        850.01      1,953.21     2,238.28
61885      Insrt/redo neurostim 1 array         S            S        0039   194.9690      8,633.23    19,838.10    22,733.39
61886      Implant neurostim arrays             T            T        0315   312.3876     13,832.52    31,785.44    36,424.39
61888      Revise/remove neuroreceiver          T            T        0688   42.8588       1,897.79     4,360.88     4,997.34
62000      Treat skull fracture                 C            C        0000    0.0000         0.00         0.00         0.00
62005      Treat skull fracture                 C            C        0000    0.0000         0.00         0.00         0.00
62010      Treatment of head injury             C            C        0000    0.0000         0.00         0.00         0.00
62100      Repair brain fluid leakage           C            C        0000    0.0000         0.00         0.00         0.00
62115      Reduction of skull defect            C            C        0000    0.0000         0.00         0.00         0.00
62116      Reduction of skull defect            C            C        0000    0.0000         0.00         0.00         0.00
62117      Reduction of skull defect            C            C        0000    0.0000         0.00         0.00         0.00
62120      Repair skull cavity lesion           C            C        0000    0.0000         0.00         0.00         0.00
62121      Incise skull repair                  C            C        0000    0.0000         0.00         0.00         0.00
62140      Repair of skull defect               C            C        0000    0.0000         0.00         0.00         0.00
62141      Repair of skull defect               C            C        0000    0.0000         0.00         0.00         0.00
62142      Remove skull plate/flap              C            C        0000    0.0000         0.00         0.00         0.00
62143      Replace skull plate/flap             C            C        0000    0.0000         0.00         0.00         0.00
62145      Repair of skull & brain              C            C        0000    0.0000         0.00         0.00         0.00
62146      Repair of skull with graft           C            C        0000    0.0000         0.00         0.00         0.00
62147      Repair of skull with graft           C            C        0000    0.0000         0.00         0.00         0.00
62148      Retr bone flap to fix skull          C            C        0000    0.0000         0.00         0.00         0.00
62160      Neuroendoscopy add-on                T            T        0122    6.9179        306.32       703.90       806.63
62161      Dissect brain w/scope                C            C        0000    0.0000         0.00         0.00         0.00
62162      Remove colloid cyst w/scope          C            C        0000    0.0000         0.00         0.00         0.00
62163      Neuroendoscopy w/fb removal          C            C        0000    0.0000         0.00         0.00         0.00
62164      Remove brain tumor w/scope           C            C        0000    0.0000         0.00         0.00         0.00
62165      Remove pituit tumor w/scope          C            C        0000    0.0000         0.00         0.00         0.00
62180      Establish brain cavity shunt         C            C        0000    0.0000         0.00         0.00         0.00
62190      Establish brain cavity shunt         C            C        0000    0.0000         0.00         0.00         0.00
62192      Establish brain cavity shunt         C            C        0000    0.0000         0.00         0.00         0.00
62194      Replace/irrigate catheter            T            T        0427   10.0109        443.28      1,018.61     1,167.27
62200      Establish brain cavity shunt         C            C        0000    0.0000         0.00         0.00         0.00
62201      Brain cavity shunt w/scope           C            C        0000    0.0000         0.00         0.00         0.00
62220      Establish brain cavity shunt         C            C        0000    0.0000         0.00         0.00         0.00
62223      Establish brain cavity shunt         C            C        0000    0.0000         0.00         0.00         0.00
62225      Replace/irrigate catheter            T            T        0427   10.0109        443.28      1,018.61     1,167.27
62230      Replace/revise brain shunt           T            T        0224   41.1421       1,821.77     4,186.21     4,797.17
62252      Csf shunt reprogram                  S            S        0691    2.5464        112.75       259.10       296.91
62256      Remove brain cavity shunt            C            C        0000    0.0000         0.00         0.00         0.00
62258      Replace brain cavity shunt           C            C        0000    0.0000         0.00         0.00         0.00
62263      Epidural lysis mult sessions         T            T        0203   10.0965        447.07      1,027.32     1,177.25
62264      Epidural lysis on single day         T            T        0203   10.0965        447.07      1,027.32     1,177.25
62268      Drain spinal cord cyst               T            T        0212    2.7712        122.71       281.97       323.12
62269      Needle biopsy, spinal cord           T            T        0685    6.0034        265.83       610.85       700.00
62270      Spinal fluid tap, diagnostic         T            T        0204    2.2667        100.37       230.64       264.30

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                             94 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

62272      Drain cerebro spinal fluid           T            T        0204    2.2667        100.37       230.64       264.30
62273      Inject epidural patch                T            T        0206    5.4011        239.16       549.56       629.77
62280      Treat spinal cord lesion             T            T        0207    6.0140        266.30       611.92       701.23
62281      Treat spinal cord lesion             T            T        0207    6.0140        266.30       611.92       701.23
62282      Treat spinal canal lesion            T            T        0207    6.0140        266.30       611.92       701.23
62284      Injection for myelogram              N            N        0000    0.0000         0.00         0.00         0.00
62287      Percutaneous diskectomy              T            T        0221   31.0536       1,375.05     3,159.70     3,620.85
62290      Inject for spine disk x-ray          N            N        0000    0.0000         0.00         0.00         0.00
62291      Inject for spine disk x-ray          N            N        0000    0.0000         0.00         0.00         0.00
62292      Injection into disk lesion           T            T        0212    2.7712        122.71       281.97       323.12
62294      Injection into spinal artery         T            T        0212    2.7712        122.71       281.97       323.12
62310      Inject spine c/t                     T            T        0207    6.0140        266.30       611.92       701.23
62311      Inject spine l/s (cd)                T            T        0207    6.0140        266.30       611.92       701.23
62318      Inject spine w/cath, c/t             T            T        0207    6.0140        266.30       611.92       701.23
62319      Inject spine w/cath l/s (cd)         T            T        0207    6.0140        266.30       611.92       701.23
62350      Implant spinal canal cath            T            T        0223   28.5636       1,264.80     2,906.35     3,330.52
62351      Implant spinal canal cath            T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
62355      Remove spinal canal catheter         T            T        0203   10.0965        447.07      1,027.32     1,177.25
62360      Insert spine infusion device         T            T        0226   72.5804       3,213.86     7,385.06     8,462.87
62361      Implant spine infusion pump          T            T        0227   155.0431      6,865.31    15,775.64    18,078.03
62362      Implant spine infusion pump          T            T        0227   155.0431      6,865.31    15,775.64    18,078.03
62365      Remove spine infusion device         T            T        0221   31.0536       1,375.05     3,159.70     3,620.85
62367      Analyze spine infusion pump          S            S        0691    2.5464        112.75       259.10       296.91
62368      Analyze spine infusion pump          S            S        0691    2.5464        112.75       259.10       296.91
63001      Removal of spinal lamina             T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63003      Removal of spinal lamina             T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63005      Removal of spinal lamina             T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63011      Removal of spinal lamina             T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63012      Removal of spinal lamina             T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63015      Removal of spinal lamina             T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63016      Removal of spinal lamina             T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63017      Removal of spinal lamina             T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63020      Neck spine disk surgery              T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63030      Low back disk surgery                T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63035      Spinal disk surgery add-on           T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63040      Laminotomy, single cervical          T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63042      Laminotomy, single lumbar            T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63043      Laminotomy, add’l cervical           C            C        0000    0.0000         0.00         0.00         0.00
63044      Laminotomy, add’l lumbar             C            C        0000    0.0000         0.00         0.00         0.00
63045      Removal of spinal lamina             T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63046      Removal of spinal lamina             T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63047      Removal of spinal lamina             T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63048      Remove spinal lamina add-on          T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63050      Cervical laminoplasty                C            C        0000    0.0000         0.00         0.00         0.00
63051      C-laminoplasty w/graft/plate         C            C        0000    0.0000         0.00         0.00         0.00
63055      Decompress spinal cord               T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63056      Decompress spinal cord               T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63057      Decompress spine cord add-on         T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63064      Decompress spinal cord               T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63066      Decompress spine cord add-on         T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63075      Neck spine disk surgery              T            T        0208   42.5200       1,882.79     4,326.41     4,957.83
63076      Neck spine disk surgery              C            C        0000    0.0000         0.00         0.00         0.00
63077      Spine disk surgery, thorax           C            C        0000    0.0000         0.00         0.00         0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                             95 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated     4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

63078      Spine disk surgery, thorax           C            C        0000    0.0000         0.00         0.00         0.00
63081      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63082      Remove vertebral body add-on         C            C        0000    0.0000         0.00         0.00         0.00
63085      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63086      Remove vertebral body add-on         C            C        0000    0.0000         0.00         0.00         0.00
63087      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63088      Remove vertebral body add-on         C            C        0000    0.0000         0.00         0.00         0.00
63090      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63091      Remove vertebral body add-on         C            C        0000    0.0000         0.00         0.00         0.00
63101      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63102      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63103      Remove vertebral body add-on         C            C        0000    0.0000         0.00         0.00         0.00
63170      Incise spinal cord tract(s)          C            C        0000    0.0000         0.00         0.00         0.00
63172      Drainage of spinal cyst              C            C        0000    0.0000         0.00         0.00         0.00
63173      Drainage of spinal cyst              C            C        0000    0.0000         0.00         0.00         0.00
63180      Revise spinal cord ligaments         C            C        0000    0.0000         0.00         0.00         0.00
63182      Revise spinal cord ligaments         C            C        0000    0.0000         0.00         0.00         0.00
63185      Incise spinal column/nerves          C            C        0000    0.0000         0.00         0.00         0.00
63190      Incise spinal column/nerves          C            C        0000    0.0000         0.00         0.00         0.00
63191      Incise spinal column/nerves          C            C        0000    0.0000         0.00         0.00         0.00
63194      Incise spinal column & cord          C            C        0000    0.0000         0.00         0.00         0.00
63195      Incise spinal column & cord          C            C        0000    0.0000         0.00         0.00         0.00
63196      Incise spinal column & cord          C            C        0000    0.0000         0.00         0.00         0.00
63197      Incise spinal column & cord          C            C        0000    0.0000         0.00         0.00         0.00
63198      Incise spinal column & cord          C            C        0000    0.0000         0.00         0.00         0.00
63199      Incise spinal column & cord          C            C        0000    0.0000         0.00         0.00         0.00
63200      Release of spinal cord               C            C        0000    0.0000         0.00         0.00         0.00
63250      Revise spinal cord vessels           C            C        0000    0.0000         0.00         0.00         0.00
63251      Revise spinal cord vessels           C            C        0000    0.0000         0.00         0.00         0.00
63252      Revise spinal cord vessels           C            C        0000    0.0000         0.00         0.00         0.00
63265      Excise intraspinal lesion            C            C        0000    0.0000         0.00         0.00         0.00
63266      Excise intraspinal lesion            C            C        0000    0.0000         0.00         0.00         0.00
63267      Excise intraspinal lesion            C            C        0000    0.0000         0.00         0.00         0.00
63268      Excise intraspinal lesion            C            C        0000    0.0000         0.00         0.00         0.00
63270      Excise intraspinal lesion            C            C        0000    0.0000         0.00         0.00         0.00
63271      Excise intraspinal lesion            C            C        0000    0.0000         0.00         0.00         0.00
63272      Excise intraspinal lesion            C            C        0000    0.0000         0.00         0.00         0.00
63273      Excise intraspinal lesion            C            C        0000    0.0000         0.00         0.00         0.00
63275      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63276      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63277      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63278      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63280      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63281      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63282      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63283      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63285      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63286      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63287      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63290      Biopsy/excise spinal tumor           C            C        0000    0.0000         0.00         0.00         0.00
63295      Repair of laminectomy defect         C            C        0000    0.0000         0.00         0.00         0.00
63300      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63301      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                               96 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

63302      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63303      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63304      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63305      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63306      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63307      Removal of vertebral body            C            C        0000    0.0000         0.00         0.00         0.00
63308      Remove vertebral body add-on         C            C        0000    0.0000         0.00         0.00         0.00
63600      Remove spinal cord lesion            T            T        0220   17.3203        766.94      1,762.34     2,019.55
63610      Stimulation of spinal cord           T            T        0220   17.3203        766.94      1,762.34     2,019.55
63615      Remove lesion of spinal cord         T            T        0220   17.3203        766.94      1,762.34     2,019.55
63650      Implant neuroelectrodes              S            S        0040   50.8322       2,250.85     5,172.18     5,927.03
63655      Implant neuroelectrodes              S            S        0061   93.4063       4,136.03     9,504.09    10,891.17
63660      Revise/remove neuroelectrode         T            T        0687   19.1962        850.01      1,953.21     2,238.28
63685      Insrt/redo spine n generator         T            T        0222   192.4950      8,523.68    19,586.37    22,444.92
63688      Revise/remove neuroreceiver          T            T        0688   42.8588       1,897.79     4,360.88     4,997.34
63700      Repair of spinal herniation          C            C        0000    0.0000         0.00         0.00         0.00
63702      Repair of spinal herniation          C            C        0000    0.0000         0.00         0.00         0.00
63704      Repair of spinal herniation          C            C        0000    0.0000         0.00         0.00         0.00
63706      Repair of spinal herniation          C            C        0000    0.0000         0.00         0.00         0.00
63707      Repair spinal fluid leakage          C            C        0000    0.0000         0.00         0.00         0.00
63709      Repair spinal fluid leakage          C            C        0000    0.0000         0.00         0.00         0.00
63710      Graft repair of spine defect         C            C        0000    0.0000         0.00         0.00         0.00
63740      Install spinal shunt                 C            C        0000    0.0000         0.00         0.00         0.00
63741      Install spinal shunt                 T            T        0228   46.4126       2,055.15     4,722.48     5,411.71
63744      Revision of spinal shunt             T            T        0228   46.4126       2,055.15     4,722.48     5,411.71
63746      Removal of spinal shunt              T            T        0109   11.1714        494.67      1,136.69     1,302.59
64400      N block inj, trigeminal              T            T        0204    2.2667        100.37       230.64       264.30
64402      N block inj, facial                  T            T        0204    2.2667        100.37       230.64       264.30
64405      N block inj, occipital               T            T        0204    2.2667        100.37       230.64       264.30
64408      N block inj, vagus                   T            T        0204    2.2667        100.37       230.64       264.30
64410      N block inj, phrenic                 T            T        0206    5.4011        239.16       549.56       629.77
64412      N block inj, spinal accessor         T            T        0206    5.4011        239.16       549.56       629.77
64413      N block inj, cervical plexus         T            T        0204    2.2667        100.37       230.64       264.30
64415      N block inj, brachial plexus         T            T        0204    2.2667        100.37       230.64       264.30
64416      N block cont infuse, b plex          T            T        0204    2.2667        100.37       230.64       264.30
64417      N block inj, axillary                T            T        0204    2.2667        100.37       230.64       264.30
64418      N block inj, suprascapular           T            T        0204    2.2667        100.37       230.64       264.30
64420      N block inj, intercost, sng          T            T        0204    2.2667        100.37       230.64       264.30
64421      N block inj, intercost, mlt          T            T        0206    5.4011        239.16       549.56       629.77
64425      N block inj, ilio-ing/hypogi         T            T        0204    2.2667        100.37       230.64       264.30
64430      N block inj, pudendal                T            T        0204    2.2667        100.37       230.64       264.30
64435      N block inj, paracervical            T            T        0204    2.2667        100.37       230.64       264.30
64445      N block inj, sciatic, sng            T            T        0204    2.2667        100.37       230.64       264.30
64446      N blk inj, sciatic, cont inf         T            T        0206    5.4011        239.16       549.56       629.77
64447      N block inj fem, single              T            T        0204    2.2667        100.37       230.64       264.30
64448      N block inj fem, cont inf            T            T        0204    2.2667        100.37       230.64       264.30
64449      N block inj, lumbar plexus           T            T        0204    2.2667        100.37       230.64       264.30
64450      N block, other peripheral            T            T        0204    2.2667        100.37       230.64       264.30
64470      Inj paravertebral c/t                T            T        0207    6.0140        266.30       611.92       701.23
64472      Inj paravertebral c/t add-on         T            T        0206    5.4011        239.16       549.56       629.77
64475      Inj paravertebral l/s                T            T        0207    6.0140        266.30       611.92       701.23
64476      Inj paravertebral l/s add-on         T            T        0206    5.4011        239.16       549.56       629.77
64479      Inj foramen epidural c/t             T            T        0207    6.0140        266.30       611.92       701.23

