Procedure Code	Procedure Description	Pricing Indicator	Rate Type	Mod1	Mod2	Mod3	Mod4	Max Fee	Max Fee Eff. Date	Max Fee End Date	PA
0001A	ADM SARSCOV2 30MCG/0.3ML 1ST	PRXOVR	DEF					NA	NA	NA	N
0001A	ADM SARSCOV2 30MCG/0.3ML 1ST	MAXFEE	DEF					37.66	1/1/2022	12/31/2299	N
0001F	HEART FAILURE COMPOSITE	PRXOVR	DEF					NA	NA	NA	N
0001F	HEART FAILURE COMPOSITE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0002A	ADM SARSCOV2 30MCG/0.3ML 2ND	PRXOVR	DEF					NA	NA	NA	N
0002A	ADM SARSCOV2 30MCG/0.3ML 2ND	MAXFEE	DEF					37.66	1/1/2022	12/31/2299	N
0002F	TOBACCO USE; SMOKING; ASSESS	PRXOVR	DEF					NA	NA	NA	N
0002F	TOBACCO USE; SMOKING; ASSESS	MAXFEE	DEF					NA			N
0003A	ADM SARSCOV2 30MCG/0.3ML 3RD	PRXOVR	DEF					NA	NA	NA	N
0003A	ADM SARSCOV2 30MCG/0.3ML 3RD	MAXFEE	DEF					37.66	1/1/2022	12/31/2299	N
0003F	TOBACCO USE; NON-SMOKING	PRXOVR	DEF					NA	NA	NA	N
0003F	TOBACCO USE; NON-SMOKING	MAXFEE	DEF					NA			N
0004A	ADM SARSCOV2 30MCG/0.3ML BST	PRXOVR	DEF					NA	NA	NA	N
0004A	ADM SARSCOV2 30MCG/0.3ML BST	MAXFEE	DEF					37.66	1/1/2022	12/31/2299	N
0004F	TOBACCO USE TXMNT COUNSELING	PRXOVR	DEF					NA	NA	NA	N
0004F	TOBACCO USE TXMNT COUNSELING	MAXFEE	DEF					NA			N
0005F	OSTEOARTHRITIS COMPOSITE	PRXOVR	DEF					NA	NA	NA	N
0005F	OSTEOARTHRITIS COMPOSITE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0006F	STATIN THERAPY; PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
0006F	STATIN THERAPY; PRESCRIBED	MAXFEE	DEF					NA			N
0007F	BETA-BLOCKER THX PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
0007F	BETA-BLOCKER THX PRESCRIBED	MAXFEE	DEF					NA			N
0008F	ACE INHIBITOR THX PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
0008F	ACE INHIBITOR THX PRESCRIBED	MAXFEE	DEF					NA			N
0009F	ASSESS ANGINAL SYMPTOM/LEVEL	PRXOVR	DEF					NA	NA	NA	N
0009F	ASSESS ANGINAL SYMPTOM/LEVEL	MAXFEE	DEF					NA			N
0010F	ASSESS ANGINAL SYMPTOM/LEVEL	PRXOVR	DEF					NA	NA	NA	N
0010F	ASSESS ANGINAL SYMPTOM/LEVEL	MAXFEE	DEF					NA			N
0011A	ADM SARSCOV2 100MCG/0.5ML1ST	PRXOVR	DEF					NA	NA	NA	N
0011A	ADM SARSCOV2 100MCG/0.5ML1ST	MAXFEE	DEF					37.66	1/1/2022	12/31/2299	N
0011F	ORAL ANTIPLAT THX PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
0011F	ORAL ANTIPLAT THX PRESCRIBED	MAXFEE	DEF					NA			N
0012A	ADM SARSCOV2 100MCG/0.5ML2ND	PRXOVR	DEF					NA	NA	NA	N
0012A	ADM SARSCOV2 100MCG/0.5ML2ND	MAXFEE	DEF					37.66	1/1/2022	12/31/2299	N
0012F	CAP BACTERIAL ASSESS	PRXOVR	DEF					NA	NA	NA	N
0012F	CAP BACTERIAL ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0013A	ADM SARSCOV2 100MCG/0.5ML3RD	PRXOVR	DEF					NA	NA	NA	N
0013A	ADM SARSCOV2 100MCG/0.5ML3RD	MAXFEE	DEF					37.66	1/1/2022	12/31/2299	N
0014F	COMP PREOP ASSESS CAT SURG	PRXOVR	DEF					NA	NA	NA	N
0014F	COMP PREOP ASSESS CAT SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0015F	MELAN FOLLOW-UP COMPLETE	PRXOVR	DEF					NA	NA	NA	N
0015F	MELAN FOLLOW-UP COMPLETE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0041A	ADM SARSCOV2 5MCG/0.5ML 1ST	PRXOVR	DEF					NA	NA	NA	N
0041A	ADM SARSCOV2 5MCG/0.5ML 1ST	MAXFEE	DEF					39.94	7/1/2023	12/31/2299	N
0042A	ADM SARSCOV2 5MCG/0.5ML 2ND	PRXOVR	DEF					NA	NA	NA	N
0042A	ADM SARSCOV2 5MCG/0.5ML 2ND	MAXFEE	DEF					39.94	7/1/2023	12/31/2299	N
0044A	ADM SARSCOV2 5MCG/0.5ML BST	PRXOVR	DEF					NA	NA	NA	N
0044A	ADM SARSCOV2 5MCG/0.5ML BST	MAXFEE	DEF					39.94	7/1/2023	12/31/2299	N
0051A	ADM SARSCV2 30MCG TRS-SUCR 1	PRXOVR	DEF					NA	NA	NA	N
0051A	ADM SARSCV2 30MCG TRS-SUCR 1	MAXFEE	DEF					37.66	1/3/2022	12/31/2299	N
0052A	ADM SARSCV2 30MCG TRS-SUCR 2	PRXOVR	DEF					NA	NA	NA	N
0052A	ADM SARSCV2 30MCG TRS-SUCR 2	MAXFEE	DEF					37.66	1/3/2022	12/31/2299	N
0053A	ADM SARSCV2 30MCG TRS-SUCR 3	PRXOVR	DEF					NA	NA	NA	N
0053A	ADM SARSCV2 30MCG TRS-SUCR 3	MAXFEE	DEF					37.66	1/3/2022	12/31/2299	N
0054A	ADM SARSCV2 30MCG TRS-SUCR B	PRXOVR	DEF					NA	NA	NA	N
0054A	ADM SARSCV2 30MCG TRS-SUCR B	MAXFEE	DEF					37.66	1/3/2022	12/31/2299	N
0064A	ADM SARSCOV2 50MCG/0.25MLBST	PRXOVR	DEF					NA	NA	NA	N
0064A	ADM SARSCOV2 50MCG/0.25MLBST	MAXFEE	DEF					37.66	1/1/2022	12/31/2299	N
0071A	ADM SARSCV2 10MCG TRS-SUCR 1	PRXOVR	DEF					NA	NA	NA	N
0071A	ADM SARSCV2 10MCG TRS-SUCR 1	MAXFEE	DEF					37.66	1/1/2022	12/31/2299	N
0072A	ADM SARSCV2 10MCG TRS-SUCR 2	PRXOVR	DEF					NA	NA	NA	N
0072A	ADM SARSCV2 10MCG TRS-SUCR 2	MAXFEE	DEF					37.66	1/1/2022	12/31/2299	N
0073A	ADM SARSCV2 10MCG TRS-SUCR 3	PRXOVR	DEF					NA	NA	NA	N
0073A	ADM SARSCV2 10MCG TRS-SUCR 3	MAXFEE	DEF					37.66	1/3/2022	12/31/2299	N
0074A	ADM SARSCV2 10MCG TRS-SUCR B	PRXOVR	DEF					NA	NA	NA	N
0074A	ADM SARSCV2 10MCG TRS-SUCR B	MAXFEE	DEF					37.66	5/17/2022	12/31/2299	N
0081A	ADM SARSCV2 3MCG TRS-SUCR 1	PRXOVR	DEF					NA	NA	NA	N
0081A	ADM SARSCV2 3MCG TRS-SUCR 1	MAXFEE	DEF					37.66	6/17/2022	12/31/2299	N
0082A	ADM SARSCV2 3MCG TRS-SUCR 2	PRXOVR	DEF					NA	NA	NA	N
0082A	ADM SARSCV2 3MCG TRS-SUCR 2	MAXFEE	DEF					37.66	6/17/2022	12/31/2299	N
0083A	ADM SARSCV2 3MCG TRS-SUCR 3	PRXOVR	DEF					NA	NA	NA	N
0083A	ADM SARSCV2 3MCG TRS-SUCR 3	MAXFEE	DEF					37.66	6/17/2022	12/31/2299	N
0091A	ADM SARSCOV2 50 MCG/.5 ML1ST	PRXOVR	DEF					NA	NA	NA	N
0091A	ADM SARSCOV2 50 MCG/.5 ML1ST	MAXFEE	DEF					37.66	6/17/2022	12/31/2299	N
0092A	ADM SARSCOV2 50 MCG/.5 ML2ND	PRXOVR	DEF					NA	NA	NA	N
0092A	ADM SARSCOV2 50 MCG/.5 ML2ND	MAXFEE	DEF					37.66	6/17/2022	12/31/2299	N
0093A	ADM SARSCOV2 50 MCG/.5 ML3RD	PRXOVR	DEF					NA	NA	NA	N
0093A	ADM SARSCOV2 50 MCG/.5 ML3RD	MAXFEE	DEF					37.66	6/17/2022	12/31/2299	N
0094A	ADM SARSCOV2 50 MCG/.5 MLBST	PRXOVR	DEF					NA	NA	NA	N
0094A	ADM SARSCOV2 50 MCG/.5 MLBST	MAXFEE	DEF					37.66	3/29/2022	12/31/2299	N
0111A	ADM SARSCOV2 25MCG/0.25ML1ST	PRXOVR	DEF					NA	NA	NA	N
0111A	ADM SARSCOV2 25MCG/0.25ML1ST	MAXFEE	DEF					37.66	6/17/2022	12/31/2299	N
0112A	ADM SARSCOV2 25MCG/0.25ML2ND	PRXOVR	DEF					NA	NA	NA	N
0112A	ADM SARSCOV2 25MCG/0.25ML2ND	MAXFEE	DEF					37.66	6/17/2022	12/31/2299	N
0113A	ADM SARSCOV2 25MCG/0.25ML3RD	PRXOVR	DEF					NA	NA	NA	N
0113A	ADM SARSCOV2 25MCG/0.25ML3RD	MAXFEE	DEF					37.66	8/31/2022	12/31/2299	N
