Services can be paid by BCHC only for breast and/or cervical cancer screening and diagnosis. BCHC does not require preauthorization. OFFICE VISITS New Patient - Office Visit (0 minutes face to face) 9920 54.86 New Patient - Office Visit (20 minutes face to face) 99202 95.20 New Patient - Office Visit (30 minutes face to face) 99203 38.56 New Patient - Office Visit (45 minutes face to face) 99204 24.69 New Patient - Office Visit (60 minutes face to face) 99205 27.20 Established Patient - Office Visit (5 minutes face to face) 992 24.55 Established Patient - Office Visit (0 minutes face to face) 9922 54.86 Established Patient - Office Visit (5 minutes face to face) 9923 93.53 Established Patient - Office Visit (25 minutes face to face) 9924 39.59 Established Patient - Office Visit (40 minutes face to face) 9925 89.27 New Patient Initial Preventive. Medicine Visit, 8-39 Years 99385 38.56 New Patient Initial Preventive Medicine Visit, 40-64 Years 99386 38.56 New Patient Initial Preventive Medicine Visit, 65 Years and older 99387 38.56 Established Patient Periodic Prev. Medicine Visit, 8-39 Years 99395 93.53 Established Patient Periodic Prev. Medicine Visit, 40-64 Years 99396 93.53 Established Patient Periodic Prev. Medicine Visit, 65 Years and 99397 93.53 older CERVICAL Pap Smear, reported in Bethesda System (See Note re 8864 4.38 Conventional Pap test, slides cervical or vaginal reported in Bethesda System, manual screening and rescreening under physician supervision Conventional Pap test, reported in Bethesda System requiring interpretation by physician as determined by laboratory (See Note re Liquid-based Pap test, cytopathology, cervical or vaginal collected in preservative fluid, automated thin layer preparation (See Note re pap/colpo) Pap Smear, cytopathology, cervical or vaginal collected, manual screening and re-screening under physician supervision Pap Smear, cytopathology, cervical or vaginal collected in preservative fluid, automated thin layer preparation, screening by automated system under physician supervision (See Note re Pap Smear, cytopathology, cervical or vaginal collected in preservative fluid, automated thin layer preparation, re-screening by automated system under physician supervision (See Note re 8865 4.38 884 4.64 8842 27.57 8843 27.57 8874 29.08 8875 36.05 TECH- NICAL PROFES- SIONAL Colposcopy Biopsy Interpretation Level IV 88305 9.00 37.46 53.54 Colposcopy Biopsy Interpretation Level V 88307 360.59 243.53 7.05 Cervical pathology consultation during surgery; first tissue block, with frozen section(s), single specimen Cervical pathology consultation during surgery; each additional tissue block with frozen sections(s) 8833 30.83 43.00 87.82 88332 58.28 4.90 43.38

TECH- PROFES- NICAL SIONAL Immunocytochemistry 88342 Immunocytochemistry or immunohistochemistry, per specimen; st stain G046 04.63 62.55 42.08 Immunocytochemistry or immunohistochemistry, per specimen; each additional stain G0462 77.64 60.60 7.04 Colposcopy without Biopsy (surgical procedure only) (See Note re 57452 40.8 Colposcopy with Biopsy and/or endocervical curettage (surgical procedure only) (See Note re 57454 200.68 Colposcopy with biopsy(s) of the cervix (See Note re 57455 85.24 Colposcopy with endocervical curettage (surgical procedure only) (See Note re 57456 74.20 Colposcopy of the cervix with loop electrode biopsy(s) of the cervix (only when there is no biopsy proven diagnosis)*not for 57460 35.33 treatment Colposcopy with loop electrode conization of the cervix (only when there is no biopsy proven diagnosis)*not for treatment 5746 400.30 Biopsy, single or multiple, or local excision of lesion, with or without fulgration (separate procedure) 57500 58.25 Endocervical curettage (not done as part of a dilation and curettage) (See Note re 57505 28.85 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair, cold knife or laser 57520 393.88 *only when there is no biopsy proven diagnosis Loop electrode excision *only when there is no biopsy proven diagnosis 57522 340.32 Papillomavirus, Human, high-risk types *Covered in combination with cytology for women 30years and older who want to lengthen the screening interval. *Follow up for abnormal Pap result as per ASCCP guidelines *cannot be used for reimbursement of genotyping (6/8) Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method, (separate procedure) Endometrial sampling (biopsy) performed in conjunction with colposcopy. List separately in addition to code for primary procedure. BREAST Mammary ductogram or galactogram, single duct, radiological supervision and interpretation 8762 87624 47.76 5800 4.2 580 63.63 77053 69.5 44.9 24.96 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation 77054 90.46 58.83 3.63 Computer diagnostic mammogram add-on (payment specifically disallowed by CDC) 7705 0.46 6.9 4.26 Computer screening mammogram add-on (payment specifically disallowed by CDC) 77052 0.46 6.9 4.26 Diagnostic/Follow-up Unilateral mammogram 77055 08.87 60.02 48.85 Diagnostic/Follow-up Bilateral mammogram 77056 39.62 79.02 60.60 2