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                             97 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

64480      Inj foramen epidural add-on          T            T        0207    6.0140        266.30       611.92       701.23
64483      Inj foramen epidural l/s             T            T        0207    6.0140        266.30       611.92       701.23
64484      Inj foramen epidural add-on          T            T        0207    6.0140        266.30       611.92       701.23
64505      N block, spenopalatine gangl         T            T        0204    2.2667        100.37       230.64       264.30
64508      N block, carotid sinus s/p           T            T        0204    2.2667        100.37       230.64       264.30
64510      N block, stellate ganglion           T            T        0207    6.0140        266.30       611.92       701.23
64517      N block inj, hypogas plxs            T            T        0204    2.2667        100.37       230.64       264.30
64520      N block, lumbar/thoracic             T            T        0207    6.0140        266.30       611.92       701.23
64530      N block inj, celiac pelus            T            T        0207    6.0140        266.30       611.92       701.23
64550      Apply neurostimulator                A            3        0000    0.0000         M01          M01          M01
64553      Implant neuroelectrodes              S            S        0225   250.8484     11,107.57    25,523.82    29,248.92
64555      Implant neuroelectrodes              S            S        0040   50.8322       2,250.85     5,172.18     5,927.03
64560      Implant neuroelectrodes              S            S        0040   50.8322       2,250.85     5,172.18     5,927.03
64561      Implant neuroelectrodes              S            S        0040   50.8322       2,250.85     5,172.18     5,927.03
64565      Implant neuroelectrodes              S            S        0040   50.8322       2,250.85     5,172.18     5,927.03
64573      Implant neuroelectrodes              S            S        0225   250.8484     11,107.57    25,523.82    29,248.92
64575      Implant neuroelectrodes              S            S        0061   93.4063       4,136.03     9,504.09    10,891.17
64577      Implant neuroelectrodes              S            S        0061   93.4063       4,136.03     9,504.09    10,891.17
64580      Implant neuroelectrodes              S            S        0061   93.4063       4,136.03     9,504.09    10,891.17
64581      Implant neuroelectrodes              S            S        0061   93.4063       4,136.03     9,504.09    10,891.17
64585      Revise/remove neuroelectrode         T            T        0687   19.1962        850.01      1,953.21     2,238.28
64590      Insrt/redo perph n generator         T            T        0222   192.4950      8,523.68    19,586.37    22,444.92
64595      Revise/remove neuroreceiver          T            T        0688   42.8588       1,897.79     4,360.88     4,997.34
64600      Injection treatment of nerve         T            T        0203   10.0965        447.07      1,027.32     1,177.25
64605      Injection treatment of nerve         T            T        0203   10.0965        447.07      1,027.32     1,177.25
64610      Injection treatment of nerve         T            T        0203   10.0965        447.07      1,027.32     1,177.25
64612      Destroy nerve, face muscle           T            T        0204    2.2667        100.37       230.64       264.30
64613      Destroy nerve, spine muscle          T            T        0204    2.2667        100.37       230.64       264.30
64614      Destroy nerve, extrem musc           T            T        0204    2.2667        100.37       230.64       264.30
64620      Injection treatment of nerve         T            T        0203   10.0965        447.07      1,027.32     1,177.25
64622      Destr paravertebrl nerve l/s         T            T        0203   10.0965        447.07      1,027.32     1,177.25
64623      Destr paravertebral n add-on         T            T        0207    6.0140        266.30       611.92       701.23
64626      Destr paravertebrl nerve c/t         T            T        0203   10.0965        447.07      1,027.32     1,177.25
64627      Destr paravertebral n add-on         T            T        0207    6.0140        266.30       611.92       701.23
64630      Injection treatment of nerve         T            T        0206    5.4011        239.16       549.56       629.77
64640      Injection treatment of nerve         T            T        0206    5.4011        239.16       549.56       629.77
64650      Chemodenerv eccrine glands           T            T        0204    2.2667        100.37       230.64       264.30
64653      Chemodenerv eccrine glands           T            T        0204    2.2667        100.37       230.64       264.30
64680      Injection treatment of nerve         T            T        0207    6.0140        266.30       611.92       701.23
64681      Injection treatment of nerve         T            T        0203   10.0965        447.07      1,027.32     1,177.25
64702      Revise finger/toe nerve              T            T        0220   17.3203        766.94      1,762.34     2,019.55
64704      Revise hand/foot nerve               T            T        0220   17.3203        766.94      1,762.34     2,019.55
64708      Revise arm/leg nerve                 T            T        0220   17.3203        766.94      1,762.34     2,019.55
64712      Revision of sciatic nerve            T            T        0220   17.3203        766.94      1,762.34     2,019.55
64713      Revision of arm nerve(s)             T            T        0220   17.3203        766.94      1,762.34     2,019.55
64714      Revise low back nerve(s)             T            T        0220   17.3203        766.94      1,762.34     2,019.55
64716      Revision of cranial nerve            T            T        0220   17.3203        766.94      1,762.34     2,019.55
64718      Revise ulnar nerve at elbow          T            T        0220   17.3203        766.94      1,762.34     2,019.55
64719      Revise ulnar nerve at wrist          T            T        0220   17.3203        766.94      1,762.34     2,019.55
64721      Carpal tunnel surgery                T            T        0220   17.3203        766.94      1,762.34     2,019.55
64722      Relieve pressure on nerve(s)         T            T        0220   17.3203        766.94      1,762.34     2,019.55
64726      Release foot/toe nerve               T            T        0220   17.3203        766.94      1,762.34     2,019.55
64727      Internal nerve revision              T            T        0220   17.3203        766.94      1,762.34     2,019.55

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                             98 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated       4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                       Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                      Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                              Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                   Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                         Fee

64732      Incision of brow nerve               T            T        0220    17.3203       766.94      1,762.34       2,019.55
64734      Incision of cheek nerve              T            T        0220    17.3203       766.94      1,762.34       2,019.55
64736      Incision of chin nerve               T            T        0220    17.3203       766.94      1,762.34       2,019.55
64738      Incision of jaw nerve                T            T        0220    17.3203       766.94      1,762.34       2,019.55
64740      Incision of tongue nerve             T            T        0220    17.3203       766.94      1,762.34       2,019.55
64742      Incision of facial nerve             T            T        0220    17.3203       766.94      1,762.34       2,019.55
64744      Incise nerve, back of head           T            T        0220    17.3203       766.94      1,762.34       2,019.55
64746      Incise diaphragm nerve               T            T        0220    17.3203       766.94      1,762.34       2,019.55
64752      Incision of vagus nerve              C            C        0000     0.0000        0.00         0.00           0.00
64755      Incision of stomach nerves           C            C        0000     0.0000        0.00         0.00           0.00
64760      Incision of vagus nerve              C            C        0000     0.0000        0.00         0.00           0.00
64761      Incision of pelvis nerve             T            T        0220    17.3203       766.94      1,762.34       2,019.55
64763      Incise hip/thigh nerve               T            T        0220    17.3203       766.94      1,762.34       2,019.55
64766      Incise hip/thigh nerve               T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64771      Sever cranial nerve                  T            T        0220    17.3203       766.94      1,762.34       2,019.55
64772      Incision of spinal nerve             T            T        0220    17.3203       766.94      1,762.34       2,019.55
64774      Remove skin nerve lesion             T            T        0220    17.3203       766.94      1,762.34       2,019.55
64776      Remove digit nerve lesion            T            T        0220    17.3203       766.94      1,762.34       2,019.55
64778      Digit nerve surgery add-on           T            T        0220    17.3203       766.94      1,762.34       2,019.55
64782      Remove limb nerve lesion             T            T        0220    17.3203       766.94      1,762.34       2,019.55
64783      Limb nerve surgery add-on            T            T        0220    17.3203       766.94      1,762.34       2,019.55
64784      Remove nerve lesion                  T            T        0220    17.3203       766.94      1,762.34       2,019.55
64786      Remove sciatic nerve lesion          T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64787      Implant nerve end                    T            T        0220    17.3203       766.94      1,762.34       2,019.55
64788      Remove skin nerve lesion             T            T        0220    17.3203       766.94      1,762.34       2,019.55
64790      Removal of nerve lesion              T            T        0220    17.3203       766.94      1,762.34       2,019.55
64792      Removal of nerve lesion              T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64795      Biopsy of nerve                      T            T        0220    17.3203       766.94      1,762.34       2,019.55
64802      Remove sympathetic nerves            T            T        0220    17.3203       766.94      1,762.34       2,019.55
64804      Remove sympathetic nerves            C            C        0000     0.0000        0.00         0.00           0.00
64809      Remove sympathetic nerves            C            C        0000     0.0000        0.00         0.00           0.00
64818      Remove sympathetic nerves            C            C        0000     0.0000        0.00         0.00           0.00
64820      Remove sympathetic nerves            T            T        0220    17.3203       766.94      1,762.34       2,019.55
64821      Remove sympathetic nerves            T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
64822      Remove sympathetic nerves            T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
64823      Remove sympathetic nerves            T            T        0054    25.1321      1,112.85     2,557.19       2,930.40
64831      Repair of digit nerve                T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64832      Repair nerve add-on                  T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64834      Repair of hand or foot nerve         T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64835      Repair of hand or foot nerve         T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64836      Repair of hand or foot nerve         T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64837      Repair nerve add-on                  T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64840      Repair of leg nerve                  T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64856      Repair/transpose nerve               T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64857      Repair arm/leg nerve                 T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64858      Repair sciatic nerve                 T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64859      Nerve surgery                        T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64861      Repair of arm nerves                 T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64862      Repair of low back nerves            T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64864      Repair of facial nerve               T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64865      Repair of facial nerve               T            T        0221    31.0536      1,375.05     3,159.70       3,620.85
64866      Fusion of facial/other nerve         C            C        0000     0.0000        0.00         0.00           0.00
64868      Fusion of facial/other nerve         C            C        0000     0.0000        0.00         0.00           0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                                 99 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

64870      Fusion of facial/other nerve         T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64872      Subsequent repair of nerve           T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64874      Repair & revise nerve add-on         T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64876      Repair nerve/shorten bone            T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64885      Nerve graft, head or neck            T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64886      Nerve graft, head or neck            T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64890      Nerve graft, hand or foot            T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64891      Nerve graft, hand or foot            T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64892      Nerve graft, arm or leg              T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64893      Nerve graft, arm or leg              T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64895      Nerve graft, hand or foot            T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64896      Nerve graft, hand or foot            T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64897      Nerve graft, arm or leg              T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64898      Nerve graft, arm or leg              T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64901      Nerve graft add-on                   T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64902      Nerve graft add-on                   T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64905      Nerve pedicle transfer               T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64907      Nerve pedicle transfer               T            T        0221    31.0536      1,375.05     3,159.70     3,620.85
64999      Nervous system surgery               T            1        0000     0.0000        0.00         0.00         0.00
65091      Revise eye                           T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
65093      Revise eye with implant              T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
65101      Removal of eye                       T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
65103      Remove eye/insert implant            T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
65105      Remove eye/attach implant            T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
65110      Removal of eye                       T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
65112      Remove eye/revise socket             T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
65114      Remove eye/revise socket             T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
65125      Revise ocular implant                T            T        0240    18.0194       797.90      1,833.47     2,101.06
65130      Insert ocular implant                T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
65135      Insert ocular implant                T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
65140      Attach ocular implant                T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
65150      Revise ocular implant                T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
65155      Reinsert ocular implant              T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
65175      Removal of ocular implant            T            T        0240    18.0194       797.90      1,833.47     2,101.06
65205      Remove foreign body from eye         S            S        0698     1.2378        54.81       125.95       144.33
65210      Remove foreign body from eye         S            S        0698     1.2378        54.81       125.95       144.33
65220      Remove foreign body from eye         S            S        0698     1.2378        54.81       125.95       144.33
65222      Remove foreign body from eye         S            S        0698     1.2378        54.81       125.95       144.33
65235      Remove foreign body from eye         T            T        0233    14.6645       649.34      1,492.11     1,709.88
65260      Remove foreign body from eye         T            T        0236    16.9771       751.75      1,727.42     1,979.53
65265      Remove foreign body from eye         T            T        0237    28.7866      1,274.67     2,929.04     3,356.52
65270      Repair of eye wound                  T            T        0240    18.0194       797.90      1,833.47     2,101.06
65272      Repair of eye wound                  T            T        0234    22.0521       976.47      2,243.80     2,571.27
65273      Repair of eye wound                  C            C        0000     0.0000        0.00         0.00         0.00
65275      Repair of eye wound                  T            T        0234    22.0521       976.47      2,243.80     2,571.27
65280      Repair of eye wound                  T            T        0236    16.9771       751.75      1,727.42     1,979.53
65285      Repair of eye wound                  T            T        0672    36.8773      1,632.93     3,752.27     4,299.89
65286      Repair of eye wound                  T            T        0232     6.9204       306.44       704.15       806.92
65290      Repair of eye socket wound           T            T        0243    22.0338       975.66      2,241.94     2,569.14
65400      Removal of eye lesion                T            T        0233    14.6645       649.34      1,492.11     1,709.88
65410      Biopsy of cornea                     T            T        0233    14.6645       649.34      1,492.11     1,709.88
65420      Removal of eye lesion                T            T        0233    14.6645       649.34      1,492.11     1,709.88
65426      Removal of eye lesion                T            T        0234    22.0521       976.47      2,243.80     2,571.27

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            100 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