0124A	ADM SARSCV2 BVL 30MCG/.3ML A	PRXOVR	DEF					NA	NA	NA	N
0124A	ADM SARSCV2 BVL 30MCG/.3ML A	MAXFEE	DEF					39.94	7/1/2023	12/31/2299	N
0134A	ADM SARSCV2 BVL 50MCG/.5ML A	PRXOVR	DEF					NA	NA	NA	N
0134A	ADM SARSCV2 BVL 50MCG/.5ML A	MAXFEE	DEF					39.94	7/1/2023	12/31/2299	N
0144A	ADM SRSCV2 BVL 25MCG/.25ML A	PRXOVR	DEF					NA	NA	NA	N
0144A	ADM SRSCV2 BVL 25MCG/.25ML A	MAXFEE	DEF					39.94	7/1/2023	12/31/2299	N
0154A	ADM SARSCV2 BVL 10MCG/.2ML A	PRXOVR	DEF					NA	NA	NA	N
0154A	ADM SARSCV2 BVL 10MCG/.2ML A	MAXFEE	DEF					39.94	7/1/2023	12/31/2299	N
0164A	ADM SRSCV2 BVL 10MCG/0.2ML A	PRXOVR	DEF					NA	NA	NA	N
0164A	ADM SRSCV2 BVL 10MCG/0.2ML A	MAXFEE	DEF					39.94	7/1/2023	12/31/2299	N
0173A	ADM SARSCV2 BVL 3MCG/0.2ML 3	PRXOVR	DEF					NA	NA	NA	N
0173A	ADM SARSCV2 BVL 3MCG/0.2ML 3	MAXFEE	DEF					39.94	7/1/2023	12/31/2299	N
0174A	ADM SARSCV2 BVL 3MCG/0.2ML A	PRXOVR	DEF					NA	NA	NA	N
0174A	ADM SARSCV2 BVL 3MCG/0.2ML A	MAXFEE	DEF					39.94	7/1/2023	12/31/2299	N
0500F	INITIAL PRENATAL CARE VISIT	PRXOVR	DEF					NA	NA	NA	N
0500F	INITIAL PRENATAL CARE VISIT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0501F	PRENATAL FLOW SHEET	PRXOVR	DEF					NA	NA	NA	N
0501F	PRENATAL FLOW SHEET	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0502F	SUBSEQUENT PRENATAL CARE	PRXOVR	DEF					NA	NA	NA	N
0502F	SUBSEQUENT PRENATAL CARE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0503F	POSTPARTUM CARE VISIT	PRXOVR	DEF					NA	NA	NA	N
0503F	POSTPARTUM CARE VISIT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0505F	HEMODIALYSIS PLAN DOCD	PRXOVR	DEF					NA	NA	NA	N
0505F	HEMODIALYSIS PLAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0507F	PERITON DIALYSIS PLAN DOCD	PRXOVR	DEF					NA	NA	NA	N
0507F	PERITON DIALYSIS PLAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0509F	URINE INCON PLAN DOCD	PRXOVR	DEF					NA	NA	NA	N
0509F	URINE INCON PLAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0513F	ELEV BP PLAN OF CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0513F	ELEV BP PLAN OF CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0514F	CARE PLAN HGB DOCD ESA PT	PRXOVR	DEF					NA	NA	NA	N
0514F	CARE PLAN HGB DOCD ESA PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0516F	ANEMIA PLAN OF CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0516F	ANEMIA PLAN OF CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0517F	GLAUCOMA PLAN OF CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0517F	GLAUCOMA PLAN OF CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0518F	FALL PLAN OF CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0518F	FALL PLAN OF CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0519F	PLAND CHEMO DOCD B/4 TXMNT	PRXOVR	DEF					NA	NA	NA	N
0519F	PLAND CHEMO DOCD B/4 TXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0520F	RAD DOS LIMTS B/4 3D RAD	PRXOVR	DEF					NA	NA	NA	N
0520F	RAD DOS LIMTS B/4 3D RAD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0521F	PLAN OF CARE 4 PAIN DOCD	PRXOVR	DEF					NA	NA	NA	N
0521F	PLAN OF CARE 4 PAIN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0525F	INITIAL VISIT FOR EPISODE	PRXOVR	DEF					NA	NA	NA	N
0525F	INITIAL VISIT FOR EPISODE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0526F	SUBS VISIT FOR EPISODE	PRXOVR	DEF					NA	NA	NA	N
0526F	SUBS VISIT FOR EPISODE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0528F	RCMND FLW-UP 10 YRS DOCD	PRXOVR	DEF					NA	NA	NA	N
0528F	RCMND FLW-UP 10 YRS DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0529F	INTRVL 3/>YR PTS CLNSCP DOCD	PRXOVR	DEF					NA	NA	NA	N
0529F	INTRVL 3/>YR PTS CLNSCP DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0535F	DYSPNEA MNGMNT PLAN DOCD	PRXOVR	DEF					NA	NA	NA	N
0535F	DYSPNEA MNGMNT PLAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0540F	GLUCO MNGMNT PLAN DOCD	PRXOVR	DEF					NA	NA	NA	N
0540F	GLUCO MNGMNT PLAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0545F	FOLLOW UP CARE PLAN MDD DOCD	PRXOVR	DEF					NA	NA	NA	N
0545F	FOLLOW UP CARE PLAN MDD DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0550F	CYTOPATH REPORT NONGYN SPCMN	PRXOVR	DEF					NA	NA	NA	N
0550F	CYTOPATH REPORT NONGYN SPCMN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0551F	CYTOPATH REPORT NON ROUTINE	PRXOVR	DEF					NA	NA	NA	N
0551F	CYTOPATH REPORT NON ROUTINE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0555F	SYMPTOM MGMNT PLAN CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0555F	SYMPTOM MGMNT PLAN CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0556F	PLAN CARE LIPID CONTROL DOCD	PRXOVR	DEF					NA	NA	NA	N
0556F	PLAN CARE LIPID CONTROL DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0557F	PLAN CAREMNG ANGNL SYMPTDOCD	PRXOVR	DEF					NA	NA	NA	N
0557F	PLAN CAREMNG ANGNL SYMPTDOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0575F	HIV RNA PLAN CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0575F	HIV RNA PLAN CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0580F	MULTIDISCIPLINARY CARE PLAN	PRXOVR	DEF					NA	NA	NA	N
0580F	MULTIDISCIPLINARY CARE PLAN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0581F	PT TRNSFRD FROM ANESTH TO CC	PRXOVR	DEF					NA	NA	NA	N
0581F	PT TRNSFRD FROM ANESTH TO CC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0582F	NO TRNSFR FROM ANESTH TO CC	PRXOVR	DEF					NA	NA	NA	N
0582F	NO TRNSFR FROM ANESTH TO CC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0583F	TRANSFER CARE CHECKLIST USED	PRXOVR	DEF					NA	NA	NA	N
0583F	TRANSFER CARE CHECKLIST USED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0584F	NO TRANSFERCARE CHKLIST USED	PRXOVR	DEF					NA	NA	NA	N
0584F	NO TRANSFERCARE CHKLIST USED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1000F	TOBACCO USE ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1000F	TOBACCO USE ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1001F	TOBACCO USE; NON-SMOKING	PRXOVR	DEF					NA	NA	NA	N
1001F	TOBACCO USE; NON-SMOKING	MAXFEE	DEF					NA			N
1002F	ASSESS ANGINAL SYMPTOM/LEVEL	PRXOVR	DEF					NA	NA	NA	N
