List of Common Outpatient Procedures for Hospital Name: HCAI Facility No: Effective Date of Charges: Evaluation & Management Services (CPT Codes 99201-99499) 2024 CPT Code Average Charge Emergency Room Visit (straightforward) 99282 Emergency Room Visit (low level) 99283 Emergency Room Visit (moderate level) 99284 Emergency Room Visit (high level) 99285 Outpatient Visit, established patient, 20+ minutes Laboratory & Pathology Services (CPT Codes 80047-89398) 2024 CPT Code Average Charge Basic Metabolic Panel Blood Gas Analysis, including saturation Complete Blood Count, automated Complete Blood Count, with differential WBC, automated Comprehensive Metabolic Panel Creatine Kinase (CK), (CPK), Total Lipid Panel Partial Thromboplastin Time Prothrombin Time Thyroid Stimulating Hormone Troponin, Quantitative Urinalysis, without microscopy or Urinalysis, with microscopy or Radiology Services (CPT Codes 70010-79999) 2024 CPT Code Average Charge CT Scan, Abdomen, with contrast CT Scan, Head or Brain, without contrast CT Scan, Pelvis, with contrast Mammography, Screening, Bilateral MRI, Brain, without contrast, followed by contrast Ultrasound, Abdomen, Complete Ultrasound, OB, 14 weeks or more, transabdominal X-Ray, Lower Back, minimum four views X-Ray, Chest, two views Medicine Services (CPT Codes 90281-99607) 2023 CPT Code Average Charge Cardiac Catheterization, Left Heart, percutaneous Echocardiography, Transthoracic, complete, without Doppler Electrocardiogram, routine, with

interpretation and report Inhalation Treatment, pressurized or nonpressurized Physical Therapy, Evaluation 97161-97163 Physical Therapy, Gait Training Physical Therapy, Therapeutic Exercise In response to requests from hospitals and the public, HCAI has developed this form to assist hospitals in collecting and submitting the average charge for common outpatient procedures performed by hospitals, as required by AB 1045 (Chapter 532, Statutes of 2005).

Use of the HCAI form is voluntary, but highly encouraged, as it allows hospitals to report and the public to compare uniform information regarding common outpatient procedures.

Department of Health Care Access and Information 5-2024 v1.0 List of Common Outpatient Procedures for Hospital Name: HCAI Facility No: Effective Date of Charges: Surgery Services (CPT Codes 10021-69990) 2024 CPT Code Average Charge Arthroscopy, Knee, with meniscectomy (medial or lateral) 29881 Arthroscopy, Shoulder, with partial acromioplasty Carpal Tunnel Surgery Cataract Removal with Insertion of Intraocular Lens, 1 Stage Colonoscopy, diagnostic Colonoscopy, with biopsy Colonoscopy, with lesion removal, by snare technique Discission, secondary membranous cataract, laser surgery Endoscopy, Upper GI, with biopsy Endoscopy, Upper GI, diagnostic Excision, Breast Lesion, without preoperative radiological marker Hernia Repair, Inguinal, 5 years and older Injection, Diagnostic or Therapeutic substance, epidural, lumbar 62322-62323 Injection, Anesthetic or Steroid, transforaminal epidural, lumbar Laparoscopic Cholecystectomy Tympanostomy (insert ventilating tube, general anesthesia) 69436 Tonsillectomy with Adenoidectomy, less than years old Other Common Outpatient Procedures (list as needed) 2024 CPT Code Average Charge Count of Reported Procedures (minimum required) 0 Instructions for Completing AB Common Outpatient Procedure Form 1.

Enter Hospital Name and HCAI Facility Number. Revise Effective Date of Charges, if necessary. 2. Enter Average Charge for at least commonly performed outpatient procedures. For Evaluation & Management Services, do not include related ancillary charges. For all other procedures, include related ancillary charges. NOTE: The CPT codes are included on this form to help identify the listed procedures based on the frequencies across hospital-based ambulatory surgery data.

The average charge for all related services and procedures (e.g., supplies, drugs, lab, use of operating room, etc.) should be included in the average charge for that procedure. 3. Do not change procedure descriptions or CPT code references. Use "Other Common Outpatient Procedures" (rows 62-71) if you are unable to select procedures from list. 4. Submit completed form as Excel (.xls) file, along with chargemaster and percent change in gross revenue calculation, by e-mail to chargemaster@hcai.ca.gov or by standard mail on CD. Department of Health Care Access and Information 5-2024 v1.0