65430      Corneal smear                        S            S        0698     1.2378        54.81       125.95       144.33
65435      Curette/treat cornea                 T            T        0239     7.0583       312.54       718.18       823.00
65436      Curette/treat cornea                 T            T        0233    14.6645       649.34      1,492.11     1,709.88
65450      Treatment of corneal lesion          S            S        0231     1.9167        84.87       195.02       223.49
65600      Revision of cornea                   T            T        0240    18.0194       797.90      1,833.47     2,101.06
65710      Corneal transplant                   T            T        0244    38.2309      1,692.86     3,889.99     4,457.72
65730      Corneal transplant                   T            T        0244    38.2309      1,692.86     3,889.99     4,457.72
65750      Corneal transplant                   T            T        0244    38.2309      1,692.86     3,889.99     4,457.72
65755      Corneal transplant                   T            T        0244    38.2309      1,692.86     3,889.99     4,457.72
65760      Revision of cornea                   E            1        0000     0.0000        0.00         0.00         0.00
65765      Revision of cornea                   E            1        0000     0.0000        0.00         0.00         0.00
65767      Corneal tissue transplant            E            1        0000     0.0000        0.00         0.00         0.00
65770      Revise cornea with implant           T            1        0000     0.0000        0.00         0.00         0.00
65771      Radial keratotomy                    E            1        0000     0.0000        0.00         0.00         0.00
65772      Correction of astigmatism            T            1        0000     0.0000        0.00         0.00         0.00
65775      Correction of astigmatism            T            1        0000     0.0000        0.00         0.00         0.00
65780      Ocular reconst, transplant           T            1        0000     0.0000        0.00         0.00         0.00
65781      Ocular reconst, transplant           T            1        0000     0.0000        0.00         0.00         0.00
65782      Ocular reconst, transplant           T            1        0000     0.0000        0.00         0.00         0.00
65800      Drainage of eye                      T            T        0233    14.6645       649.34      1,492.11     1,709.88
65805      Drainage of eye                      T            T        0233    14.6645       649.34      1,492.11     1,709.88
65810      Drainage of eye                      T            T        0234    22.0521       976.47      2,243.80     2,571.27
65815      Drainage of eye                      T            T        0234    22.0521       976.47      2,243.80     2,571.27
65820      Relieve inner eye pressure           T            T        0232     6.9204       306.44       704.15       806.92
65850      Incision of eye                      T            T        0234    22.0521       976.47      2,243.80     2,571.27
65855      Laser surgery of eye                 T            T        0247     5.0255       222.53       511.34       585.97
65860      Incise inner eye adhesions           T            T        0247     5.0255       222.53       511.34       585.97
65865      Incise inner eye adhesions           T            T        0233    14.6645       649.34      1,492.11     1,709.88
65870      Incise inner eye adhesions           T            T        0234    22.0521       976.47      2,243.80     2,571.27
65875      Incise inner eye adhesions           T            T        0234    22.0521       976.47      2,243.80     2,571.27
65880      Incise inner eye adhesions           T            T        0233    14.6645       649.34      1,492.11     1,709.88
65900      Remove eye lesion                    T            T        0233    14.6645       649.34      1,492.11     1,709.88
65920      Remove implant of eye                T            T        0234    22.0521       976.47      2,243.80     2,571.27
65930      Remove blood clot from eye           T            T        0234    22.0521       976.47      2,243.80     2,571.27
66020      Injection treatment of eye           T            T        0233    14.6645       649.34      1,492.11     1,709.88
66030      Injection treatment of eye           T            T        0232     6.9204       306.44       704.15       806.92
66130      Remove eye lesion                    T            T        0234    22.0521       976.47      2,243.80     2,571.27
66150      Glaucoma surgery                     T            T        0234    22.0521       976.47      2,243.80     2,571.27
66155      Glaucoma surgery                     T            T        0234    22.0521       976.47      2,243.80     2,571.27
66160      Glaucoma surgery                     T            T        0234    22.0521       976.47      2,243.80     2,571.27
66165      Glaucoma surgery                     T            T        0234    22.0521       976.47      2,243.80     2,571.27
66170      Glaucoma surgery                     T            T        0234    22.0521       976.47      2,243.80     2,571.27
66172      Incision of eye                      T            T        0673    29.0835      1,287.82     2,959.25     3,391.14
66180      Implant eye shunt                    T            T        0673    29.0835      1,287.82     2,959.25     3,391.14
66185      Revise eye shunt                     T            T        0673    29.0835      1,287.82     2,959.25     3,391.14
66220      Repair eye lesion                    T            T        0672    36.8773      1,632.93     3,752.27     4,299.89
66225      Repair/graft eye lesion              T            T        0673    29.0835      1,287.82     2,959.25     3,391.14
66250      Follow-up surgery of eye             T            T        0233    14.6645       649.34      1,492.11     1,709.88
66500      Incision of iris                     T            T        0232     6.9204       306.44       704.15       806.92
66505      Incision of iris                     T            T        0232     6.9204       306.44       704.15       806.92
66600      Remove iris and lesion               T            T        0234    22.0521       976.47      2,243.80     2,571.27
66605      Removal of iris                      T            T        0234    22.0521       976.47      2,243.80     2,571.27
66625      Removal of iris                      T            T        0232     6.9204       306.44       704.15       806.92

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            101 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

66630      Removal of iris                      T            T        0234    22.0521       976.47      2,243.80     2,571.27
66635      Removal of iris                      T            T        0234    22.0521       976.47      2,243.80     2,571.27
66680      Repair iris & ciliary body           T            T        0234    22.0521       976.47      2,243.80     2,571.27
66682      Repair iris & ciliary body           T            T        0234    22.0521       976.47      2,243.80     2,571.27
66700      Destruction, ciliary body            T            T        0233    14.6645       649.34      1,492.11     1,709.88
66710      Ciliary transsleral therapy          T            T        0233    14.6645       649.34      1,492.11     1,709.88
66711      Ciliary endoscopic ablation          T            T        0233    14.6645       649.34      1,492.11     1,709.88
66720      Destruction, ciliary body            T            T        0233    14.6645       649.34      1,492.11     1,709.88
66740      Destruction, ciliary body            T            T        0234    22.0521       976.47      2,243.80     2,571.27
66761      Revision of iris                     T            T        0247     5.0255       222.53       511.34       585.97
66762      Revision of iris                     T            T        0247     5.0255       222.53       511.34       585.97
66770      Removal of inner eye lesion          T            T        0247     5.0255       222.53       511.34       585.97
66820      Incision, secondary cataract         T            T        0232     6.9204       306.44       704.15       806.92
66821      After cataract laser surgery         T            T        0247     5.0255       222.53       511.34       585.97
66825      Reposition intraocular lens          T            T        0234    22.0521       976.47      2,243.80     2,571.27
66830      Removal of lens lesion               T            T        0232     6.9204       306.44       704.15       806.92
66840      Removal of lens material             T            T        0245    13.0344       577.16      1,326.25     1,519.81
66850      Removal of lens material             T            T        0249    27.6388      1,223.85     2,812.25     3,222.68
66852      Removal of lens material             T            T        0249    27.6388      1,223.85     2,812.25     3,222.68
66920      Extraction of lens                   T            T        0249    27.6388      1,223.85     2,812.25     3,222.68
66930      Extraction of lens                   T            T        0249    27.6388      1,223.85     2,812.25     3,222.68
66940      Extraction of lens                   T            T        0245    13.0344       577.16      1,326.25     1,519.81
66982      Cataract surgery, complex            T            T        0246    23.3185      1,032.54     2,372.66     2,718.94
66983      Cataract surg w/iol, 1 stage         T            T        0246    23.3185      1,032.54     2,372.66     2,718.94
66984      Cataract surg w/iol, 1 stage         T            T        0246    23.3185      1,032.54     2,372.66     2,718.94
66985      Insert lens prosthesis               T            T        0246    23.3185      1,032.54     2,372.66     2,718.94
66986      Exchange lens prosthesis             T            T        0246    23.3185      1,032.54     2,372.66     2,718.94
66990      Ophthalmic endoscope add-on          N            N        0000     0.0000        0.00         0.00         0.00
66999      Eye surgery procedure                T            1        0000     0.0000        0.00         0.00         0.00
67005      Partial removal of eye fluid         T            T        0237    28.7866      1,274.67     2,929.04     3,356.52
67010      Partial removal of eye fluid         T            T        0237    28.7866      1,274.67     2,929.04     3,356.52
67015      Release of eye fluid                 T            T        0237    28.7866      1,274.67     2,929.04     3,356.52
67025      Replace eye fluid                    T            T        0237    28.7866      1,274.67     2,929.04     3,356.52
67027      Implant eye drug system              T            T        0672    36.8773      1,632.93     3,752.27     4,299.89
67028      Injection eye drug                   T            T        0235     4.7925       212.21       487.64       558.81
67030      Incise inner eye strands             T            T        0236    16.9771       751.75      1,727.42     1,979.53
67031      Laser surgery, eye strands           T            T        0247     5.0255       222.53       511.34       585.97
67036      Removal of inner eye fluid           T            T        0672    36.8773      1,632.93     3,752.27     4,299.89
67038      Strip retinal membrane               T            T        0672    36.8773      1,632.93     3,752.27     4,299.89
67039      Laser treatment of retina            T            T        0672    36.8773      1,632.93     3,752.27     4,299.89
67040      Laser treatment of retina            T            T        0672    36.8773      1,632.93     3,752.27     4,299.89
67101      Repair detached retina               T            T        0236    16.9771       751.75      1,727.42     1,979.53
67105      Repair detached retina               T            T        0248     4.7199       209.00       480.25       550.34
67107      Repair detached retina               T            T        0672    36.8773      1,632.93     3,752.27     4,299.89
67108      Repair detached retina               T            T        0672    36.8773      1,632.93     3,752.27     4,299.89
67110      Repair detached retina               T            T        0236    16.9771       751.75      1,727.42     1,979.53
67112      Rerepair detached retina             T            T        0672    36.8773      1,632.93     3,752.27     4,299.89
67115      Release encircling material          T            T        0236    16.9771       751.75      1,727.42     1,979.53
67120      Remove eye implant material          T            T        0236    16.9771       751.75      1,727.42     1,979.53
67121      Remove eye implant material          T            T        0237    28.7866      1,274.67     2,929.04     3,356.52
67141      Treatment of retina                  T            T        0235     4.7925       212.21       487.64       558.81
67145      Treatment of retina                  T            T        0248     4.7199       209.00       480.25       550.34
67208      Treatment of retinal lesion          T            T        0236    16.9771       751.75      1,727.42     1,979.53

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            102 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

67210      Treatment of retinal lesion          T            T        0248     4.7199       209.00       480.25       550.34
67218      Treatment of retinal lesion          T            T        0236    16.9771       751.75      1,727.42     1,979.53
67220      Treatment of choroid lesion          T            T        0235     4.7925       212.21       487.64       558.81
67221      Ocular photodynamic ther             T            T        0235     4.7925       212.21       487.64       558.81
67225      Eye photodynamic ther add-on         T            T        0235     4.7925       212.21       487.64       558.81
67227      Treatment of retinal lesion          T            T        0236    16.9771       751.75      1,727.42     1,979.53
67228      Treatment of retinal lesion          T            T        0248     4.7199       209.00       480.25       550.34
67250      Reinforce eye wall                   T            T        0240    18.0194       797.90      1,833.47     2,101.06
67255      Reinforce/graft eye wall             T            T        0237    28.7866      1,274.67     2,929.04     3,356.52
67299      Eye surgery procedure                T            1        0000     0.0000        0.00         0.00         0.00
67311      Revise eye muscle                    T            T        0243    22.0338       975.66      2,241.94     2,569.14
67312      Revise two eye muscles               T            T        0243    22.0338       975.66      2,241.94     2,569.14
67314      Revise eye muscle                    T            T        0243    22.0338       975.66      2,241.94     2,569.14
67316      Revise two eye muscles               T            T        0243    22.0338       975.66      2,241.94     2,569.14
67318      Revise eye muscle(s)                 T            T        0243    22.0338       975.66      2,241.94     2,569.14
67320      Revise eye muscle(s) add-on          T            T        0243    22.0338       975.66      2,241.94     2,569.14
67331      Eye surgery follow-up add-on         T            T        0243    22.0338       975.66      2,241.94     2,569.14
67332      Rerevise eye muscles add-on          T            T        0243    22.0338       975.66      2,241.94     2,569.14
67334      Revise eye muscle w/suture           T            T        0243    22.0338       975.66      2,241.94     2,569.14
67335      Eye suture during surgery            T            T        0243    22.0338       975.66      2,241.94     2,569.14
67340      Revise eye muscle add-on             T            T        0243    22.0338       975.66      2,241.94     2,569.14
67343      Release eye tissue                   T            T        0243    22.0338       975.66      2,241.94     2,569.14
67345      Destroy nerve of eye muscle          T            T        0238     2.6031       115.27       264.87       303.52
67350      Biopsy eye muscle                    T            T        0699     8.9556       396.55       911.23      1,044.22
67399      Eye muscle surgery procedure         T            1        0000     0.0000        0.00         0.00         0.00
67400      Explore/biopsy eye socket            T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
67405      Explore/drain eye socket             T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
67412      Explore/treat eye socket             T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
67413      Explore/treat eye socket             T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
67414      Explr/decompress eye socket          T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
67415      Aspiration, orbital contents         T            T        0240    18.0194       797.90      1,833.47     2,101.06
67420      Explore/treat eye socket             T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
67430      Explore/treat eye socket             T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
67440      Explore/drain eye socket             T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
67445      Explr/decompress eye socket          T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
67450      Explore/biopsy eye socket            T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
67500      Inject/treat eye socket              S            S        0231     1.9167        84.87       195.02       223.49
67505      Inject/treat eye socket              T            T        0238     2.6031       115.27       264.87       303.52
67515      Inject/treat eye socket              T            T        0238     2.6031       115.27       264.87       303.52
67550      Insert eye socket implant            T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
67560      Revise eye socket implant            T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
67570      Decompress optic nerve               T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
67599      Orbit surgery procedure              T            1        0000     0.0000        0.00         0.00         0.00
67700      Drainage of eyelid abscess           T            T        0238     2.6031       115.27       264.87       303.52
67710      Incision of eyelid                   T            T        0239     7.0583       312.54       718.18       823.00
67715      Incision of eyelid fold              T            T        0240    18.0194       797.90      1,833.47     2,101.06
67800      Remove eyelid lesion                 T            T        0238     2.6031       115.27       264.87       303.52
67801      Remove eyelid lesions                T            T        0239     7.0583       312.54       718.18       823.00
67805      Remove eyelid lesions                T            T        0238     2.6031       115.27       264.87       303.52
67808      Remove eyelid lesion(s)              T            T        0240    18.0194       797.90      1,833.47     2,101.06
67810      Biopsy of eyelid                     T            T        0238     2.6031       115.27       264.87       303.52
67820      Revise eyelashes                     S            S        0698     1.2378        54.81       125.95       144.33
67825      Revise eyelashes                     T            T        0238     2.6031       115.27       264.87       303.52

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            103 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

67830      Revise eyelashes                     T            T        0239     7.0583       312.54       718.18       823.00
67835      Revise eyelashes                     T            T        0240    18.0194       797.90      1,833.47     2,101.06
67840      Remove eyelid lesion                 T            T        0239     7.0583       312.54       718.18       823.00
67850      Treat eyelid lesion                  T            T        0239     7.0583       312.54       718.18       823.00
67875      Closure of eyelid by suture          T            T        0239     7.0583       312.54       718.18       823.00
67880      Revision of eyelid                   T            T        0233    14.6645       649.34      1,492.11     1,709.88
67882      Revision of eyelid                   T            T        0240    18.0194       797.90      1,833.47     2,101.06
67900      Repair brow defect                   T            T        0240    18.0194       797.90      1,833.47     2,101.06
67901      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67902      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67903      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67904      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67906      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67908      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67909      Revise eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67911      Revise eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67912      Correction eyelid w/implant          T            T        0240    18.0194       797.90      1,833.47     2,101.06
67914      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67915      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67916      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67917      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67921      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67922      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67923      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67924      Repair eyelid defect                 T            T        0240    18.0194       797.90      1,833.47     2,101.06
67930      Repair eyelid wound                  T            T        0240    18.0194       797.90      1,833.47     2,101.06
67935      Repair eyelid wound                  T            T        0240    18.0194       797.90      1,833.47     2,101.06
67938      Remove eyelid foreign body           S            S        0698     1.2378        54.81       125.95       144.33
67950      Revision of eyelid                   T            T        0240    18.0194       797.90      1,833.47     2,101.06
67961      Revision of eyelid                   T            T        0240    18.0194       797.90      1,833.47     2,101.06
67966      Revision of eyelid                   T            T        0240    18.0194       797.90      1,833.47     2,101.06
67971      Reconstruction of eyelid             T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
67973      Reconstruction of eyelid             T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
67974      Reconstruction of eyelid             T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
67975      Reconstruction of eyelid             T            T        0240    18.0194       797.90      1,833.47     2,101.06
67999      Revision of eyelid                   T            1        0000     0.0000        0.00         0.00         0.00
68020      Incise/drain eyelid lining           T            T        0240    18.0194       797.90      1,833.47     2,101.06
68040      Treatment of eyelid lesions          S            S        0698     1.2378        54.81       125.95       144.33
68100      Biopsy of eyelid lining              T            T        0232     6.9204       306.44       704.15       806.92
68110      Remove eyelid lining lesion          T            T        0699     8.9556       396.55       911.23      1,044.22
68115      Remove eyelid lining lesion          T            T        0240    18.0194       797.90      1,833.47     2,101.06
68130      Remove eyelid lining lesion          T            T        0233    14.6645       649.34      1,492.11     1,709.88
68135      Remove eyelid lining lesion          T            T        0239     7.0583       312.54       718.18       823.00
68200      Treat eyelid by injection            S            S        0230     0.7902        34.99        80.40        92.14
68320      Revise/graft eyelid lining           T            T        0240    18.0194       797.90      1,833.47     2,101.06
68325      Revise/graft eyelid lining           T            T        0242    30.3478      1,343.80     3,087.89     3,538.55
68326      Revise/graft eyelid lining           T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
68328      Revise/graft eyelid lining           T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
68330      Revise eyelid lining                 T            T        0234    22.0521       976.47      2,243.80     2,571.27
68335      Revise/graft eyelid lining           T            T        0241    23.1681      1,025.88     2,357.35     2,701.40
68340      Separate eyelid adhesions            T            T        0240    18.0194       797.90      1,833.47     2,101.06
68360      Revise eyelid lining                 T            T        0234    22.0521       976.47      2,243.80     2,571.27
68362      Revise eyelid lining                 T            T        0234    22.0521       976.47      2,243.80     2,571.27