1002F	ASSESS ANGINAL SYMPTOM/LEVEL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1003F	LEVEL OF ACTIVITY ASSESS	PRXOVR	DEF					NA	NA	NA	N
1003F	LEVEL OF ACTIVITY ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1004F	CLIN SYMP VOL OVRLD ASSESS	PRXOVR	DEF					NA	NA	NA	N
1004F	CLIN SYMP VOL OVRLD ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1005F	ASTHMA SYMPTOMS EVALUATE	PRXOVR	DEF					NA	NA	NA	N
1005F	ASTHMA SYMPTOMS EVALUATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1006F	OSTEOARTHRITIS ASSESS	PRXOVR	DEF					NA	NA	NA	N
1006F	OSTEOARTHRITIS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1007F	ANTI-INFLM/ANLGSC OTC ASSESS	PRXOVR	DEF					NA	NA	NA	N
1007F	ANTI-INFLM/ANLGSC OTC ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1008F	GI/RENAL RISK ASSESS	PRXOVR	DEF					NA	NA	NA	N
1008F	GI/RENAL RISK ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1010F	SEVERITY ANGINA BY ACTVTY	PRXOVR	DEF					NA	NA	NA	N
1010F	SEVERITY ANGINA BY ACTVTY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1011F	ANGINA PRESENT	PRXOVR	DEF					NA	NA	NA	N
1011F	ANGINA PRESENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1012F	ANGINA ABSENT	PRXOVR	DEF					NA	NA	NA	N
1012F	ANGINA ABSENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1015F	COPD SYMPTOMS ASSESS	PRXOVR	DEF					NA	NA	NA	N
1015F	COPD SYMPTOMS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1018F	ASSESS DYSPNEA NOT PRESENT	PRXOVR	DEF					NA	NA	NA	N
1018F	ASSESS DYSPNEA NOT PRESENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1019F	ASSESS DYSPNEA PRESENT	PRXOVR	DEF					NA	NA	NA	N
1019F	ASSESS DYSPNEA PRESENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1022F	PNEUMO IMM STATUS ASSESS	PRXOVR	DEF					NA	NA	NA	N
1022F	PNEUMO IMM STATUS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1026F	CO-MORBID CONDITION ASSESS	PRXOVR	DEF					NA	NA	NA	N
1026F	CO-MORBID CONDITION ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1030F	INFLUENZA IMM STATUS ASSESS	PRXOVR	DEF					NA	NA	NA	N
1030F	INFLUENZA IMM STATUS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1031F	SMOKING & 2ND HAND ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1031F	SMOKING & 2ND HAND ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1032F	SMOKER/EXPOSED 2ND HND SMOKE	PRXOVR	DEF					NA	NA	NA	N
1032F	SMOKER/EXPOSED 2ND HND SMOKE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1033F	TOBACCO NONSMOKER NOR 2NDHND	PRXOVR	DEF					NA	NA	NA	N
1033F	TOBACCO NONSMOKER NOR 2NDHND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1034F	CURRENT TOBACCO SMOKER	PRXOVR	DEF					NA	NA	NA	N
1034F	CURRENT TOBACCO SMOKER	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
1035F	SMOKELESS TOBACCO USER	PRXOVR	DEF					NA	NA	NA	N
1035F	SMOKELESS TOBACCO USER	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
1036F	TOBACCO NON-USER	PRXOVR	DEF					NA	NA	NA	N
1036F	TOBACCO NON-USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1038F	PERSISTENT ASTHMA	PRXOVR	DEF					NA	NA	NA	N
1038F	PERSISTENT ASTHMA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1039F	INTERMITTENT ASTHMA	PRXOVR	DEF					NA	NA	NA	N
1039F	INTERMITTENT ASTHMA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1040F	DSM-5 INFO MDD DOCD	PRXOVR	DEF					NA	NA	NA	N
1040F	DSM-5 INFO MDD DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1050F	HISTORY OF MOLE CHANGES	PRXOVR	DEF					NA	NA	NA	N
1050F	HISTORY OF MOLE CHANGES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1052F	TYPE LOCATION ACTIVITYASSESS	PRXOVR	DEF					NA	NA	NA	N
1052F	TYPE LOCATION ACTIVITYASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1055F	VISUAL FUNCT STATUS ASSESS	PRXOVR	DEF					NA	NA	NA	N
1055F	VISUAL FUNCT STATUS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1060F	DOC PERM/CONT/PAROX ATR FIB	PRXOVR	DEF					NA	NA	NA	N
1060F	DOC PERM/CONT/PAROX ATR FIB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1061F	DOC LACK PERM&CONT&PAROX FIB	PRXOVR	DEF					NA	NA	NA	N
1061F	DOC LACK PERM&CONT&PAROX FIB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1065F	ISCHM STROKE SYMP LT3 HRSB/4	PRXOVR	DEF					NA	NA	NA	N
1065F	ISCHM STROKE SYMP LT3 HRSB/4	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1066F	ISCHM STROKE SYMP GE3 HRSB/4	PRXOVR	DEF					NA	NA	NA	N
1066F	ISCHM STROKE SYMP GE3 HRSB/4	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1070F	ALARM SYMP ASSESSED-ABSENT	PRXOVR	DEF					NA	NA	NA	N
1070F	ALARM SYMP ASSESSED-ABSENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1071F	ALARM SYMP ASSESSED-1+ PRSNT	PRXOVR	DEF					NA	NA	NA	N
1071F	ALARM SYMP ASSESSED-1+ PRSNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1080F	DECIS MKR/ADVNCD PLAN DOC'D	PRXOVR	DEF					NA	NA	NA	N
1080F	DECIS MKR/ADVNCD PLAN DOC'D	MAXFEE	DEF					NA			N
1090F	PRES/ABSN URINE INCON ASSESS	PRXOVR	DEF					NA	NA	NA	N
1090F	PRES/ABSN URINE INCON ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1091F	URINE INCON CHARACTERIZED	PRXOVR	DEF					NA	NA	NA	N
1091F	URINE INCON CHARACTERIZED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1100F	PTFALLS ASSESS-DOCD GE2>/YR	PRXOVR	DEF					NA	NA	NA	N
1100F	PTFALLS ASSESS-DOCD GE2>/YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1101F	PT FALLS ASSESS-DOCD LE1/YR	PRXOVR	DEF					NA	NA	NA	N
1101F	PT FALLS ASSESS-DOCD LE1/YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1110F	PT LFT INPT FAC W/IN 60 DAYS	PRXOVR	DEF					NA	NA	NA	N
1110F	PT LFT INPT FAC W/IN 60 DAYS	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
1111F	DSCHRG MED/CURRENT MED MERGE	PRXOVR	DEF					NA	NA	NA	N
1111F	DSCHRG MED/CURRENT MED MERGE	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
1116F	AURIC/PERI PAIN ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1116F	AURIC/PERI PAIN ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1118F	GERD SYMPS ASSESSED 12 MONTH	PRXOVR	DEF					NA	NA	NA	N
1118F	GERD SYMPS ASSESSED 12 MONTH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1119F	INIT EVAL FOR CONDITION	PRXOVR	DEF					NA	NA	NA	N