TECH- PROFES- NICAL SIONAL Screening mammogram 77057 00.56 5.7 48.85 Magnetic Resonance Imaging, breast, with and/or without contrast, 77058 unilateral (MRI) See note 622.04 508.33 3.7 **see restrictions below Magnetic Resonance Imaging, breast, with and/or without contrast, bilateral (MRI) **see restrictions below 77059 See note 65.7 50.99 3.7 Tomosynthesis, Screening bilateral 77063 70.0 28.36 4.65 Tomosynthesis, Diagnostic or unilateral digital G0279 70.26 28.36 4.9 Digital screening mammogram G0202 58.35 09.89 48.46 Digital bilateral mammogram G0204 93.05 32.45 60.60 Digital unilateral mammogram G0206 52.4 03.96 48.46 Radiological examination, surgical specimen 76098 20.7 8.96.2 Ultrasound Echography, Breasts (unilateral or bilateral) B-scan 76645 and/or real time image documentation Ultrasound, complete examination of breast including axilla, unilateral 7664 30.53 79.42 5. Ultrasound, limited examination of breast including axilla, unilateral 76642 08.45 60.8 47.64 Ultrasonic guidance for needle biopsy, radiological supervision and interpretation 76942 76.00 29.94 46.06 Surgical Tray. Reimbursed only in conjunction with 90, 920, 925, 926, 76095 99070 2.95 Evaluation of Fine Needle Aspiration 8872 72.35 2.63 50.72 Interpretation and report of File Needle Aspiration 8873 86.93 87.59 99.34 Cytopathology, fluids, washings, or brushings, except cervical or 8806 02.28 75.06 27.22 vaginal, filter method only with interpretation Cytopathology, concentration technique, smears and interpretation 8808 99.7 67.54 32.6 Nipple Smear 886 74.03 38.65 35.38 Breast Biopsy Interpretation Level IV 88305 9.00 37.46 53.54 Breast Biopsy Interpretation Level V 88307 360.59 243.53 7.05 Breast pathology consultation during surgery; first tissue block; with frozen section(s) single specimen Breast pathology consultation during surgery; each additional tissue block; with frozen section(s) Immunocytochemistry or immunohistochemistry, per specimen; st stain Immunocytochemistry or immunohistochemistry, per specimen; each additional stain 8833 30.83 43.00 87.82 88332 58.28 4.90 43.38 G046 04.63 62.55 42.08 G0462 77.64 60.60 7.04 BREAST PROCEDURES by Location Office Fine Needle Aspiration without imaging guidance 002 82.73 94.46 Fine Needle Aspiration with imaging guidance 0022 74.84 90.93 Aspiration of Cyst of Breast (surgical procedure only) 9000 37.30 60.2 Aspiration of Cyst of Breast, additional 900 35.67 30.3 Facility Office Facility 3

Injection procedure only for mammary ductogram or galactogram 9030 205.66 08.69 908 biopsy specimen, percutaneous; stereotactic guidance; first lesion 788.06 233.4 9082 biopsy specimen, percutaneous; stereotactic guidance; each additional lesion 632.84 6.7 biopsy specimen, percutaneous; ultrasound guidance; first lesion biopsy specimen, percutaneous; ultrasonic guidance; each additional lesion biopsy specimen, percutaneous; magnetic resonance guidance; first lesion biopsy specimen, percutaneous; magnetic resonance guidance; each additional lesion 9083 9084 9085 9086 765.68 225.0 608.62 09.90 92.29 269.27 942.97 30.38 Biopsy of breast; needle core (surgical procedure only) 900 84.20 93.96 Incisional biopsy of breast. 90 49.0 287.20 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct Excision of cyst, fibroadenoma, or other benign or malignant tumor aberrant breast tissue, duct lesion or nipple lesion Excision of breast lesion identified by pre-operative placement of radiological marker single lesion Excision of breast lesion identified by pre-operative placement of radiological marker each additional lesion Placement of breast localization device, percutaneous; mammographic guidance; first lesion Placement of breast localization device, percutaneous; mammographic guidance; each additional lesion Placement of breast localization device, percutaneous; stereotactic guidance; fist lesion Placement of breast localization device, percutaneous; stereotactic guidance; each additional lesion Placement of breast localization device, percutaneous; ultrasound guidance; fist lesion Placement of breast localization device, percutaneous; ultrasound guidance; each additional lesion Placement of breast localization device, percutaneous; magnetic resonance guidance; fist lesion Placement of breast localization device, percutaneous; magnetic resonance guidance; each additional lesion Anesthesia: Reimbursement Amount = $3.05 x (Time Units + Base Units) Anesthesia for procedures on the integumentary system, anterior trunk, not otherwise specified. Medicare Base Units= 3 NOTES: 90 593.52 434.80 920 620.34 532.47 925 690.9 592.82 926 26.52 26.52 928 9282 9283 9284 9285 9286 9287 9288 0000 00948 00400 294.57 4.79 200.76 7.33 332.7 42.8 239.5 7.73 52.92 20.97 435.63 60.80 007.25 86.36 80.00 92.2 4

) MRI restrictions: Breast MRI can be reimbursed by the NBCCEDP in conjunction with a mammogram when a client has a BRCA mutation, a first-degree relative who is a BRCA carrier, or a lifetime risk of 20-25% or greater as defined by risk assessment models such as BRCAPRO that are largely dependent on family history. Breast MRI can also be used to better assess areas of concern on a mammogram or for evaluation of a client with a past history of breast cancer after completing treatment. Breast MRI should never be done alone as a breast cancer screening tool. Breast MRI cannot be reimbursed for by the NBCCEDP to assess the extent of disease in a woman who is already diagnosed with breast cancer. 2) Codes 908-9086 are to be used for breast biopsies that include image guidance, placement of localization device, and imaging of specimen. These codes should not be used in conjunction with 928-9288 3) Codes 928-9288 are for image guidance placement of localization device without image-guided biopsy. These codes should not be used in conjunction with 908-9086. 5