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            104 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            105 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

69421      Incision of eardrum                  T            T        0253    16.0740       711.76      1,635.53     1,874.23
69424      Remove ventilating tube              T            T        0252     8.1033       358.81       824.51       944.84
69433      Create eardrum opening               T            T        0252     8.1033       358.81       824.51       944.84
69436      Create eardrum opening               T            T        0253    16.0740       711.76      1,635.53     1,874.23
69440      Exploration of middle ear            T            T        0254    23.3114      1,032.23     2,371.93     2,718.11
69450      Eardrum revision                     T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69501      Mastoidectomy                        T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69502      Mastoidectomy                        T            T        0254    23.3114      1,032.23     2,371.93     2,718.11
69505      Remove mastoid structures            T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69511      Extensive mastoid surgery            T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69530      Extensive mastoid surgery            T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69535      Remove part of temporal bone         C            C        0000     0.0000        0.00         0.00         0.00
69540      Remove ear lesion                    T            T        0253    16.0740       711.76      1,635.53     1,874.23
69550      Remove ear lesion                    T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69552      Remove ear lesion                    T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69554      Remove ear lesion                    C            C        0000     0.0000        0.00         0.00         0.00
69601      Mastoid surgery revision             T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69602      Mastoid surgery revision             T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69603      Mastoid surgery revision             T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69604      Mastoid surgery revision             T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69605      Mastoid surgery revision             T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69610      Repair of eardrum                    T            T        0254    23.3114      1,032.23     2,371.93     2,718.11
69620      Repair of eardrum                    T            T        0254    23.3114      1,032.23     2,371.93     2,718.11
69631      Repair eardrum structures            T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69632      Rebuild eardrum structures           T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69633      Rebuild eardrum structures           T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69635      Repair eardrum structures            T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69636      Rebuild eardrum structures           T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69637      Rebuild eardrum structures           T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69641      Revise middle ear & mastoid          T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69642      Revise middle ear & mastoid          T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69643      Revise middle ear & mastoid          T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69644      Revise middle ear & mastoid          T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69645      Revise middle ear & mastoid          T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69646      Revise middle ear & mastoid          T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69650      Release middle ear bone              T            T        0254    23.3114      1,032.23     2,371.93     2,718.11
69660      Revise middle ear bone               T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69661      Revise middle ear bone               T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69662      Revise middle ear bone               T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69666      Repair middle ear structures         T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69667      Repair middle ear structures         T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69670      Remove mastoid air cells             T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69676      Remove middle ear nerve              T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69700      Close mastoid fistula                T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69710      Implant/replace hearing aid          E            3        0000     0.0000        M01          M01          M01
69711      Remove/repair hearing aid            T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69714      Implant temple bone w/stimul         T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69715      Temple bne implnt w/stimulat         T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69717      Temple bone implant revision         T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69718      Revise temple bone implant           T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69720      Release facial nerve                 T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69725      Release facial nerve                 T            T        0256    37.0000      1,638.36     3,764.75     4,314.20
69740      Repair facial nerve                  T            T        0256    37.0000      1,638.36     3,764.75     4,314.20

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            106 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

69745      Repair facial nerve                  T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69799      Middle ear surgery procedure         T            1        0000    0.0000         0.00         0.00         0.00
69801      Incise inner ear                     T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69802      Incise inner ear                     T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69805      Explore inner ear                    T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69806      Explore inner ear                    T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69820      Establish inner ear window           T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69840      Revise inner ear window              T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69905      Remove inner ear                     T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69910      Remove inner ear & mastoid           T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69915      Incise inner ear nerve               T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69930      Implant cochlear device              T            T        0259   393.7337     17,434.53    40,062.40    45,909.35
69949      Inner ear surgery procedure          T            1        0000    0.0000         0.00         0.00         0.00
69950      Incise inner ear nerve               C            C        0000    0.0000         0.00         0.00         0.00
69955      Release facial nerve                 T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69960      Release inner ear canal              T            T        0256   37.0000       1,638.36     3,764.75     4,314.20
69970      Remove inner ear lesion              C            C        0000    0.0000         0.00         0.00         0.00
69979      Temporal bone surgery                T            1        0000    0.0000         0.00         0.00         0.00
69990      Microsurgery add-on                  N            N        0000    0.0000         0.00         0.00         0.00
70010      Contrast x-ray of brain              S            S        0274    2.9160        129.12       296.70       340.01
70015      Contrast x-ray of brain              S            S        0274    2.9160        129.12       296.70       340.01
70030      X-ray eye for foreign body           X            X        0260    0.7296         32.31        74.24        85.07
70100      X-ray exam of jaw                    X            X        0260    0.7296         32.31        74.24        85.07
70110      X-ray exam of jaw                    X            X        0260    0.7296         32.31        74.24        85.07
70120      X-ray exam of mastoids               X            X        0260    0.7296         32.31        74.24        85.07
70130      X-ray exam of mastoids               X            X        0260    0.7296         32.31        74.24        85.07
70134      X-ray exam of middle ear             X            X        0261    1.2416         54.98       126.33       144.77
70140      X-ray exam of facial bones           X            X        0260    0.7296         32.31        74.24        85.07
70150      X-ray exam of facial bones           X            X        0260    0.7296         32.31        74.24        85.07
70160      X-ray exam of nasal bones            X            X        0260    0.7296         32.31        74.24        85.07
70170      X-ray exam of tear duct              X            X        0264    3.4542        152.95       351.46       402.76
70190      X-ray exam of eye sockets            X            X        0260    0.7296         32.31        74.24        85.07
70200      X-ray exam of eye sockets            X            X        0260    0.7296         32.31        74.24        85.07
70210      X-ray exam of sinuses                X            X        0260    0.7296         32.31        74.24        85.07
70220      X-ray exam of sinuses                X            X        0260    0.7296         32.31        74.24        85.07
70240      X-ray exam, pituitary saddle         X            X        0260    0.7296         32.31        74.24        85.07
70250      X-ray exam of skull                  X            X        0260    0.7296         32.31        74.24        85.07
70260      X-ray exam of skull                  X            X        0261    1.2416         54.98       126.33       144.77
70300      X-ray exam of teeth                  X            X        0262    0.8019         35.51        81.59        93.50
70310      X-ray exam of teeth                  X            X        0262    0.8019         35.51        81.59        93.50
70320      Full mouth x-ray of teeth            X            X        0262    0.8019         35.51        81.59        93.50
70328      X-ray exam of jaw joint              X            X        0260    0.7296         32.31        74.24        85.07
70330      X-ray exam of jaw joints             X            X        0260    0.7296         32.31        74.24        85.07
70332      X-ray exam of jaw joint              S            S        0275    3.4927        154.66       355.38       407.25
70336      Magnetic image, jaw joint            S            S        0335    5.0997        225.81       518.89       594.63
70350      X-ray head for orthodontia           X            X        0260    0.7296         32.31        74.24        85.07
70355      Panoramic x-ray of jaws              X            X        0260    0.7296         32.31        74.24        85.07
70360      X-ray exam of neck                   X            X        0260    0.7296         32.31        74.24        85.07
70370      Throat x-ray & fluoroscopy           X            X        0272    1.3291         58.85       135.24       154.97
70371      Speech evaluation, complex           X            X        0272    1.3291         58.85       135.24       154.97
70373      Contrast x-ray of larynx             X            X        0263    1.6979         75.18       172.76       197.98
70380      X-ray exam of salivary gland         X            X        0260    0.7296         32.31        74.24        85.07
70390      X-ray exam of salivary duct          X            X        0263    1.6979         75.18       172.76       197.98

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            107 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

70450      Ct head/brain w/o dye                S            S        0332    3.1608        139.96      321.61       368.55
70460      Ct head/brain w/dye                  S            S        0283    4.2921        190.05      436.72       500.46
70470      Ct head/brain w/o & w/dye            S            S        0333    5.1053        226.06      519.46       595.28
70480      Ct orbit/ear/fossa w/o dye           S            S        0332    3.1608        139.96      321.61       368.55
70481      Ct orbit/ear/fossa w/dye             S            S        0283    4.2921        190.05      436.72       500.46
70482      Ct orbit/ear/fossa w/o&w/dye         S            S        0333    5.1053        226.06      519.46       595.28
70486      Ct maxillofacial w/o dye             S            S        0332    3.1608        139.96      321.61       368.55
70487      Ct maxillofacial w/dye               S            S        0283    4.2921        190.05      436.72       500.46
70488      Ct maxillofacial w/o & w/dye         S            S        0333    5.1053        226.06      519.46       595.28
70490      Ct soft tissue neck w/o dye          S            S        0332    3.1608        139.96      321.61       368.55
70491      Ct soft tissue neck w/dye            S            S        0283    4.2921        190.05      436.72       500.46
70492      Ct sft tsue nck w/o & w/dye          S            S        0333    5.1053        226.06      519.46       595.28
70496      Ct angiography, head                 S            S        0662    4.9944        221.15      508.18       582.35
70498      Ct angiography, neck                 S            S        0662    4.9944        221.15      508.18       582.35
70540      Mri orbit/face/neck w/o dye          S            S        0336    5.8678        259.83      597.05       684.19
70542      Mri orbit/face/neck w/dye            S            S        0284    6.2342        276.05      634.33       726.91
70543      Mri orbt/fac/nck w/o & w/dye         S            S        0337    8.5070        376.69      865.59       991.92
70544      Mr angiography head w/o dye          S            S        0336    5.8678        259.83      597.05       684.19
70545      Mr angiography head w/dye            S            S        0284    6.2342        276.05      634.33       726.91
70546      Mr angiograph head w/o&w/dye         S            S        0337    8.5070        376.69      865.59       991.92
70547      Mr angiography neck w/o dye          S            S        0336    5.8678        259.83      597.05       684.19
70548      Mr angiography neck w/dye            S            S        0284    6.2342        276.05      634.33       726.91
70549      Mr angiograph neck w/o&w/dye         S            S        0337    8.5070        376.69      865.59       991.92
70551      Mri brain w/o dye                    S            S        0336    5.8678        259.83      597.05       684.19
70552      Mri brain w/dye                      S            S        0284    6.2342        276.05      634.33       726.91
70553      Mri brain w/o & w/dye                S            S        0337    8.5070        376.69      865.59       991.92
70557      Mri brain w/o dye                    S            S        0336    5.8678        259.83      597.05       684.19
70558      Mri brain w/dye                      S            S        0284    6.2342        276.05      634.33       726.91
70559      Mri brain w/o & w/dye                S            S        0337    8.5070        376.69      865.59       991.92
71010      Chest x-ray                          X            X        0260    0.7296         32.31       74.24        85.07
71015      Chest x-ray                          X            X        0260    0.7296         32.31       74.24        85.07
71020      Chest x-ray                          X            X        0260    0.7296         32.31       74.24        85.07
71021      Chest x-ray                          X            X        0260    0.7296         32.31       74.24        85.07
71022      Chest x-ray                          X            X        0260    0.7296         32.31       74.24        85.07
71023      Chest x-ray and fluoroscopy          X            X        0272    1.3291         58.85      135.24       154.97
71030      Chest x-ray                          X            X        0260    0.7296         32.31       74.24        85.07
71034      Chest x-ray and fluoroscopy          X            X        0272    1.3291         58.85      135.24       154.97
71035      Chest x-ray                          X            X        0260    0.7296         32.31       74.24        85.07
71040      Contrast x-ray of bronchi            X            X        0263    1.6979         75.18      172.76       197.98
71060      Contrast x-ray of bronchi            X            X        0263    1.6979         75.18      172.76       197.98
71090      X-ray & pacemaker insertion          X            X        0272    1.3291         58.85      135.24       154.97
71100      X-ray exam of ribs                   X            X        0260    0.7296         32.31       74.24        85.07
71101      X-ray exam of ribs/chest             X            X        0260    0.7296         32.31       74.24        85.07
71110      X-ray exam of ribs                   X            X        0260    0.7296         32.31       74.24        85.07
71111      X-ray exam of ribs/chest             X            X        0261    1.2416         54.98      126.33       144.77
71120      X-ray exam of breastbone             X            X        0260    0.7296         32.31       74.24        85.07
71130      X-ray exam of breastbone             X            X        0260    0.7296         32.31       74.24        85.07
71250      Ct thorax w/o dye                    S            S        0332    3.1608        139.96      321.61       368.55
71260      Ct thorax w/dye                      S            S        0283    4.2921        190.05      436.72       500.46
71270      Ct thorax w/o & w/dye                S            S        0333    5.1053        226.06      519.46       595.28
71275      Ct angiography, chest                S            S        0662    4.9944        221.15      508.18       582.35
71550      Mri chest w/o dye                    S            S        0336    5.8678        259.83      597.05       684.19
71551      Mri chest w/dye                      S            S        0284    6.2342        276.05      634.33       726.91

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            108 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