1119F	INIT EVAL FOR CONDITION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1121F	SUBS EVAL FOR CONDITION	PRXOVR	DEF					NA	NA	NA	N
1121F	SUBS EVAL FOR CONDITION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1123F	ACP DISCUSS/DSCN MKR DOCD	PRXOVR	DEF					NA	NA	NA	N
1123F	ACP DISCUSS/DSCN MKR DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1124F	ACP DISCUSS-NO DSCNMKR DOCD	PRXOVR	DEF					NA	NA	NA	N
1124F	ACP DISCUSS-NO DSCNMKR DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1125F	AMNT PAIN NOTED PAIN PRSNT	PRXOVR	DEF					NA	NA	NA	N
1125F	AMNT PAIN NOTED PAIN PRSNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1126F	AMNT PAIN NOTED NONE PRSNT	PRXOVR	DEF					NA	NA	NA	N
1126F	AMNT PAIN NOTED NONE PRSNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1127F	NEW EPISODE FOR CONDITION	PRXOVR	DEF					NA	NA	NA	N
1127F	NEW EPISODE FOR CONDITION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1128F	SUBS EPISODE FOR CONDITION	PRXOVR	DEF					NA	NA	NA	N
1128F	SUBS EPISODE FOR CONDITION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1130F	BK PAIN & FXN ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1130F	BK PAIN & FXN ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1134F	EPSD BK PAIN FOR 6 WKS/<	PRXOVR	DEF					NA	NA	NA	N
1134F	EPSD BK PAIN FOR 6 WKS/<	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1135F	EPSD BK PAIN FOR >6 WKS	PRXOVR	DEF					NA	NA	NA	N
1135F	EPSD BK PAIN FOR >6 WKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1136F	EPSD BK PAIN FOR 12 WKS/<	PRXOVR	DEF					NA	NA	NA	N
1136F	EPSD BK PAIN FOR 12 WKS/<	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1137F	EPSD BK PAIN FOR >12 WKS	PRXOVR	DEF					NA	NA	NA	N
1137F	EPSD BK PAIN FOR >12 WKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1150F	DOC PT RSK DEATH W/IN 1YR	PRXOVR	DEF					NA	NA	NA	N
1150F	DOC PT RSK DEATH W/IN 1YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1151F	DOC NO PT RSK DEATH W/IN 1YR	PRXOVR	DEF					NA	NA	NA	N
1151F	DOC NO PT RSK DEATH W/IN 1YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1152F	DOC ADVNCD DIS COMFORT 1ST	PRXOVR	DEF					NA	NA	NA	N
1152F	DOC ADVNCD DIS COMFORT 1ST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1153F	DOC ADVNCD DIS CMFRT NOT 1ST	PRXOVR	DEF					NA	NA	NA	N
1153F	DOC ADVNCD DIS CMFRT NOT 1ST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1157F	ADVNC CARE PLAN IN RCRD	PRXOVR	DEF					NA	NA	NA	N
1157F	ADVNC CARE PLAN IN RCRD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1158F	ADVNC CARE PLAN TLK DOCD	PRXOVR	DEF					NA	NA	NA	N
1158F	ADVNC CARE PLAN TLK DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1159F	MED LIST DOCD IN RCRD	PRXOVR	DEF					NA	NA	NA	N
1159F	MED LIST DOCD IN RCRD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1160F	RVW MEDS BY RX/DR IN RCRD	PRXOVR	DEF					NA	NA	NA	N
1160F	RVW MEDS BY RX/DR IN RCRD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1170F	FXNL STATUS ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1170F	FXNL STATUS ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1175F	FUNCTION STAT ASSESSED RVWD	PRXOVR	DEF					NA	NA	NA	N
1175F	FUNCTION STAT ASSESSED RVWD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1180F	THROMBOEMB RISK ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1180F	THROMBOEMB RISK ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1181F	NEUROPSYCHIA SYMPTS ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1181F	NEUROPSYCHIA SYMPTS ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1182F	NEUROPSYCHI SYMPT 1+PRESENT	PRXOVR	DEF					NA	NA	NA	N
1182F	NEUROPSYCHI SYMPT 1+PRESENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1183F	NEUROPSYCHIATRIC SYMP ABSENT	PRXOVR	DEF					NA	NA	NA	N
1183F	NEUROPSYCHIATRIC SYMP ABSENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1200F	SEIZURE TYPE& FREQU DOCD	PRXOVR	DEF					NA	NA	NA	N
1200F	SEIZURE TYPE& FREQU DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1205F	EPI ETIOL SYND RVWD AND DOCD	PRXOVR	DEF					NA	NA	NA	N
1205F	EPI ETIOL SYND RVWD AND DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1220F	PT SCREENED FOR DEPRESSION	PRXOVR	DEF					NA	NA	NA	N
1220F	PT SCREENED FOR DEPRESSION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1400F	PRKNS DIAG RVIEWED	PRXOVR	DEF					NA	NA	NA	N
1400F	PRKNS DIAG RVIEWED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1450F	SYMPTOMS IMPROVED/CONSIST	PRXOVR	DEF					NA	NA	NA	N
1450F	SYMPTOMS IMPROVED/CONSIST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1451F	SYMPT SHOW CLIN IMPORT DROP	PRXOVR	DEF					NA	NA	NA	N
1451F	SYMPT SHOW CLIN IMPORT DROP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1460F	QUAL CARD DIAG PRIOR 12 MONS	PRXOVR	DEF					NA	NA	NA	N
1460F	QUAL CARD DIAG PRIOR 12 MONS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1461F	NO QUAL CARD DIAG PRIOR12MON	PRXOVR	DEF					NA	NA	NA	N
1461F	NO QUAL CARD DIAG PRIOR12MON	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1490F	DEM SEVERITY CLASSIFIED MILD	PRXOVR	DEF					NA	NA	NA	N
1490F	DEM SEVERITY CLASSIFIED MILD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1491F	DEM SEVERITY CLASSIFIED MOD	PRXOVR	DEF					NA	NA	NA	N
1491F	DEM SEVERITY CLASSIFIED MOD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1493F	DEM SEVERITY CLASS SEVERE	PRXOVR	DEF					NA	NA	NA	N
1493F	DEM SEVERITY CLASS SEVERE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1494F	COGNIT ASSESSED AND REVIEWED	PRXOVR	DEF					NA	NA	NA	N
1494F	COGNIT ASSESSED AND REVIEWED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1500F	SYMPTOM&SIGN SYMM POLYNEURO	PRXOVR	DEF					NA	NA	NA	N
1500F	SYMPTOM&SIGN SYMM POLYNEURO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1501F	NOT INITIAL EVAL FOR COND	PRXOVR	DEF					NA	NA	NA	N
1501F	NOT INITIAL EVAL FOR COND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1502F	PT QUERIED PAIN FXN W/ INSTR	PRXOVR	DEF					NA	NA	NA	N
1502F	PT QUERIED PAIN FXN W/ INSTR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1503F	PT QUERIED SYMP RESP INSUFF	PRXOVR	DEF					NA	NA	NA	N