71552      Mri chest w/o & w/dye                S            S        0337    8.5070        376.69      865.59       991.92
71555      Mri angio chest w or w/o dye         B            1        0000    0.0000         0.00        0.00         0.00
72010      X-ray exam of spine                  X            X        0260    0.7296         32.31       74.24        85.07
72020      X-ray exam of spine                  X            X        0260    0.7296         32.31       74.24        85.07
72040      X-ray exam of neck spine             X            X        0260    0.7296         32.31       74.24        85.07
72050      X-ray exam of neck spine             X            X        0261    1.2416         54.98      126.33       144.77
72052      X-ray exam of neck spine             X            X        0261    1.2416         54.98      126.33       144.77
72069      X-ray exam of trunk spine            X            X        0260    0.7296         32.31       74.24        85.07
72070      X-ray exam of thoracic spine         X            X        0260    0.7296         32.31       74.24        85.07
72072      X-ray exam of thoracic spine         X            X        0260    0.7296         32.31       74.24        85.07
72074      X-ray exam of thoracic spine         X            X        0260    0.7296         32.31       74.24        85.07
72080      X-ray exam of trunk spine            X            X        0260    0.7296         32.31       74.24        85.07
72090      X-ray exam of trunk spine            X            X        0261    1.2416         54.98      126.33       144.77
72100      X-ray exam of lower spine            X            X        0260    0.7296         32.31       74.24        85.07
72110      X-ray exam of lower spine            X            X        0261    1.2416         54.98      126.33       144.77
72114      X-ray exam of lower spine            X            X        0261    1.2416         54.98      126.33       144.77
72120      X-ray exam of lower spine            X            X        0261    1.2416         54.98      126.33       144.77
72125      Ct neck spine w/o dye                S            S        0332    3.1608        139.96      321.61       368.55
72126      Ct neck spine w/dye                  S            S        0283    4.2921        190.05      436.72       500.46
72127      Ct neck spine w/o & w/dye            S            S        0333    5.1053        226.06      519.46       595.28
72128      Ct chest spine w/o dye               S            S        0332    3.1608        139.96      321.61       368.55
72129      Ct chest spine w/dye                 S            S        0283    4.2921        190.05      436.72       500.46
72130      Ct chest spine w/o & w/dye           S            S        0333    5.1053        226.06      519.46       595.28
72131      Ct lumbar spine w/o dye              S            S        0332    3.1608        139.96      321.61       368.55
72132      Ct lumbar spine w/dye                S            S        0283    4.2921        190.05      436.72       500.46
72133      Ct lumbar spine w/o & w/dye          S            S        0333    5.1053        226.06      519.46       595.28
72141      Mri neck spine w/o dye               S            S        0336    5.8678        259.83      597.05       684.19
72142      Mri neck spine w/dye                 S            S        0284    6.2342        276.05      634.33       726.91
72146      Mri chest spine w/o dye              S            S        0336    5.8678        259.83      597.05       684.19
72147      Mri chest spine w/dye                S            S        0284    6.2342        276.05      634.33       726.91
72148      Mri lumbar spine w/o dye             S            S        0336    5.8678        259.83      597.05       684.19
72149      Mri lumbar spine w/dye               S            S        0284    6.2342        276.05      634.33       726.91
72156      Mri neck spine w/o & w/dye           S            S        0337    8.5070        376.69      865.59       991.92
72157      Mri chest spine w/o & w/dye          S            S        0337    8.5070        376.69      865.59       991.92
72158      Mri lumbar spine w/o & w/dye         S            S        0337    8.5070        376.69      865.59       991.92
72159      Mr angio spine w/o&w/dye             E            3        0000    0.0000         M01         M01          M01
72170      X-ray exam of pelvis                 X            X        0260    0.7296         32.31       74.24        85.07
72190      X-ray exam of pelvis                 X            X        0260    0.7296         32.31       74.24        85.07
72191      Ct angiograph pelv w/o&w/dye         S            S        0662    4.9944        221.15      508.18       582.35
72192      Ct pelvis w/o dye                    S            S        0332    3.1608        139.96      321.61       368.55
72193      Ct pelvis w/dye                      S            S        0283    4.2921        190.05      436.72       500.46
72194      Ct pelvis w/o & w/dye                S            S        0333    5.1053        226.06      519.46       595.28
72195      Mri pelvis w/o dye                   S            S        0336    5.8678        259.83      597.05       684.19
72196      Mri pelvis w/dye                     S            S        0284    6.2342        276.05      634.33       726.91
72197      Mri pelvis w/o & w/dye               S            S        0337    8.5070        376.69      865.59       991.92
72198      Mr angio pelvis w/o & w/dye          B            1        0000    0.0000         0.00        0.00         0.00
72200      X-ray exam sacroiliac joints         X            X        0260    0.7296         32.31       74.24        85.07
72202      X-ray exam sacroiliac joints         X            X        0260    0.7296         32.31       74.24        85.07
72220      X-ray exam of tailbone               X            X        0260    0.7296         32.31       74.24        85.07
72240      Contrast x-ray of neck spine         S            S        0274    2.9160        129.12      296.70       340.01
72255      Contrast x-ray, thorax spine         S            S        0274    2.9160        129.12      296.70       340.01
72265      Contrast x-ray, lower spine          S            S        0274    2.9160        129.12      296.70       340.01
72270      Contrast x-ray, spine                S            S        0274    2.9160        129.12      296.70       340.01

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            109 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

72275      Epidurography                        S            S        0274     2.9160       129.12       296.70       340.01
72285      X-ray c/t spine disk                 S            S        0388    12.1712       538.94      1,238.42     1,419.16
72295      X-ray of lower spine disk            S            S        0388    12.1712       538.94      1,238.42     1,419.16
73000      X-ray exam of collar bone            X            X        0260     0.7296        32.31        74.24        85.07
73010      X-ray exam of shoulder blade         X            X        0260     0.7296        32.31        74.24        85.07
73020      X-ray exam of shoulder               X            X        0260     0.7296        32.31        74.24        85.07
73030      X-ray exam of shoulder               X            X        0260     0.7296        32.31        74.24        85.07
73040      Contrast x-ray of shoulder           S            S        0275     3.4927       154.66       355.38       407.25
73050      X-ray exam of shoulders              X            X        0260     0.7296        32.31        74.24        85.07
73060      X-ray exam of humerus                X            X        0260     0.7296        32.31        74.24        85.07
73070      X-ray exam of elbow                  X            X        0260     0.7296        32.31        74.24        85.07
73080      X-ray exam of elbow                  X            X        0260     0.7296        32.31        74.24        85.07
73085      Contrast x-ray of elbow              S            S        0275     3.4927       154.66       355.38       407.25
73090      X-ray exam of forearm                X            X        0260     0.7296        32.31        74.24        85.07
73092      X-ray exam of arm, infant            X            X        0260     0.7296        32.31        74.24        85.07
73100      X-ray exam of wrist                  X            X        0260     0.7296        32.31        74.24        85.07
73110      X-ray exam of wrist                  X            X        0260     0.7296        32.31        74.24        85.07
73115      Contrast x-ray of wrist              S            S        0275     3.4927       154.66       355.38       407.25
73120      X-ray exam of hand                   X            X        0260     0.7296        32.31        74.24        85.07
73130      X-ray exam of hand                   X            X        0260     0.7296        32.31        74.24        85.07
73140      X-ray exam of finger(s)              X            X        0260     0.7296        32.31        74.24        85.07
73200      Ct upper extremity w/o dye           S            S        0332     3.1608       139.96       321.61       368.55
73201      Ct upper extremity w/dye             S            S        0283     4.2921       190.05       436.72       500.46
73202      Ct uppr extremity w/o&w/dye          S            S        0333     5.1053       226.06       519.46       595.28
73206      Ct angio upr extrm w/o&w/dye         S            S        0662     4.9944       221.15       508.18       582.35
73218      Mri upper extremity w/o dye          S            S        0336     5.8678       259.83       597.05       684.19
73219      Mri upper extremity w/dye            S            S        0284     6.2342       276.05       634.33       726.91
73220      Mri uppr extremity w/o&w/dye         S            S        0337     8.5070       376.69       865.59       991.92
73221      Mri joint upr extrem w/o dye         S            S        0336     5.8678       259.83       597.05       684.19
73222      Mri joint upr extrem w/dye           S            S        0284     6.2342       276.05       634.33       726.91
73223      Mri joint upr extr w/o&w/dye         S            S        0337     8.5070       376.69       865.59       991.92
73225      Mr angio upr extr w/o&w/dye          E            3        0000     0.0000        M01          M01          M01
73500      X-ray exam of hip                    X            X        0260     0.7296        32.31        74.24        85.07
73510      X-ray exam of hip                    X            X        0260     0.7296        32.31        74.24        85.07
73520      X-ray exam of hips                   X            X        0261     1.2416        54.98       126.33       144.77
73525      Contrast x-ray of hip                S            S        0275     3.4927       154.66       355.38       407.25
73530      X-ray exam of hip                    X            X        0261     1.2416        54.98       126.33       144.77
73540      X-ray exam of pelvis & hips          X            X        0260     0.7296        32.31        74.24        85.07
73542      X-ray exam, sacroiliac joint         S            S        0275     3.4927       154.66       355.38       407.25
73550      X-ray exam of thigh                  X            X        0260     0.7296        32.31        74.24        85.07
73560      X-ray exam of knee, 1 or 2           X            X        0260     0.7296        32.31        74.24        85.07
73562      X-ray exam of knee, 3                X            X        0260     0.7296        32.31        74.24        85.07
73564      X-ray exam, knee, 4 or more          X            X        0260     0.7296        32.31        74.24        85.07
73565      X-ray exam of knees                  X            X        0260     0.7296        32.31        74.24        85.07
73580      Contrast x-ray of knee joint         S            S        0275     3.4927       154.66       355.38       407.25
73590      X-ray exam of lower leg              X            X        0260     0.7296        32.31        74.24        85.07
73592      X-ray exam of leg, infant            X            X        0260     0.7296        32.31        74.24        85.07
73600      X-ray exam of ankle                  X            X        0260     0.7296        32.31        74.24        85.07
73610      X-ray exam of ankle                  X            X        0260     0.7296        32.31        74.24        85.07
73615      Contrast x-ray of ankle              S            S        0275     3.4927       154.66       355.38       407.25
73620      X-ray exam of foot                   X            X        0260     0.7296        32.31        74.24        85.07
73630      X-ray exam of foot                   X            X        0260     0.7296        32.31        74.24        85.07
73650      X-ray exam of heel                   X            X        0260     0.7296        32.31        74.24        85.07

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            110 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

73660      X-ray exam of toe(s)                 X            X        0260    0.7296         32.31       74.24        85.07
73700      Ct lower extremity w/o dye           S            S        0332    3.1608        139.96      321.61       368.55
73701      Ct lower extremity w/dye             S            S        0283    4.2921        190.05      436.72       500.46
73702      Ct lwr extremity w/o&w/dye           S            S        0333    5.1053        226.06      519.46       595.28
73706      Ct angio lwr extr w/o&w/dye          S            S        0662    4.9944        221.15      508.18       582.35
73718      Mri lower extremity w/o dye          S            S        0336    5.8678        259.83      597.05       684.19
73719      Mri lower extremity w/dye            S            S        0284    6.2342        276.05      634.33       726.91
73720      Mri lwr extremity w/o&w/dye          S            S        0337    8.5070        376.69      865.59       991.92
73721      Mri jnt of lwr extre w/o dye         S            S        0336    5.8678        259.83      597.05       684.19
73722      Mri joint of lwr extr w/dye          S            S        0284    6.2342        276.05      634.33       726.91
73723      Mri joint lwr extr w/o&w/dye         S            S        0337    8.5070        376.69      865.59       991.92
73725      Mr ang lwr ext w or w/o dye          B            1        0000    0.0000         0.00        0.00         0.00
74000      X-ray exam of abdomen                X            X        0260    0.7296         32.31       74.24        85.07
74010      X-ray exam of abdomen                X            X        0260    0.7296         32.31       74.24        85.07
74020      X-ray exam of abdomen                X            X        0260    0.7296         32.31       74.24        85.07
74022      X-ray exam series, abdomen           X            X        0261    1.2416         54.98      126.33       144.77
74150      Ct abdomen w/o dye                   S            S        0332    3.1608        139.96      321.61       368.55
74160      Ct abdomen w/dye                     S            S        0283    4.2921        190.05      436.72       500.46
74170      Ct abdomen w/o & w/dye               S            S        0333    5.1053        226.06      519.46       595.28
74175      Ct angio abdom w/o & w/dye           S            S        0662    4.9944        221.15      508.18       582.35
74181      Mri abdomen w/o dye                  S            S        0336    5.8678        259.83      597.05       684.19
74182      Mri abdomen w/dye                    S            S        0284    6.2342        276.05      634.33       726.91
74183      Mri abdomen w/o & w/dye              S            S        0337    8.5070        376.69      865.59       991.92
74185      Mri angio, abdom w orw/o dye         B            1        0000    0.0000         0.00        0.00         0.00
74190      X-ray exam of peritoneum             X            X        0264    3.4542        152.95      351.46       402.76
74210      Contrst x-ray exam of throat         S            S        0276    1.4693         65.06      149.50       171.32
74220      Contrast x-ray, esophagus            S            S        0276    1.4693         65.06      149.50       171.32
74230      Cine/vid x-ray, throat/esoph         S            S        0276    1.4693         65.06      149.50       171.32
74235      Remove esophagus obstruction         S            S        0296    2.2684        100.44      230.81       264.50
74240      X-ray exam, upper gi tract           S            S        0276    1.4693         65.06      149.50       171.32
74241      X-ray exam, upper gi tract           S            S        0276    1.4693         65.06      149.50       171.32
74245      X-ray exam, upper gi tract           S            S        0277    2.2951        101.63      233.53       267.61
74246      Contrst x-ray uppr gi tract          S            S        0276    1.4693         65.06      149.50       171.32
74247      Contrst x-ray uppr gi tract          S            S        0276    1.4693         65.06      149.50       171.32
74249      Contrst x-ray uppr gi tract          S            S        0277    2.2951        101.63      233.53       267.61
74250      X-ray exam of small bowel            S            S        0276    1.4693         65.06      149.50       171.32
74251      X-ray exam of small bowel            S            S        0277    2.2951        101.63      233.53       267.61
74260      X-ray exam of small bowel            S            S        0277    2.2951        101.63      233.53       267.61
74270      Contrast x-ray exam of colon         S            S        0276    1.4693         65.06      149.50       171.32
74280      Contrast x-ray exam of colon         S            S        0277    2.2951        101.63      233.53       267.61
74283      Contrast x-ray exam of colon         S            S        0276    1.4693         65.06      149.50       171.32
74290      Contrast x-ray, gallbladder          S            S        0276    1.4693         65.06      149.50       171.32
74291      Contrast x-rays, gallbladder         S            S        0276    1.4693         65.06      149.50       171.32
74300      X-ray bile ducts/pancreas            X            X        0263    1.6979         75.18      172.76       197.98
74301      X-rays at surgery add-on             X            X        0263    1.6979         75.18      172.76       197.98
74305      X-ray bile ducts/pancreas            X            X        0263    1.6979         75.18      172.76       197.98
74320      Contrast x-ray of bile ducts         X            X        0264    3.4542        152.95      351.46       402.76
74327      X-ray bile stone removal             S            S        0296    2.2684        100.44      230.81       264.50
74328      X-ray bile duct endoscopy            N            N        0000    0.0000         0.00        0.00         0.00
74329      X-ray for pancreas endoscopy         N            N        0000    0.0000         0.00        0.00         0.00
74330      X-ray bile/panc endoscopy            N            N        0000    0.0000         0.00        0.00         0.00
74340      X-ray guide for GI tube              X            X        0272    1.3291         58.85      135.24       154.97
74350      X-ray guide, stomach tube            X            X        0263    1.6979         75.18      172.76       197.98

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            111 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

74355      X-ray guide, intestinal tube         X            X        0263     1.6979        75.18       172.76       197.98
74360      X-ray guide, GI dilation             S            S        0296     2.2684       100.44       230.81       264.50
74363      X-ray, bile duct dilation            S            S        0297     5.0977       225.73       518.69       594.39
74400      Contrst x-ray, urinary tract         S            S        0278     2.5559       113.18       260.06       298.02
74410      Contrst x-ray, urinary tract         S            S        0278     2.5559       113.18       260.06       298.02
74415      Contrst x-ray, urinary tract         S            S        0278     2.5559       113.18       260.06       298.02
74420      Contrst x-ray, urinary tract         S            S        0278     2.5559       113.18       260.06       298.02
74425      Contrst x-ray, urinary tract         S            S        0278     2.5559       113.18       260.06       298.02
74430      Contrast x-ray, bladder              S            S        0278     2.5559       113.18       260.06       298.02
74440      X-ray, male genital tract            S            S        0278     2.5559       113.18       260.06       298.02
74445      X-ray exam of penis                  S            S        0278     2.5559       113.18       260.06       298.02
74450      X-ray, urethra/bladder               S            S        0278     2.5559       113.18       260.06       298.02
74455      X-ray, urethra/bladder               S            S        0278     2.5559       113.18       260.06       298.02
74470      X-ray exam of kidney lesion          X            X        0263     1.6979        75.18       172.76       197.98
74475      X-ray control, cath insert           S            S        0297     5.0977       225.73       518.69       594.39
74480      X-ray control, cath insert           S            S        0296     2.2684       100.44       230.81       264.50
74485      X-ray guide, GU dilation             S            S        0296     2.2684       100.44       230.81       264.50
74710      X-ray measurement of pelvis          X            X        0261     1.2416        54.98       126.33       144.77
74740      X-ray, female genital tract          X            X        0264     3.4542       152.95       351.46       402.76
74742      X-ray, fallopian tube                X            X        0264     3.4542       152.95       351.46       402.76
74775      X-ray exam of perineum               S            S        0278     2.5559       113.18       260.06       298.02
75552      Heart mri for morph w/o dye          S            S        0336     5.8678       259.83       597.05       684.19
75553      Heart mri for morph w/dye            S            S        0284     6.2342       276.05       634.33       726.91
75554      Cardiac MRI/function                 S            S        0336     5.8678       259.83       597.05       684.19
75555      Cardiac MRI/limited study            S            S        0336     5.8678       259.83       597.05       684.19
75556      Cardiac MRI/flow mapping             E            3        0000     0.0000        M01          M01          M01
75600      Contrast x-ray exam of aorta         S            S        0280    20.4187       904.14      2,077.60     2,380.82
75605      Contrast x-ray exam of aorta         S            S        0280    20.4187       904.14      2,077.60     2,380.82
75625      Contrast x-ray exam of aorta         S            S        0280    20.4187       904.14      2,077.60     2,380.82
75630      X-ray aorta, leg arteries            S            S        0280    20.4187       904.14      2,077.60     2,380.82
75635      Ct angio abdominal arteries          S            S        0662     4.9944       221.15       508.18       582.35
75650      Artery x-rays, head & neck           S            S        0280    20.4187       904.14      2,077.60     2,380.82
75658      Artery x-rays, arm                   S            S        0279     8.6988       385.18       885.10      1,014.28
75660      Artery x-rays, head & neck           S            S        0668     6.3104       279.42       642.08       735.79
75662      Artery x-rays, head & neck           S            S        0280    20.4187       904.14      2,077.60     2,380.82
75665      Artery x-rays, head & neck           S            S        0280    20.4187       904.14      2,077.60     2,380.82
75671      Artery x-rays, head & neck           S            S        0280    20.4187       904.14      2,077.60     2,380.82
75676      Artery x-rays, neck                  S            S        0280    20.4187       904.14      2,077.60     2,380.82
75680      Artery x-rays, neck                  S            S        0280    20.4187       904.14      2,077.60     2,380.82
75685      Artery x-rays, spine                 S            S        0280    20.4187       904.14      2,077.60     2,380.82
75705      Artery x-rays, spine                 S            S        0668     6.3104       279.42       642.08       735.79
75710      Artery x-rays, arm/leg               S            S        0280    20.4187       904.14      2,077.60     2,380.82
75716      Artery x-rays, arms/legs             S            S        0280    20.4187       904.14      2,077.60     2,380.82
75722      Artery x-rays, kidney                S            S        0280    20.4187       904.14      2,077.60     2,380.82
75724      Artery x-rays, kidneys               S            S        0280    20.4187       904.14      2,077.60     2,380.82
75726      Artery x-rays, abdomen               S            S        0280    20.4187       904.14      2,077.60     2,380.82
75731      Artery x-rays, adrenal gland         S            S        0280    20.4187       904.14      2,077.60     2,380.82
75733      Artery x-rays, adrenals              S            S        0668     6.3104       279.42       642.08       735.79
75736      Artery x-rays, pelvis                S            S        0280    20.4187       904.14      2,077.60     2,380.82
75741      Artery x-rays, lung                  S            S        0279     8.6988       385.18       885.10      1,014.28
75743      Artery x-rays, lungs                 S            S        0280    20.4187       904.14      2,077.60     2,380.82
75746      Artery x-rays, lung                  S            S        0279     8.6988       385.18       885.10      1,014.28
75756      Artery x-rays, chest                 S            S        0279     8.6988       385.18       885.10      1,014.28

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            112 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

75774      Artery x-ray, each vessel            S            S        0279     8.6988       385.18       885.10      1,014.28
75790      Visualize A-V shunt                  S            S        0279     8.6988       385.18       885.10      1,014.28
75801      Lymph vessel x-ray, arm/leg          X            X        0264     3.4542       152.95       351.46       402.76
75803      Lymph vessel x-ray,arms/legs         X            X        0264     3.4542       152.95       351.46       402.76
75805      Lymph vessel x-ray, trunk            X            X        0264     3.4542       152.95       351.46       402.76
75807      Lymph vessel x-ray, trunk            X            X        0264     3.4542       152.95       351.46       402.76
75809      Nonvascular shunt, x-ray             X            X        0263     1.6979        75.18       172.76       197.98
75810      Vein x-ray, spleen/liver             S            S        0279     8.6988       385.18       885.10      1,014.28
75820      Vein x-ray, arm/leg                  S            S        0668     6.3104       279.42       642.08       735.79
75822      Vein x-ray, arms/legs                S            S        0668     6.3104       279.42       642.08       735.79
75825      Vein x-ray, trunk                    S            S        0279     8.6988       385.18       885.10      1,014.28
75827      Vein x-ray, chest                    S            S        0279     8.6988       385.18       885.10      1,014.28
75831      Vein x-ray, kidney                   S            S        0279     8.6988       385.18       885.10      1,014.28
75833      Vein x-ray, kidneys                  S            S        0279     8.6988       385.18       885.10      1,014.28
75840      Vein x-ray, adrenal gland            S            S        0280    20.4187       904.14      2,077.60     2,380.82
75842      Vein x-ray, adrenal glands           S            S        0280    20.4187       904.14      2,077.60     2,380.82
75860      Vein x-ray, neck                     S            S        0668     6.3104       279.42       642.08       735.79
75870      Vein x-ray, skull                    S            S        0668     6.3104       279.42       642.08       735.79
75872      Vein x-ray, skull                    S            S        0279     8.6988       385.18       885.10      1,014.28
75880      Vein x-ray, eye socket               S            S        0668     6.3104       279.42       642.08       735.79
75885      Vein x-ray, liver                    S            S        0280    20.4187       904.14      2,077.60     2,380.82
75887      Vein x-ray, liver                    S            S        0279     8.6988       385.18       885.10      1,014.28
75889      Vein x-ray, liver                    S            S        0280    20.4187       904.14      2,077.60     2,380.82
75891      Vein x-ray, liver                    S            S        0279     8.6988       385.18       885.10      1,014.28
75893      Venous sampling by catheter          N            N        0000     0.0000        0.00         0.00         0.00
75894      X-rays, transcath therapy            S            S        0297     5.0977       225.73       518.69       594.39
75896      X-rays, transcath therapy            S            S        0297     5.0977       225.73       518.69       594.39
75898      Follow-up angiography                X            X        0263     1.6979        75.18       172.76       197.98
75900      Arterial catheter exchange           C            C        0000     0.0000        0.00         0.00         0.00
75901      Remove cva device obstruct           X            X        0263     1.6979        75.18       172.76       197.98
75902      Remove cva lumen obstruct            X            X        0263     1.6979        75.18       172.76       197.98
75940      X-ray placement, vein filter         S            S        0297     5.0977       225.73       518.69       594.39
75945      Intravascular us                     S            S        0267     2.5543       113.10       259.90       297.83
75946      Intravascular us add-on              S            S        0266     1.5883        70.33       161.61       185.20
75952      Endovasc repair abdom aorta          C            C        0000     0.0000        0.00         0.00         0.00
75953      Abdom aneurysm endovas rpr           C            C        0000     0.0000        0.00         0.00         0.00
75954      Iliac aneurysm endovas rpr           C            C        0000     0.0000        0.00         0.00         0.00
75956      Xray, endovasc thor ao repr          C            C        0000     0.0000        0.00         0.00         0.00
75957      Xray, endovasc thor ao repr          C            C        0000     0.0000        0.00         0.00         0.00
75958      Xray, place prox ext thor ao         C            C        0000     0.0000        0.00         0.00         0.00
75959      Xray, place dist ext thor ao         C            C        0000     0.0000        0.00         0.00         0.00
75960      Transcath iv stent rs&i              S            S        0668     6.3104       279.42       642.08       735.79
75961      Retrieval, broken catheter           S            S        0668     6.3104       279.42       642.08       735.79
75962      Repair arterial blockage             S            S        0668     6.3104       279.42       642.08       735.79
75964      Repair artery blockage, each         S            S        0668     6.3104       279.42       642.08       735.79
75966      Repair arterial blockage             S            S        0668     6.3104       279.42       642.08       735.79
75968      Repair artery blockage, each         S            S        0668     6.3104       279.42       642.08       735.79
75970      Vascular biopsy                      S            S        0668     6.3104       279.42       642.08       735.79
75978      Repair venous blockage               S            S        0668     6.3104       279.42       642.08       735.79
75980      Contrast xray exam bile duct         S            S        0297     5.0977       225.73       518.69       594.39
75982      Contrast xray exam bile duct         S            S        0297     5.0977       225.73       518.69       594.39
75984      Xray control catheter change         X            X        0263     1.6979        75.18       172.76       197.98
75989      Abscess drainage under x-ray         N            N        0000     0.0000        0.00         0.00         0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            113 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

75992      Atherectomy, x-ray exam              S            S        0279    8.6988        385.18      885.10       1,014.28
75993      Atherectomy, x-ray exam              S            S        0279    8.6988        385.18      885.10       1,014.28
75994      Atherectomy, x-ray exam              S            S        0279    8.6988        385.18      885.10       1,014.28
75995      Atherectomy, x-ray exam              S            S        0279    8.6988        385.18      885.10       1,014.28
75996      Atherectomy, x-ray exam              S            S        0279    8.6988        385.18      885.10       1,014.28
75998      Fluoroguide for vein device          N            N        0000    0.0000         0.00        0.00          0.00
76000      Fluoroscope examination              X            X        0272    1.3291         58.85      135.24        154.97
76001      Fluoroscope exam, extensive          N            N        0000    0.0000         0.00        0.00          0.00
76003      Needle localization by x-ray         N            N        0000    0.0000         0.00        0.00          0.00
76005      Fluoroguide for spine inject         N            N        0000    0.0000         0.00        0.00          0.00
76006      X-ray stress view                    X            X        0260    0.7296         32.31       74.24         85.07
76010      X-ray, nose to rectum                X            X        0260    0.7296         32.31       74.24         85.07
76012      Percut vertebroplasty fluor          S            S        0274    2.9160        129.12      296.70        340.01
76013      Percut vertebroplasty, ct            S            S        0274    2.9160        129.12      296.70        340.01
76020      X-rays for bone age                  X            X        0260    0.7296         32.31       74.24         85.07
76040      X-rays, bone evaluation              X            X        0261    1.2416         54.98      126.33        144.77
76061      X-rays, bone survey                  X            X        0261    1.2416         54.98      126.33        144.77
76062      X-rays, bone survey                  X            X        0261    1.2416         54.98      126.33        144.77
76065      X-rays, bone evaluation              X            X        0261    1.2416         54.98      126.33        144.77
76066      Joint survey, single view            X            X        0260    0.7296         32.31       74.24         85.07
76070      Ct bone density, axial               S            S        0288    1.2216         54.09      124.30        142.44
76071      Ct bone density, peripheral          S            S        0282    1.5934         70.56      162.13        185.79
76075      Dxa bone density, axial              S            S        0288    1.2216         54.09      124.30        142.44
76076      Dxa bone density/peripheral          S            S        0665    0.6381         28.26       64.93         74.40
76077      Dxa bone density/v-fracture          X            X        0260    0.7296         32.31       74.24         85.07
76078      Radiographic absorptiometry          X            X        0260    0.7296         32.31       74.24         85.07
76080      X-ray exam of fistula                X            X        0263    1.6979         75.18      172.76        197.98
76082      Computer mammogram add-on            A            3        0000    0.0000         M01         M01           M01
76083      Computer mammogram add-on            A            3        0000    0.0000         M01         M01           M01
76086      X-ray of mammary duct                X            X        0263    1.6979         75.18      172.76        197.98
76088      X-ray of mammary ducts               X            X        0263    1.6979         75.18      172.76        197.98
76090      Mammogram, one breast                A            3        0000    0.0000         M01         M01           M01
76091      Mammogram, both breasts              A            3        0000    0.0000         M01         M01           M01
76092      Mammogram, screening                 A            3        0000    0.0000         M01         M01           M01
76093      Magnetic image, breast               E            1        0000    0.0000         0.00        0.00          0.00
76094      Magnetic image, both breasts         E            1        0000    0.0000         0.00        0.00          0.00
76095      Stereotactic breast biopsy           X            X        0264    3.4542        152.95      351.46        402.76
76096      X-ray of needle wire, breast         X            X        0263    1.6979         75.18      172.76        197.98
76098      X-ray exam, breast specimen          X            X        0260    0.7296         32.31       74.24         85.07
76100      X-ray exam of body section           X            X        0261    1.2416         54.98      126.33        144.77
76101      Complex body section x-ray           X            X        0263    1.6979         75.18      172.76        197.98
76102      Complex body section x-rays          X            X        0264    3.4542        152.95      351.46        402.76
76120      Cine/video x-rays                    X            X        0272    1.3291         58.85      135.24        154.97
76125      Cine/video x-rays add-on             X            X        0260    0.7296         32.31       74.24         85.07
76140      X-ray consultation                   E            1        0000    0.0000         0.00        0.00          0.00
76150      X-ray exam, dry process              X            X        0260    0.7296         32.31       74.24         85.07
76350      Special x-ray contrast study         N            N        0000    0.0000         0.00        0.00          0.00
76355      Ct scan for localization             S            S        0283    4.2921        190.05      436.72        500.46
76360      Ct scan for needle biopsy            S            S        0283    4.2921        190.05      436.72        500.46
76362      Ct guide for tissue ablation         S            S        0333    5.1053        226.06      519.46        595.28
76370      Ct scan for therapy guide            S            S        0282    1.5934         70.56      162.13        185.79
76376      3d render w/o postprocess            X            X        0340    0.6137         27.17       62.44         71.56
76377      3d rendering w/postprocess           S            1        0000    0.0000         0.00        0.00          0.00

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            114 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

76380      CAT scan follow-up study             S            S        0282    1.5934         70.56      162.13       185.79
76390      Mr spectroscopy                      E            3        0000    0.0000         M01         M01          M01
76393      Mr guidance for needle place         S            S        0335    5.0997        225.81      518.89       594.63
76394      Mri for tissue ablation              S            S        0335    5.0997        225.81      518.89       594.63
76400      Magnetic image, bone marrow          S            S        0335    5.0997        225.81      518.89       594.63
76496      Fluoroscopic procedure               X            1        0000    0.0000         0.00        0.00         0.00
76497      Ct procedure                         S            1        0000    0.0000         0.00        0.00         0.00
76498      Mri procedure                        S            1        0000    0.0000         0.00        0.00         0.00
76499      Radiographic procedure               X            1        0000    0.0000         0.00        0.00         0.00
76506      Echo exam of head                    S            S        0265    0.9930         43.97      101.04       115.78
76510      Ophth us, b & quant a                S            S        0266    1.5883         70.33      161.61       185.20
76511      Ophth us, quant a only               S            S        0266    1.5883         70.33      161.61       185.20
76512      Ophth us, b w/non-quant a            S            S        0266    1.5883         70.33      161.61       185.20
76513      Echo exam of eye, water bath         S            S        0266    1.5883         70.33      161.61       185.20
76514      Echo exam of eye, thickness          X            X        0340    0.6137         27.17       62.44        71.56
76516      Echo exam of eye                     S            S        0265    0.9930         43.97      101.04       115.78
76519      Echo exam of eye                     S            S        0266    1.5883         70.33      161.61       185.20
76529      Echo exam of eye                     S            S        0265    0.9930         43.97      101.04       115.78
76536      Us exam of head and neck             S            S        0266    1.5883         70.33      161.61       185.20
76604      Us exam, chest, b-scan               S            S        0266    1.5883         70.33      161.61       185.20
76645      Us exam, breast(s)                   S            S        0265    0.9930         43.97      101.04       115.78
76700      Us exam, abdom, complete             S            S        0266    1.5883         70.33      161.61       185.20
76705      Echo exam of abdomen                 S            S        0266    1.5883         70.33      161.61       185.20
76770      Us exam abdo back wall, comp         S            S        0266    1.5883         70.33      161.61       185.20
76775      Us exam abdo back wall, lim          S            S        0266    1.5883         70.33      161.61       185.20
76778      Us exam kidney transplant            S            S        0266    1.5883         70.33      161.61       185.20
76800      Us exam, spinal canal                S            S        0266    1.5883         70.33      161.61       185.20
76801      Ob us < 14 wks, single fetus         S            S        0266    1.5883         70.33      161.61       185.20
76802      Ob us < 14 wks, add’l fetus          S            S        0265    0.9930         43.97      101.04       115.78
76805      Ob us >/= 14 wks, sngl fetus         S            S        0266    1.5883         70.33      161.61       185.20
76810      Ob us >/= 14 wks, addl fetus         S            S        0266    1.5883         70.33      161.61       185.20
76811      Ob us, detailed, sngl fetus          S            S        0267    2.5543        113.10      259.90       297.83
76812      Ob us, detailed, addl fetus          S            S        0266    1.5883         70.33      161.61       185.20
76815      Ob us, limited, fetus(s)             S            S        0265    0.9930         43.97      101.04       115.78
76816      Ob us, follow-up, per fetus          S            S        0265    0.9930         43.97      101.04       115.78
76817      Transvaginal us, obstetric           S            S        0266    1.5883         70.33      161.61       185.20
76818      Fetal biophys profile w/nst          S            S        0266    1.5883         70.33      161.61       185.20
76819      Fetal biophys profil w/o nst         S            S        0266    1.5883         70.33      161.61       185.20
76820      Umbilical artery echo                S            S        0096    1.6020         70.94      163.00       186.79
76821      Middle cerebral artery echo          S            S        0096    1.6020         70.94      163.00       186.79
76825      Echo exam of fetal heart             S            S        0671    1.6763         74.23      170.56       195.46
76826      Echo exam of fetal heart             S            S        0697    1.5121         66.96      153.86       176.31
76827      Echo exam of fetal heart             S            S        0671    1.6763         74.23      170.56       195.46
76828      Echo exam of fetal heart             S            S        0697    1.5121         66.96      153.86       176.31
76830      Transvaginal us, non-ob              S            S        0266    1.5883         70.33      161.61       185.20
76831      Echo exam, uterus                    S            S        0267    2.5543        113.10      259.90       297.83
76856      Us exam, pelvic, complete            S            S        0266    1.5883         70.33      161.61       185.20
76857      Us exam, pelvic, limited             S            S        0265    0.9930         43.97      101.04       115.78
76870      Us exam, scrotum                     S            S        0266    1.5883         70.33      161.61       185.20
76872      Us, transrectal                      S            S        0266    1.5883         70.33      161.61       185.20
76873      Echograp trans r, pros study         S            S        0266    1.5883         70.33      161.61       185.20
76880      Us exam, extremity                   S            S        0266    1.5883         70.33      161.61       185.20
76885      Us exam infant hips, dynamic         S            S        0265    0.9930         43.97      101.04       115.78