1503F	PT QUERIED SYMP RESP INSUFF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1504F	PT HAS RESP INSUFFICIENCY	PRXOVR	DEF					NA	NA	NA	N
1504F	PT HAS RESP INSUFFICIENCY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1505F	PT HAS NO RESP INSUFFICIENCY	PRXOVR	DEF					NA	NA	NA	N
1505F	PT HAS NO RESP INSUFFICIENCY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
15853	REMOVAL SUTR/STAPL XREQ ANES	PRXOVR	DEF					NA	NA	NA	N
15853	REMOVAL SUTR/STAPL XREQ ANES	MAXFEE	DEF					8.24	1/1/2023	12/31/2299	N
15854	REMOVAL SUTR&STAPL XREQ ANES	PRXOVR	DEF					NA	NA	NA	N
15854	REMOVAL SUTR&STAPL XREQ ANES	MAXFEE	DEF					11.66	1/1/2023	12/31/2299	N
2000F	BLOOD PRESSURE MEASURE	PRXOVR	DEF					NA	NA	NA	N
2000F	BLOOD PRESSURE MEASURE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2001F	WEIGHT RECORD	PRXOVR	DEF					NA	NA	NA	N
2001F	WEIGHT RECORD	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
2002F	CLIN SIGN VOL OVRLD ASSESS	PRXOVR	DEF					NA	NA	NA	N
2002F	CLIN SIGN VOL OVRLD ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2003F	AUSCULTATION HEART PERFORM	PRXOVR	DEF					NA	NA	NA	N
2003F	AUSCULTATION HEART PERFORM	MAXFEE	DEF					NA			N
2004F	INITIAL EXAM INVOLVED JOINTS	PRXOVR	DEF					NA	NA	NA	N
2004F	INITIAL EXAM INVOLVED JOINTS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2010F	VITAL SIGNS RECORDED	PRXOVR	DEF					NA	NA	NA	N
2010F	VITAL SIGNS RECORDED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2014F	MENTAL STATUS ASSESS	PRXOVR	DEF					NA	NA	NA	N
2014F	MENTAL STATUS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2015F	ASTHMA IMPAIRMENT ASSESSED	PRXOVR	DEF					NA	NA	NA	N
2015F	ASTHMA IMPAIRMENT ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2016F	ASTHMA RISK ASSESSED	PRXOVR	DEF					NA	NA	NA	N
2016F	ASTHMA RISK ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2018F	HYDRATION STATUS ASSESS	PRXOVR	DEF					NA	NA	NA	N
2018F	HYDRATION STATUS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2019F	DILATED MACUL EXAM DONE	PRXOVR	DEF					NA	NA	NA	N
2019F	DILATED MACUL EXAM DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2020F	DILATED FUNDUS EVAL DONE	PRXOVR	DEF					NA	NA	NA	N
2020F	DILATED FUNDUS EVAL DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2021F	DILAT MACULAR EXAM DONE	PRXOVR	DEF					NA	NA	NA	N
2021F	DILAT MACULAR EXAM DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2022F	DILAT RTA XM EVC RTNOPTHY	PRXOVR	DEF					NA	NA	NA	N
2022F	DILAT RTA XM EVC RTNOPTHY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2024F	7 FLD RTA PHOTO EVC RTNOPTHY	PRXOVR	DEF					NA	NA	NA	N
2024F	7 FLD RTA PHOTO EVC RTNOPTHY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2026F	EYE IMG VALID EVC RTNOPTHY	PRXOVR	DEF					NA	NA	NA	N
2026F	EYE IMG VALID EVC RTNOPTHY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2027F	OPTIC NERVE HEAD EVAL DONE	PRXOVR	DEF					NA	NA	NA	N
2027F	OPTIC NERVE HEAD EVAL DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2028F	FOOT EXAM PERFORMED	PRXOVR	DEF					NA	NA	NA	N
2028F	FOOT EXAM PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2029F	COMPLETE PHYS SKIN EXAM DONE	PRXOVR	DEF					NA	NA	NA	N
2029F	COMPLETE PHYS SKIN EXAM DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2030F	H2O STAT DOCD NORMAL	PRXOVR	DEF					NA	NA	NA	N
2030F	H2O STAT DOCD NORMAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2031F	H2O STAT DOCD DEHYDRATED	PRXOVR	DEF					NA	NA	NA	N
2031F	H2O STAT DOCD DEHYDRATED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2035F	TYMP MEMB MOTION EXAMD	PRXOVR	DEF					NA	NA	NA	N
2035F	TYMP MEMB MOTION EXAMD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2040F	BK PN XM ON INIT VISIT DATE	PRXOVR	DEF					NA	NA	NA	N
2040F	BK PN XM ON INIT VISIT DATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2044F	DOC MNTL TST B/4 BK TRXMNT	PRXOVR	DEF					NA	NA	NA	N
2044F	DOC MNTL TST B/4 BK TRXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2050F	WOUND CHAR SIZE ETC DOCD	PRXOVR	DEF					NA	NA	NA	N
2050F	WOUND CHAR SIZE ETC DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2060F	PT TALK EVAL HLTHWKR RE MDD	PRXOVR	DEF					NA	NA	NA	N
2060F	PT TALK EVAL HLTHWKR RE MDD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3000F	BLOOD PRESS </= 140/90 MMHG	PRXOVR	DEF					NA	NA	NA	N
3000F	BLOOD PRESS </= 140/90 MMHG	MAXFEE	DEF					NA			N
3002F	BLOOD PRESSURE > 140/90 MMHG	PRXOVR	DEF					NA	NA	NA	N
3002F	BLOOD PRESSURE > 140/90 MMHG	MAXFEE	DEF					NA			N
3006F	CXR DOC REV	PRXOVR	DEF					NA	NA	NA	N
3006F	CXR DOC REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3008F	BODY MASS INDEX DOCD	PRXOVR	DEF					NA	NA	NA	N
3008F	BODY MASS INDEX DOCD	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3011F	LIPID PANEL DOC REV	PRXOVR	DEF					NA	NA	NA	N
3011F	LIPID PANEL DOC REV	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3014F	SCREEN MAMMO DOC REV	PRXOVR	DEF					NA	NA	NA	N
3014F	SCREEN MAMMO DOC REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3015F	CERV CANCER SCREEN DOCD	PRXOVR	DEF					NA	NA	NA	N
3015F	CERV CANCER SCREEN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3016F	PT SCRND UNHLTHY OH USE	PRXOVR	DEF					NA	NA	NA	N
3016F	PT SCRND UNHLTHY OH USE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3017F	COLORECTAL CA SCREEN DOC REV	PRXOVR	DEF					NA	NA	NA	N
3017F	COLORECTAL CA SCREEN DOC REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3018F	PRE-PRXD RSK ET AL DOCD	PRXOVR	DEF					NA	NA	NA	N
3018F	PRE-PRXD RSK ET AL DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3019F	LVEF ASSESS PLANPOST DSCHRGE	PRXOVR	DEF					NA	NA	NA	N
3019F	LVEF ASSESS PLANPOST DSCHRGE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3020F	LVF ASSESS	PRXOVR	DEF					NA	NA	NA	N
3020F	LVF ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3021F	LVEF MOD/SEVER DEPRS SYST	PRXOVR	DEF					NA	NA	NA	N
3021F	LVEF MOD/SEVER DEPRS SYST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3022F	LVEF >=40% SYSTOLIC	PRXOVR	DEF					NA	NA	NA	N