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            115 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            116 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

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

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            117 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

78111      Plasma volume, multiple              S            S        0393     3.4467       152.62       350.70       401.89
78120      Red cell mass, single                S            S        0393     3.4467       152.62       350.70       401.89
78121      Red cell mass, multiple              S            S        0393     3.4467       152.62       350.70       401.89
78122      Blood volume                         S            S        0393     3.4467       152.62       350.70       401.89
78130      Red cell survival study              S            S        0393     3.4467       152.62       350.70       401.89
78135      Red cell survival kinetics           S            S        0393     3.4467       152.62       350.70       401.89
78140      Red cell sequestration               S            S        0393     3.4467       152.62       350.70       401.89
78185      Spleen imaging                       S            S        0400     3.9160       173.40       398.45       456.61
78190      Platelet survival, kinetics          S            S        0392     3.5231       156.00       358.48       410.79
78191      Platelet survival                    S            S        0392     3.5231       156.00       358.48       410.79
78195      Lymph system imaging                 S            S        0400     3.9160       173.40       398.45       456.61
78199      Blood/lymph nuclear exam             S            1        0000     0.0000        0.00         0.00         0.00
78201      Liver imaging                        S            S        0394     4.3107       190.88       438.61       502.63
78202      Liver imaging with flow              S            S        0394     4.3107       190.88       438.61       502.63
78205      Liver imaging (3D)                   S            S        0394     4.3107       190.88       438.61       502.63
78206      Liver image (3d) with flow           S            S        0394     4.3107       190.88       438.61       502.63
78215      Liver and spleen imaging             S            S        0394     4.3107       190.88       438.61       502.63
78216      Liver & spleen image/flow            S            S        0394     4.3107       190.88       438.61       502.63
78220      Liver function study                 S            S        0394     4.3107       190.88       438.61       502.63
78223      Hepatobiliary imaging                S            S        0394     4.3107       190.88       438.61       502.63
78230      Salivary gland imaging               S            S        0395     3.7696       166.92       383.56       439.54
78231      Serial salivary imaging              S            S        0395     3.7696       166.92       383.56       439.54
78232      Salivary gland function exam         S            S        0395     3.7696       166.92       383.56       439.54
78258      Esophageal motility study            S            S        0395     3.7696       166.92       383.56       439.54
78261      Gastric mucosa imaging               S            S        0395     3.7696       166.92       383.56       439.54
78262      Gastroesophageal reflux exam         S            S        0395     3.7696       166.92       383.56       439.54
78264      Gastric emptying study               S            S        0395     3.7696       166.92       383.56       439.54
78267      Breath tst attain/anal c-14          A            3        0000     0.0000        M01          M01          M01
78268      Breath test analysis, c-14           A            3        0000     0.0000        M01          M01          M01
78270      Vit B-12 absorption exam             S            S        0392     3.5231       156.00       358.48       410.79
78271      Vit b-12 absrp exam, int fac         S            S        0392     3.5231       156.00       358.48       410.79
78272      Vit B-12 absorp, combined            S            S        0392     3.5231       156.00       358.48       410.79
78278      Acute GI blood loss imaging          S            S        0395     3.7696       166.92       383.56       439.54
78282      GI protein loss exam                 S            S        0395     3.7696       166.92       383.56       439.54
78290      Meckel’s divert exam                 S            S        0395     3.7696       166.92       383.56       439.54
78291      Leveen/shunt patency exam            S            S        0395     3.7696       166.92       383.56       439.54
78299      GI nuclear procedure                 S            1        0000     0.0000        0.00         0.00         0.00
78300      Bone imaging, limited area           S            S        0396     3.9921       176.77       406.20       465.48
78305      Bone imaging, multiple areas         S            S        0396     3.9921       176.77       406.20       465.48
78306      Bone imaging, whole body             S            S        0396     3.9921       176.77       406.20       465.48
78315      Bone imaging, 3 phase                S            S        0396     3.9921       176.77       406.20       465.48
78320      Bone imaging (3D)                    S            S        0396     3.9921       176.77       406.20       465.48
78350      Bone mineral, single photon          X            X        0260     0.7296        32.31        74.24        85.07
78351      Bone mineral, dual photon            E            3        0000     0.0000        M01          M01          M01
78399      Musculoskeletal nuclear exam         S            1        0000     0.0000        0.00         0.00         0.00
78414      Non-imaging heart function           S            S        0398     4.2038       186.14       427.74       490.16
78428      Cardiac shunt imaging                S            S        0398     4.2038       186.14       427.74       490.16
78445      Vascular flow imaging                S            S        0397     2.0829        92.23       211.94       242.87
78456      Acute venous thrombus image          S            S        0397     2.0829        92.23       211.94       242.87
78457      Venous thrombosis imaging            S            S        0397     2.0829        92.23       211.94       242.87
78458      Ven thrombosis images, bilat         S            S        0397     2.0829        92.23       211.94       242.87
78459      Heart muscle imaging (PET)           S            S        0306    13.4521       595.66      1,368.75     1,568.51
78460      Heart muscle blood, single           S            S        0398     4.2038       186.14       427.74       490.16

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            118 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

78461      Heart muscle blood, multiple         S            S        0377     6.6729        295.48      678.97       778.06
78464      Heart image (3d), single             S            S        0398     4.2038        186.14      427.74       490.16
78465      Heart image (3d), multiple           S            S        0377     6.6729        295.48      678.97       778.06
78466      Heart infarct image                  S            S        0398     4.2038        186.14      427.74       490.16
78468      Heart infarct image (ef)             S            S        0398     4.2038        186.14      427.74       490.16
78469      Heart infarct image (3D)             S            S        0398     4.2038        186.14      427.74       490.16
78472      Gated heart, planar, single          S            S        0398     4.2038        186.14      427.74       490.16
78473      Gated heart, multiple                S            S        0376     5.0315        222.79      511.96       586.67
78478      Heart wall motion add-on             S            S        0399     1.5039         66.59      153.02       175.35
78480      Heart function add-on                S            S        0399     1.5039         66.59      153.02       175.35
78481      Heart first pass, single             S            S        0398     4.2038        186.14      427.74       490.16
78483      Heart first pass, multiple           S            S        0376     5.0315        222.79      511.96       586.67
78491      Heart image (pet), single            S            S        0306    13.4521        595.66     1,368.75     1,568.51
78492      Heart image (pet), multiple          S            S        0307    41.7549       1,848.91    4,248.56     4,868.62
78494      Heart image, spect                   S            S        0398     4.2038        186.14      427.74       490.16
78496      Heart first pass add-on              S            S        0399     1.5039         66.59      153.02       175.35
78499      Cardiovascular nuclear exam          S            1        0000     0.0000         0.00        0.00         0.00
78580      Lung perfusion imaging               S            S        0401     3.3166        146.86      337.46       386.72
78584      Lung V/Q image single breath         S            S        0378     5.4064        239.40      550.10       630.39
78585      Lung V/Q imaging                     S            S        0378     5.4064        239.40      550.10       630.39
78586      Aerosol lung image, single           S            S        0401     3.3166        146.86      337.46       386.72
78587      Aerosol lung image, multiple         S            S        0401     3.3166        146.86      337.46       386.72
78588      Perfusion lung image                 S            S        0378     5.4064        239.40      550.10       630.39
78591      Vent image, 1 breath, 1 proj         S            S        0401     3.3166        146.86      337.46       386.72
78593      Vent image, 1 proj, gas              S            S        0401     3.3166        146.86      337.46       386.72
78594      Vent image, mult proj, gas           S            S        0401     3.3166        146.86      337.46       386.72
78596      Lung differential function           S            S        0378     5.4064        239.40      550.10       630.39
78599      Respiratory nuclear exam             S            1        0000     0.0000         0.00        0.00         0.00
78600      Brain imaging, ltd static            S            S        0402     5.1709        228.97      526.14       602.93
78601      Brain imaging, ltd w/flow            S            S        0402     5.1709        228.97      526.14       602.93
78605      Brain imaging, complete              S            S        0402     5.1709        228.97      526.14       602.93
78606      Brain imaging, compl w/flow          S            S        0402     5.1709        228.97      526.14       602.93
78607      Brain imaging (3D)                   S            S        0402     5.1709        228.97      526.14       602.93
78608      Brain imaging (PET)                  S            S        1513    19.3242   *    855.68     1,966.24     2,253.20
78609      Brain imaging (PET)                  E            1        0000     0.0000         0.00        0.00         0.00
78610      Brain flow imaging only              S            S        0402     5.1709        228.97      526.14       602.93
78615      Cerebral vascular flow image         S            S        0402     5.1709        228.97      526.14       602.93
78630      Cerebrospinal fluid scan             S            S        0403     3.5015        155.05      356.28       408.27
78635      CSF ventriculography                 S            S        0403     3.5015        155.05      356.28       408.27
78645      CSF shunt evaluation                 S            S        0403     3.5015        155.05      356.28       408.27
78647      Cerebrospinal fluid scan             S            S        0403     3.5015        155.05      356.28       408.27
78650      CSF leakage imaging                  S            S        0403     3.5015        155.05      356.28       408.27
78660      Nuclear exam of tear flow            S            S        0403     3.5015        155.05      356.28       408.27
78699      Nervous system nuclear exam          S            1        0000     0.0000         0.00        0.00         0.00
78700      Kidney imaging, static               S            S        0404     3.6558        161.88      371.98       426.27
78701      Kidney imaging with flow             S            S        0404     3.6558        161.88      371.98       426.27
78704      Imaging renogram                     S            S        0404     3.6558        161.88      371.98       426.27
78707      Kidney flow/function image           S            S        0404     3.6558        161.88      371.98       426.27
78708      Kidney flow/function image           S            S        0405     4.1493        183.73      422.19       483.81
78709      Kidney flow/function image           S            S        0405     4.1493        183.73      422.19       483.81
78710      Kidney imaging (3D)                  S            S        0404     3.6558        161.88      371.98       426.27
78715      Renal vascular flow exam             S            S        0404     3.6558        161.88      371.98       426.27
78725      Kidney function study                S            S        0389     1.4276         63.21      145.26       166.46

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            119 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated    4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

78730      Urinary bladder retention            X            X        0340     0.6137        27.17        62.44        71.56
78740      Ureteral reflux study                S            S        0404     3.6558       161.88       371.98       426.27
78760      Testicular imaging                   S            S        0404     3.6558       161.88       371.98       426.27
78761      Testicular imaging/flow              S            S        0404     3.6558       161.88       371.98       426.27
78799      Genitourinary nuclear exam           S            1        0000     0.0000        0.00         0.00         0.00
78800      Tumor imaging, limited area          S            S        0406     4.1397       183.31       421.21       482.69
78801      Tumor imaging, mult areas            S            S        0406     4.1397       183.31       421.21       482.69
78802      Tumor imaging, whole body            S            S        0406     4.1397       183.31       421.21       482.69
78803      Tumor imaging (3D)                   S            S        0406     4.1397       183.31       421.21       482.69
78804      Tumor imaging, whole body            S            S        1508    10.9224   *   483.64      1,111.35     1,273.55
78805      Abscess imaging, ltd area            S            S        0406     4.1397       183.31       421.21       482.69
78806      Abscess imaging, whole body          S            S        0406     4.1397       183.31       421.21       482.69
78807      Nuclear localization/abscess         S            S        0406     4.1397       183.31       421.21       482.69
78811      Tumor imaging (pet), limited         S            S        1513    19.3242   *   855.68      1,966.24     2,253.20
78812      Tumor image (pet)/skul-thigh         S            S        1513    19.3242   *   855.68      1,966.24     2,253.20
78813      Tumor image (pet) full body          S            S        1513    19.3242   *   855.68      1,966.24     2,253.20
78814      Tumor image pet/ct, limited          S            S        1514    21.0045   *   930.08      2,137.21     2,449.12
78815      Tumorimage pet/ct skul-thigh         S            S        1514    21.0045   *   930.08      2,137.21     2,449.12
78816      Tumor image pet/ct full body         S            S        1514    21.0045   *   930.08      2,137.21     2,449.12
78890      Nuclear medicine data proc           N            N        0000     0.0000        0.00         0.00         0.00
78891      Nuclear med data proc                N            N        0000     0.0000        0.00         0.00         0.00
78999      Nuclear diagnostic exam              S            1        0000     0.0000        0.00         0.00         0.00
79005      Nuclear rx, oral admin               S            S        0407     3.8758       171.62       394.36       451.92
79101      Nuclear rx, iv admin                 S            S        0407     3.8758       171.62       394.36       451.92
79200      Nuclear rx, intracav admin           S            S        0407     3.8758       171.62       394.36       451.92
79300      Nuclr rx, interstit colloid          S            S        0407     3.8758       171.62       394.36       451.92
79403      Hematopoietic nuclear tx             S            1        0000     0.0000   *    0.00         0.00         0.00
79440      Nuclear rx, intra-articular          S            S        0407     3.8758       171.62       394.36       451.92
79445      Nuclear rx, intra-arterial           S            S        0407     3.8758       171.62       394.36       451.92
79999      Nuclear medicine therapy             S            1        0000     0.0000        0.00         0.00         0.00
80048      Basic metabolic panel                A            3        0000     0.0000        M01          M01          M01
80050      General health panel                 E            3        0000     0.0000        M01          M01          M01
80051      Electrolyte panel                    A            3        0000     0.0000        M01          M01          M01
80053      Comprehen metabolic panel            A            3        0000     0.0000        M01          M01          M01
80055      Obstetric panel                      E            3        0000     0.0000        M01          M01          M01
80061      Lipid panel                          A            3        0000     0.0000        M01          M01          M01
80069      Renal function panel                 A            3        0000     0.0000        M01          M01          M01
80074      Acute hepatitis panel                A            3        0000     0.0000        M01          M01          M01
80076      Hepatic function panel               A            3        0000     0.0000        M01          M01          M01
80100      Drug screen, qualitate/multi         A            3        0000     0.0000        M01          M01          M01
80101      Drug screen, single                  A            3        0000     0.0000        M01          M01          M01
80102      Drug confirmation                    A            3        0000     0.0000        M01          M01          M01
80103      Drug analysis, tissue prep           N            N        0000     0.0000        0.00         0.00         0.00
80150      Assay of amikacin                    A            3        0000     0.0000        M01          M01          M01
80152      Assay of amitriptyline               A            3        0000     0.0000        M01          M01          M01
80154      Assay of benzodiazepines             A            3        0000     0.0000        M01          M01          M01
80156      Assay, carbamazepine, total          A            3        0000     0.0000        M01          M01          M01
80157      Assay, carbamazepine, free           A            3        0000     0.0000        M01          M01          M01
80158      Assay of cyclosporine                A            3        0000     0.0000        M01          M01          M01
80160      Assay of desipramine                 A            3        0000     0.0000        M01          M01          M01
80162      Assay of digoxin                     A            3        0000     0.0000        M01          M01          M01
80164      Assay, dipropylacetic acid           A            3        0000     0.0000        M01          M01          M01
80166      Assay of doxepin                     A            3        0000     0.0000        M01          M01          M01