3022F	LVEF >=40% SYSTOLIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3023F	SPIROM DOC REV	PRXOVR	DEF					NA	NA	NA	N
3023F	SPIROM DOC REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3025F	SPIROM FEV/FVC <70% W/COPD	PRXOVR	DEF					NA	NA	NA	N
3025F	SPIROM FEV/FVC <70% W/COPD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3027F	SPIROM FEV/FVC>=70%/W/OCOPD	PRXOVR	DEF					NA	NA	NA	N
3027F	SPIROM FEV/FVC>=70%/W/OCOPD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3028F	O2 SATURATION DOC REV	PRXOVR	DEF					NA	NA	NA	N
3028F	O2 SATURATION DOC REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3035F	O2 SATURATION<=88%/PAO<=55	PRXOVR	DEF					NA	NA	NA	N
3035F	O2 SATURATION<=88%/PAO<=55	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3037F	O2 SATURATION >88%/PAO>55 HG	PRXOVR	DEF					NA	NA	NA	N
3037F	O2 SATURATION >88%/PAO>55 HG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3038F	PULM FX W/IN 12 MON B/4 SURG	PRXOVR	DEF					NA	NA	NA	N
3038F	PULM FX W/IN 12 MON B/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3040F	FEV <40% PREDICTED VALUE	PRXOVR	DEF					NA	NA	NA	N
3040F	FEV <40% PREDICTED VALUE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3042F	FEV >=40% PREDICTED VALUE	PRXOVR	DEF					NA	NA	NA	N
3042F	FEV >=40% PREDICTED VALUE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3044F	HG A1C LEVEL LT 7.0%	PRXOVR	DEF					NA	NA	NA	N
3044F	HG A1C LEVEL LT 7.0%	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3045F	HG A1C LEVEL 7.0-9.0%	PRXOVR	DEF					NA	NA	NA	N
3045F	HG A1C LEVEL 7.0-9.0%	MAXFEE	DEF					NA			N
3046F	HEMOGLOBIN A1C LEVEL >9.0%	PRXOVR	DEF					NA	NA	NA	N
3046F	HEMOGLOBIN A1C LEVEL >9.0%	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3047F	HEMOGLOBIN A1C LEVEL = 9.0%	PRXOVR	DEF					NA	NA	NA	N
3047F	HEMOGLOBIN A1C LEVEL = 9.0%	MAXFEE	DEF					NA			N
3048F	LDL-C <100 MG/DL	PRXOVR	DEF					NA	NA	NA	N
3048F	LDL-C <100 MG/DL	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3049F	LDL-C 100-129 MG/DL	PRXOVR	DEF					NA	NA	NA	N
3049F	LDL-C 100-129 MG/DL	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3050F	LDL-C >= 130 MG/DL	PRXOVR	DEF					NA	NA	NA	N
3050F	LDL-C >= 130 MG/DL	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3055F	LVEF LESS THAN/EQUAL TO 35%	PRXOVR	DEF					NA	NA	NA	N
3055F	LVEF LESS THAN/EQUAL TO 35%	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3056F	LVEF GREATER THAN 35%	PRXOVR	DEF					NA	NA	NA	N
3056F	LVEF GREATER THAN 35%	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3060F	POS MICROALBUMINURIA REV	PRXOVR	DEF					NA	NA	NA	N
3060F	POS MICROALBUMINURIA REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3061F	NEG MICROALBUMINURIA REV	PRXOVR	DEF					NA	NA	NA	N
3061F	NEG MICROALBUMINURIA REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3062F	POS MACROALBUMINURIA REV	PRXOVR	DEF					NA	NA	NA	N
3062F	POS MACROALBUMINURIA REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3066F	NEPHROPATHY DOC TX	PRXOVR	DEF					NA	NA	NA	N
3066F	NEPHROPATHY DOC TX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3072F	LOW RISK FOR RETINOPATHY	PRXOVR	DEF					NA	NA	NA	N
3072F	LOW RISK FOR RETINOPATHY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3073F	PRE-SURG EYE MEASURES DOCD	PRXOVR	DEF					NA	NA	NA	N
3073F	PRE-SURG EYE MEASURES DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3074F	SYST BP LT 130 MM HG	PRXOVR	DEF					NA	NA	NA	N
3074F	SYST BP LT 130 MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3075F	SYST BP GE 130 - 139MM HG	PRXOVR	DEF					NA	NA	NA	N
3075F	SYST BP GE 130 - 139MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3076F	SYST BP < 140 MM HG	PRXOVR	DEF					NA	NA	NA	N
3076F	SYST BP < 140 MM HG	MAXFEE	DEF					NA			N
3077F	SYST BP >= 140 MM HG	PRXOVR	DEF					NA	NA	NA	N
3077F	SYST BP >= 140 MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3078F	DIAST BP <80 MM HG	PRXOVR	DEF					NA	NA	NA	N
3078F	DIAST BP <80 MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3079F	DIAST BP 80-89 MM HG	PRXOVR	DEF					NA	NA	NA	N
3079F	DIAST BP 80-89 MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3080F	DIAST BP >= 90 MM HG	PRXOVR	DEF					NA	NA	NA	N
3080F	DIAST BP >= 90 MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3082F	KT/V <1.2	PRXOVR	DEF					NA	NA	NA	N
3082F	KT/V <1.2	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3083F	KT/V =/> 1.2 & <1.7	PRXOVR	DEF					NA	NA	NA	N
3083F	KT/V =/> 1.2 & <1.7	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3084F	KT/V >= 1.7	PRXOVR	DEF					NA	NA	NA	N
3084F	KT/V >= 1.7	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3085F	SUICIDE RISK ASSESSED	PRXOVR	DEF					NA	NA	NA	N
3085F	SUICIDE RISK ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3088F	MDD MILD	PRXOVR	DEF					NA	NA	NA	N
3088F	MDD MILD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3089F	MDD MODERATE	PRXOVR	DEF					NA	NA	NA	N
3089F	MDD MODERATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3090F	MDD SEVERE W/O PSYCH	PRXOVR	DEF					NA	NA	NA	N
3090F	MDD SEVERE W/O PSYCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3091F	MDD SEVERE W/PSYCH	PRXOVR	DEF					NA	NA	NA	N
3091F	MDD SEVERE W/PSYCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3092F	MDD IN REMISSION	PRXOVR	DEF					NA	NA	NA	N
3092F	MDD IN REMISSION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3093F	DOC NEW DIAG 1ST/ADDL MDD	PRXOVR	DEF					NA	NA	NA	N
3093F	DOC NEW DIAG 1ST/ADDL MDD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3095F	CENTRAL DEXA RESULTS DOCD	PRXOVR	DEF					NA	NA	NA	N
3095F	CENTRAL DEXA RESULTS DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3096F	CENTRAL DEXA ORDERED	PRXOVR	DEF					NA	NA	NA	N
3096F	CENTRAL DEXA ORDERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3200F	BARIUM SWALLOW TEST NOT REQ	PRXOVR	DEF					NA	NA	NA	N
3200F	BARIUM SWALLOW TEST NOT REQ	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3210F	GRP A STREP TEST PERFORMED	PRXOVR	DEF					NA	NA	NA	N
3210F	GRP A STREP TEST PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3215F	PT IMMUNITY TO HEP A DOCD	PRXOVR	DEF					NA	NA	NA	N
3215F	PT IMMUNITY TO HEP A DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3216F	PT IMMUNITY TO HEP B DOCD	PRXOVR	DEF					NA	NA	NA	N
3216F	PT IMMUNITY TO HEP B DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3218F	RNA TSTNG HEP C DOCD DONE	PRXOVR	DEF					NA	NA	NA	N
3218F	RNA TSTNG HEP C DOCD DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3220F	HEP C QUANT RNA TSTNG DOCD	PRXOVR	DEF					NA	NA	NA	N
3220F	HEP C QUANT RNA TSTNG DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3230F	NOTE HRING TST W/IN 6 MON	PRXOVR	DEF					NA	NA	NA	N
3230F	NOTE HRING TST W/IN 6 MON	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3250F	NONPRIM LOC ANAT BX SITE TUM	PRXOVR	DEF					NA	NA	NA	N
3250F	NONPRIM LOC ANAT BX SITE TUM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3260F	PT CAT/PN CAT/HIST GRD DOCD	PRXOVR	DEF					NA	NA	NA	N
3260F	PT CAT/PN CAT/HIST GRD DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3265F	RNA TSTNG HEPC VIR ORD/DOCD	PRXOVR	DEF					NA	NA	NA	N
3265F	RNA TSTNG HEPC VIR ORD/DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3266F	HEPC GN TSTNG DOCD B/4TXMNT	PRXOVR	DEF					NA	NA	NA	N
3266F	HEPC GN TSTNG DOCD B/4TXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3267F	PATH RPRT W/ PT PN CAT ET AL	PRXOVR	DEF					NA	NA	NA	N
3267F	PATH RPRT W/ PT PN CAT ET AL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3268F	PSA/T/GLSC DOCD B/4 TXMNT	PRXOVR	DEF					NA	NA	NA	N
3268F	PSA/T/GLSC DOCD B/4 TXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3269F	BONE SCN B/4 TXMNT/AFTR DX	PRXOVR	DEF					NA	NA	NA	N
3269F	BONE SCN B/4 TXMNT/AFTR DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3270F	NO BONE SCN B/4 TXMNT/AFTRDX	PRXOVR	DEF					NA	NA	NA	N
3270F	NO BONE SCN B/4 TXMNT/AFTRDX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3271F	LOW RISK PROSTATE CANCER	PRXOVR	DEF					NA	NA	NA	N
3271F	LOW RISK PROSTATE CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3272F	MED RISK PROSTATE CANCER	PRXOVR	DEF					NA	NA	NA	N
3272F	MED RISK PROSTATE CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3273F	HIGH RISK PROSTATE CANCER	PRXOVR	DEF					NA	NA	NA	N
3273F	HIGH RISK PROSTATE CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3274F	PROST CNCR RSK NOT LW/MD/HGH	PRXOVR	DEF					NA	NA	NA	N
3274F	PROST CNCR RSK NOT LW/MD/HGH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3278F	SERUM LVLS CA/IPTH/LPD ORD	PRXOVR	DEF					NA	NA	NA	N
3278F	SERUM LVLS CA/IPTH/LPD ORD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3279F	HGB LVL >= 13 G/DL	PRXOVR	DEF					NA	NA	NA	N
3279F	HGB LVL >= 13 G/DL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3280F	HGB LVL 11-12.9 G/DL	PRXOVR	DEF					NA	NA	NA	N
3280F	HGB LVL 11-12.9 G/DL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3281F	HGB LVL <11 G/DL	PRXOVR	DEF					NA	NA	NA	N
3281F	HGB LVL <11 G/DL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3284F	IOP DOWN >15% OF PRE-SVC LVL	PRXOVR	DEF					NA	NA	NA	N
3284F	IOP DOWN >15% OF PRE-SVC LVL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3285F	IOP DOWN <15% OF PRE-SVC LVL	PRXOVR	DEF					NA	NA	NA	N
3285F	IOP DOWN <15% OF PRE-SVC LVL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3288F	FALL RISK ASSESSMENT DOCD	PRXOVR	DEF					NA	NA	NA	N
3288F	FALL RISK ASSESSMENT DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3290F	PT=D(RH)- AND UNSENSITIZED	PRXOVR	DEF					NA	NA	NA	N
3290F	PT=D(RH)- AND UNSENSITIZED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3291F	PT=D(RH)+ OR SENSITIZED	PRXOVR	DEF					NA	NA	NA	N
3291F	PT=D(RH)+ OR SENSITIZED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3292F	HIV TSTNG ASKED/DOCD/REVWD	PRXOVR	DEF					NA	NA	NA	N
3292F	HIV TSTNG ASKED/DOCD/REVWD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3293F	ABO RH BLOOD TYPING DOCD	PRXOVR	DEF					NA	NA	NA	N
3293F	ABO RH BLOOD TYPING DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3294F	GRP B STREP SCREENING DOCD	PRXOVR	DEF					NA	NA	NA	N
3294F	GRP B STREP SCREENING DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3300F	AJCC STAGE DOCD B/4 THXPY	PRXOVR	DEF					NA	NA	NA	N
3300F	AJCC STAGE DOCD B/4 THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3301F	CANCER STAGE DOCD METAST	PRXOVR	DEF					NA	NA	NA	N
3301F	CANCER STAGE DOCD METAST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3302F	AJCC STAGE 0 DOC'D	PRXOVR	DEF					NA	NA	NA	N
3302F	AJCC STAGE 0 DOC'D	MAXFEE	DEF					NA			N
3303F	AJCC STAGE IA DOC'D	PRXOVR	DEF					NA	NA	NA	N
3303F	AJCC STAGE IA DOC'D	MAXFEE	DEF					NA			N
3304F	AJCC STAGE IB DOC'D	PRXOVR	DEF					NA	NA	NA	N
3304F	AJCC STAGE IB DOC'D	MAXFEE	DEF					NA			N
3305F	AJCC STAGE IC DOC'D	PRXOVR	DEF					NA	NA	NA	N
3305F	AJCC STAGE IC DOC'D	MAXFEE	DEF					NA			N
3306F	AJCC STAGE IIA DOC'D	PRXOVR	DEF					NA	NA	NA	N
3306F	AJCC STAGE IIA DOC'D	MAXFEE	DEF					NA			N
3307F	AJCC STAGE IIB DOC'D	PRXOVR	DEF					NA	NA	NA	N
3307F	AJCC STAGE IIB DOC'D	MAXFEE	DEF					NA			N
3308F	AJCC STAGE IIC DOC'D	PRXOVR	DEF					NA	NA	NA	N
3308F	AJCC STAGE IIC DOC'D	MAXFEE	DEF					NA			N
3309F	AJCC STAGE IIIA DOC'D	PRXOVR	DEF					NA	NA	NA	N
3309F	AJCC STAGE IIIA DOC'D	MAXFEE	DEF					NA			N
3310F	AJCC STAGE IIIB DOC'D	PRXOVR	DEF					NA	NA	NA	N
3310F	AJCC STAGE IIIB DOC'D	MAXFEE	DEF					NA			N
3311F	AJCC STAGE IIIC DOC'D	PRXOVR	DEF					NA	NA	NA	N
3311F	AJCC STAGE IIIC DOC'D	MAXFEE	DEF					NA			N
3312F	AJCC STAGE IVA DOC'D	PRXOVR	DEF					NA	NA	NA	N
3312F	AJCC STAGE IVA DOC'D	MAXFEE	DEF					NA			N
3313F	AJCC STAGE IVB DOC'D	PRXOVR	DEF					NA	NA	NA	N
3313F	AJCC STAGE IVB DOC'D	MAXFEE	DEF					NA			N
3314F	AJCC STAGE IVC DOC'D	PRXOVR	DEF					NA	NA	NA	N
3314F	AJCC STAGE IVC DOC'D	MAXFEE	DEF					NA			N
3315F	ER+ OR PR+ BREAST CANCER	PRXOVR	DEF					NA	NA	NA	N
3315F	ER+ OR PR+ BREAST CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3316F	ER- OR PR- BREAST CANCER	PRXOVR	DEF					NA	NA	NA	N
3316F	ER- OR PR- BREAST CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3317F	PATH RPT MALIG CANCER DOCD	PRXOVR	DEF					NA	NA	NA	N