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                            120 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated      4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                      Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                     Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                             Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                  Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                        Fee

80168      Assay of ethosuximide                A            3        0000    0.0000        M01          M01            M01
80170      Assay of gentamicin                  A            3        0000    0.0000        M01          M01            M01
80172      Assay of gold                        A            3        0000    0.0000        M01          M01            M01
80173      Assay of haloperidol                 A            3        0000    0.0000        M01          M01            M01
80174      Assay of imipramine                  A            3        0000    0.0000        M01          M01            M01
80176      Assay of lidocaine                   A            3        0000    0.0000        M01          M01            M01
80178      Assay of lithium                     A            3        0000    0.0000        M01          M01            M01
80182      Assay of nortriptyline               A            3        0000    0.0000        M01          M01            M01
80184      Assay of phenobarbital               A            3        0000    0.0000        M01          M01            M01
80185      Assay of phenytoin, total            A            3        0000    0.0000        M01          M01            M01
80186      Assay of phenytoin, free             A            3        0000    0.0000        M01          M01            M01
80188      Assay of primidone                   A            3        0000    0.0000        M01          M01            M01
80190      Assay of procainamide                A            3        0000    0.0000        M01          M01            M01
80192      Assay of procainamide                A            3        0000    0.0000        M01          M01            M01
80194      Assay of quinidine                   A            3        0000    0.0000        M01          M01            M01
80195      Assay of sirolimus                   A            3        0000    0.0000        M01          M01            M01
80196      Assay of salicylate                  A            3        0000    0.0000        M01          M01            M01
80197      Assay of tacrolimus                  A            3        0000    0.0000        M01          M01            M01
80198      Assay of theophylline                A            3        0000    0.0000        M01          M01            M01
80200      Assay of tobramycin                  A            3        0000    0.0000        M01          M01            M01
80201      Assay of topiramate                  A            3        0000    0.0000        M01          M01            M01
80202      Assay of vancomycin                  A            3        0000    0.0000        M01          M01            M01
80299      Quantitative assay, drug             A            1        0000    0.0000        0.00         0.00           0.00
80400      Acth stimulation panel               A            3        0000    0.0000        M01          M01            M01
80402      Acth stimulation panel               A            3        0000    0.0000        M01          M01            M01
80406      Acth stimulation panel               A            3        0000    0.0000        M01          M01            M01
80408      Aldosterone suppression eval         A            3        0000    0.0000        M01          M01            M01
80410      Calcitonin stimul panel              A            3        0000    0.0000        M01          M01            M01
80412      CRH stimulation panel                A            3        0000    0.0000        M01          M01            M01
80414      Testosterone response                A            3        0000    0.0000        M01          M01            M01
80415      Estradiol response panel             A            3        0000    0.0000        M01          M01            M01
80416      Renin stimulation panel              A            3        0000    0.0000        M01          M01            M01
80417      Renin stimulation panel              A            3        0000    0.0000        M01          M01            M01
80418      Pituitary evaluation panel           A            3        0000    0.0000        M01          M01            M01
80420      Dexamethasone panel                  A            3        0000    0.0000        M01          M01            M01
80422      Glucagon tolerance panel             A            3        0000    0.0000        M01          M01            M01
80424      Glucagon tolerance panel             A            3        0000    0.0000        M01          M01            M01
80426      Gonadotropin hormone panel           A            3        0000    0.0000        M01          M01            M01
80428      Growth hormone panel                 A            3        0000    0.0000        M01          M01            M01
80430      Growth hormone panel                 A            3        0000    0.0000        M01          M01            M01
80432      Insulin suppression panel            A            3        0000    0.0000        M01          M01            M01
80434      Insulin tolerance panel              A            3        0000    0.0000        M01          M01            M01
80435      Insulin tolerance panel              A            3        0000    0.0000        M01          M01            M01
80436      Metyrapone panel                     A            3        0000    0.0000        M01          M01            M01
80438      TRH stimulation panel                A            3        0000    0.0000        M01          M01            M01
80439      TRH stimulation panel                A            3        0000    0.0000        M01          M01            M01
80440      TRH stimulation panel                A            3        0000    0.0000        M01          M01            M01
80500      Lab pathology consultation           X            X        0433    0.2493        11.04        25.37          29.07
80502      Lab pathology consultation           X            X        0342    0.1450        6.42         14.75          16.91
81000      Urinalysis, nonauto w/scope          A            3        0000    0.0000        M01          M01            M01
81001      Urinalysis, auto w/scope             A            3        0000    0.0000        M01          M01            M01
81002      Urinalysis nonauto w/o scope         A            3        0000    0.0000        M01          M01            M01
81003      Urinalysis, auto, w/o scope          A            3        0000    0.0000        M01          M01            M01

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                               121 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated      4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                      Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                     Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                             Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                  Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                        Fee

81005      Urinalysis                           A            3        0000    0.0000         M01          M01            M01
81007      Urine screen for bacteria            A            3        0000    0.0000         M01          M01            M01
81015      Microscopic exam of urine            A            3        0000    0.0000         M01          M01            M01
81020      Urinalysis, glass test               A            3        0000    0.0000         M01          M01            M01
81025      Urine pregnancy test                 A            3        0000    0.0000         M01          M01            M01
81050      Urinalysis, volume measure           A            3        0000    0.0000         M01          M01            M01
81099      Urinalysis test procedure            A            1        0000    0.0000         0.00         0.00           0.00
82000      Assay of blood acetaldehyde          A            3        0000    0.0000         M01          M01            M01
82003      Assay of acetaminophen               A            3        0000    0.0000         M01          M01            M01
82009      Test for acetone/ketones             A            3        0000    0.0000         M01          M01            M01
82010      Acetone assay                        A            3        0000    0.0000         M01          M01            M01
82013      Acetylcholinesterase assay           A            3        0000    0.0000         M01          M01            M01
82016      Acylcarnitines, qual                 A            3        0000    0.0000         M01          M01            M01
82017      Acylcarnitines, quant                A            3        0000    0.0000         M01          M01            M01
82024      Assay of acth                        A            3        0000    0.0000         M01          M01            M01
82030      Assay of adp & amp                   A            3        0000    0.0000         M01          M01            M01
82040      Assay of serum albumin               A            3        0000    0.0000         M01          M01            M01
82042      Assay of urine albumin               A            3        0000    0.0000         M01          M01            M01
82043      Microalbumin, quantitative           A            3        0000    0.0000         M01          M01            M01
82044      Microalbumin, semiquant              A            3        0000    0.0000         M01          M01            M01
82045      Albumin, ischemia modified           A            3        0000    0.0000         M01          M01            M01
82055      Assay of ethanol                     A            3        0000    0.0000         M01          M01            M01
82075      Assay of breath ethanol              A            3        0000    0.0000         M01          M01            M01
82085      Assay of aldolase                    A            3        0000    0.0000         M01          M01            M01
82088      Assay of aldosterone                 A            3        0000    0.0000         M01          M01            M01
82101      Assay of urine alkaloids             A            3        0000    0.0000         M01          M01            M01
82103      Alpha-1-antitrypsin, total           A            3        0000    0.0000         M01          M01            M01
82104      Alpha-1-antitrypsin, pheno           A            3        0000    0.0000         M01          M01            M01
82105      Alpha-fetoprotein, serum             A            3        0000    0.0000         M01          M01            M01
82106      Alpha-fetoprotein, amniotic          A            3        0000    0.0000         M01          M01            M01
82108      Assay of aluminum                    A            3        0000    0.0000         M01          M01            M01
82120      Amines, vaginal fluid qual           A            3        0000    0.0000         M01          M01            M01
82127      Amino acid, single qual              A            3        0000    0.0000         M01          M01            M01
82128      Amino acids, mult qual               A            3        0000    0.0000         M01          M01            M01
82131      Amino acids, single quant            A            3        0000    0.0000         M01          M01            M01
82135      Assay, aminolevulinic acid           A            3        0000    0.0000         M01          M01            M01
82136      Amino acids, quant, 2-5              A            3        0000    0.0000         M01          M01            M01
82139      Amino acids, quan, 6 or more         A            3        0000    0.0000         M01          M01            M01
82140      Assay of ammonia                     A            3        0000    0.0000         M01          M01            M01
82143      Amniotic fluid scan                  A            3        0000    0.0000         M01          M01            M01
82145      Assay of amphetamines                A            3        0000    0.0000         M01          M01            M01
82150      Assay of amylase                     A            3        0000    0.0000         M01          M01            M01
82154      Androstanediol glucuronide           A            3        0000    0.0000         M01          M01            M01
82157      Assay of androstenedione             A            3        0000    0.0000         M01          M01            M01
82160      Assay of androsterone                A            3        0000    0.0000         M01          M01            M01
82163      Assay of angiotensin II              A            3        0000    0.0000         M01          M01            M01
82164      Angiotensin I enzyme test            A            3        0000    0.0000         M01          M01            M01
82172      Assay of apolipoprotein              A            3        0000    0.0000         M01          M01            M01
82175      Assay of arsenic                     A            3        0000    0.0000         M01          M01            M01
82180      Assay of ascorbic acid               A            3        0000    0.0000         M01          M01            M01
82190      Atomic absorption                    A            3        0000    0.0000         M01          M01            M01
82205      Assay of barbiturates                A            3        0000    0.0000         M01          M01            M01
82232      Assay of beta-2 protein              A            3        0000    0.0000         M01          M01            M01

                                          966e3d67-c820-4c3d-ae14-736ebb34bd52.xls                               122 of 242
State of Wyoming Oupatient Prospective Payment System                                                     Updated     4/14/06
Procedure Code List
Effective Date: January 1, 2006

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


                                                                                                                     Critical
                                              Medicare                                     General     Children's
                                                          WY 2006                                                    Access
  CPT/                                      2006 Status                      APC Relative Hospital      Hospital
                   Description (short)                      Status    APC                                            Hospital
 HCPCS                                        Indicator                        Weight     Outpatient   Outpatient
                                                          Indicator                                                 Outpatient
                                             (FYI Only)                                      Fee          Fee
                                                                                                                       Fee

82239      Bile acids, total                    A            3        0000    0.0000         M01          M01           M01
82240      Bile acids, cholylglycine            A            3        0000    0.0000         M01          M01           M01
82247      Bilirubin, total                     A            3        0000    0.0000         M01          M01           M01
82248      Bilirubin, direct                    A            3        0000    0.0000         M01          M01           M01
82252      Fecal bilirubin test                 A            3        0000    0.0000         M01          M01           M01
82261      Assay of biotinidase                 A            3        0000    0.0000         M01          M01           M01
82270      Test for blood, feces                A            3        0000    0.0000         M01          M01           M01
82271      Occult blood, feces, single          A            3        0000    0.0000         M01          M01           M01
82272      Blood occult peroxidase              A            3        0000    0.0000         M01          M01           M01
82274      Assay test for blood, fecal          A            3        0000    0.0000         M01          M01           M01
82286      Assay of bradykinin                  A            3        0000    0.0000         M01          M01           M01
82300      Assay of cadmium                     A            3        0000    0.0000         M01          M01           M01
82306      Assay of vitamin D                   A            3        0000    0.0000         M01          M01           M01
82307      Assay of vitamin D                   A            3        0000    0.0000         M01          M01           M01
82308      Assay of calcitonin                  A            3        0000    0.0000         M01          M01           M01
82310      Assay of calcium                     A            3        0000    0.0000         M01          M01           M01
82330      Assay of calcium                     A            3        0000    0.0000         M01          M01           M01
82331      Calcium infusion test                A            3        0000    0.0000         M01          M01           M01
82340      Assay of calcium in urine            A            3        0000    0.0000         M01          M01           M01
82355      Calculus analysis, qual              A            3        0000    0.0000         M01          M01           M01
82360      Calculus assay, quant                A            3        0000    0.0000         M01          M01           M01
82365      Calculus spectroscopy                A            3        0000    0.0000         M01          M01           M01
82370      X-ray assay, calculus                A            3        0000    0.0000         M01          M01           M01
82373      Assay, c-d transfer measure          A            3        0000    0.0000         M01          M01           M01
82374      Assay, blood carbon dioxide          A            3        0000    0.0000         M01          M01           M01
82375      Assay, blood carbon monoxide         A            3        0000    0.0000         M01          M01           M01
82376      Test for carbon monoxide             A            3        0000    0.0000         M01          M01           M01
82378      Carcinoembryonic antigen             A            3        0000    0.0000         M01          M01           M01
82379      Assay of carnitine                   A            3        0000    0.0000         M01          M01           M01
82380      Assay of carotene                    A            3        0000    0.0000         M01          M01           M01
82382      Assay, urine catecholamines          A            3        0000    0.0000         M01          M01           M01
82383      Assay, blood catecholamines          A            3        0000    0.0000         M01          M01           M01
82384      Assay, three catecholamines          A            3        0000    0.0000         M01          M01           M01
82387      Assay of cathepsin-d                 A            3        0000    0.0000         M01          M01           M01
82390      Assay of ceruloplasmin               A            3        0000    0.0000         M01          M01           M01
82397      Chemiluminescent assay               A            3        0000    0.0000         M01          M01           M01
82415      Assay of chloramphenicol             A            3        0000    0.0000         M01          M01           M01
82435      Assay of blood chloride              A            3        0000    0.0000         M01          M01           M01
82436      Assay of urine chloride              A            3        0000    0.0000         M01          M01           M01
82438      Assay, other fluid chlorides         A            3        0000    0.0000         M01          M01           M01
82441      Test for chlorohydrocarbons          A            3        0000    0.0000         M01          M01           M01
82465      Assay, bld/serum cholesterol         A            3        0000    0.0000         M01          M01           M01
82480      Assay, serum cholinesterase          A            3        0000    0.0000         M01          M01           M01
82482      Assay, rbc cholinesterase            A            3        0000    0.0000         M01          M01           M01
82485      Assay, chondroitin sulfate           A            3        0000    0.0000         M01          M01           M01
82486      Gas/liquid chromatography            A            3        0000    0.0000         M01          M01           M01
82487      Paper chromatography                 A            3        0000    0.0000         M01          M01           M01
82488      Paper chromatography                 A            3        0000    0.0000         M01          M01           M01
82489      Thin layer chromatography            A            3        0000    0.0000         M01          M01           M01
82491      Chromotography, quant, sing          A            3        0000    0.0000         M01          M01           M01
82492      Chromotography, quant, mult          A