3317F	PATH RPT MALIG CANCER DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3318F	PATH RPT MALIG CANCER DOCD	PRXOVR	DEF					NA	NA	NA	N
3318F	PATH RPT MALIG CANCER DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3319F	X-RAY/CT/ULTRSND ET AL ORD	PRXOVR	DEF					NA	NA	NA	N
3319F	X-RAY/CT/ULTRSND ET AL ORD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3320F	NO XRAY/CT/ ET AL ORDD	PRXOVR	DEF					NA	NA	NA	N
3320F	NO XRAY/CT/ ET AL ORDD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3321F	AJCC CNCR 0/IA MELAN DOCD	PRXOVR	DEF					NA	NA	NA	N
3321F	AJCC CNCR 0/IA MELAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3322F	MELANOMAAJCC STAGE 0 OR IA	PRXOVR	DEF					NA	NA	NA	N
3322F	MELANOMAAJCC STAGE 0 OR IA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3323F	CLIN NODE STGNG DOCDB/4 SURG	PRXOVR	DEF					NA	NA	NA	N
3323F	CLIN NODE STGNG DOCDB/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3324F	MRI CT SCAN ORD RVWD RQSTD	PRXOVR	DEF					NA	NA	NA	N
3324F	MRI CT SCAN ORD RVWD RQSTD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3325F	PREOP ASSES 4 CATARACT SURG	PRXOVR	DEF					NA	NA	NA	N
3325F	PREOP ASSES 4 CATARACT SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3328F	PRFRMNC DOCD 2 WKS B/4 SURG	PRXOVR	DEF					NA	NA	NA	N
3328F	PRFRMNC DOCD 2 WKS B/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3330F	IMAGING STUDY ORDERED (BKP)	PRXOVR	DEF					NA	NA	NA	N
3330F	IMAGING STUDY ORDERED (BKP)	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3331F	BK IMAGING TST NOT ORDERED	PRXOVR	DEF					NA	NA	NA	N
3331F	BK IMAGING TST NOT ORDERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3340F	MAMMO ASSESS INC XRAY DOCD	PRXOVR	DEF					NA	NA	NA	N
3340F	MAMMO ASSESS INC XRAY DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3341F	MAMMO ASSESS NEGATIVE DOCD	PRXOVR	DEF					NA	NA	NA	N
3341F	MAMMO ASSESS NEGATIVE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3342F	MAMMO ASSESS BENGN DOCD	PRXOVR	DEF					NA	NA	NA	N
3342F	MAMMO ASSESS BENGN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3343F	MAMMO PROBABLY BENGN DOCD	PRXOVR	DEF					NA	NA	NA	N
3343F	MAMMO PROBABLY BENGN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3344F	MAMMO ASSESS SUSP DOCD	PRXOVR	DEF					NA	NA	NA	N
3344F	MAMMO ASSESS SUSP DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3345F	MAMMO ASSESS HGHLYMALIG DOC	PRXOVR	DEF					NA	NA	NA	N
3345F	MAMMO ASSESS HGHLYMALIG DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3350F	MAMMO BX PROVEN MALIG DOCD	PRXOVR	DEF					NA	NA	NA	N
3350F	MAMMO BX PROVEN MALIG DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3351F	NEG SCRN DEP SYMP BY DEPTOOL	PRXOVR	DEF					NA	NA	NA	N
3351F	NEG SCRN DEP SYMP BY DEPTOOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3352F	NO SIG DEP SYMP BY DEP TOOL	PRXOVR	DEF					NA	NA	NA	N
3352F	NO SIG DEP SYMP BY DEP TOOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3353F	MILD-MOD DEP SYMP BY DEPTOOL	PRXOVR	DEF					NA	NA	NA	N
3353F	MILD-MOD DEP SYMP BY DEPTOOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3354F	CLIN SIG DEP SYM BY DEP TOOL	PRXOVR	DEF					NA	NA	NA	N
3354F	CLIN SIG DEP SYM BY DEP TOOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3370F	AJCC BRST CNCR STAGE 0 DOCD	PRXOVR	DEF					NA	NA	NA	N
3370F	AJCC BRST CNCR STAGE 0 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3372F	AJCC BRST CNCR STAGE 1 DOCD	PRXOVR	DEF					NA	NA	NA	N
3372F	AJCC BRST CNCR STAGE 1 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3374F	AJCC BRST CNCR STAGE 1 DOCD	PRXOVR	DEF					NA	NA	NA	N
3374F	AJCC BRST CNCR STAGE 1 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3376F	AJCC BRSTCNCR STAGE 2 DOCD	PRXOVR	DEF					NA	NA	NA	N
3376F	AJCC BRSTCNCR STAGE 2 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3378F	AJCC BRSTCNCR STAGE 3 DOCD	PRXOVR	DEF					NA	NA	NA	N
3378F	AJCC BRSTCNCR STAGE 3 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3380F	AJCC BRSTCNCR STAGE 4 DOCD	PRXOVR	DEF					NA	NA	NA	N
3380F	AJCC BRSTCNCR STAGE 4 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3382F	AJCC CLN CNCR STAGE 0 DOCD	PRXOVR	DEF					NA	NA	NA	N
3382F	AJCC CLN CNCR STAGE 0 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3384F	AJCC CLN CNCR STAGE 1 DOCD	PRXOVR	DEF					NA	NA	NA	N
3384F	AJCC CLN CNCR STAGE 1 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3386F	AJCC CLN CNCR STAGE 2 DOCD	PRXOVR	DEF					NA	NA	NA	N
3386F	AJCC CLN CNCR STAGE 2 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3388F	AJCC CLN CNCR STAGE 3 DOCD	PRXOVR	DEF					NA	NA	NA	N
3388F	AJCC CLN CNCR STAGE 3 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3390F	AJCC CLN CNCR STAGE 4 DOCD	PRXOVR	DEF					NA	NA	NA	N
3390F	AJCC CLN CNCR STAGE 4 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3394F	QUANT HER2 IHC EVAL BRST CX	PRXOVR	DEF					NA	NA	NA	N
3394F	QUANT HER2 IHC EVAL BRST CX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3395F	QUANT NONHER2 IHC BRST CX	PRXOVR	DEF					NA	NA	NA	N
3395F	QUANT NONHER2 IHC BRST CX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3450F	DYSPNEA SCRND NO-MILD DYSP	PRXOVR	DEF					NA	NA	NA	N
3450F	DYSPNEA SCRND NO-MILD DYSP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3451F	DYSPNEA SCRND MOD-HIGH DYSP	PRXOVR	DEF					NA	NA	NA	N
3451F	DYSPNEA SCRND MOD-HIGH DYSP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3452F	DYSPNEA NOT SCREENED	PRXOVR	DEF					NA	NA	NA	N
3452F	DYSPNEA NOT SCREENED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3455F	TB SCRNG DONE-INTERPD 6MON	PRXOVR	DEF					NA	NA	NA	N
3455F	TB SCRNG DONE-INTERPD 6MON	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3470F	RA DISEASE ACTIVITY LOW	PRXOVR	DEF					NA	NA	NA	N
3470F	RA DISEASE ACTIVITY LOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3471F	RA DISEASE ACTIVITY MOD	PRXOVR	DEF					NA	NA	NA	N
3471F	RA DISEASE ACTIVITY MOD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3472F	RA DISEASE ACTIVITY HIGH	PRXOVR	DEF					NA	NA	NA	N
3472F	RA DISEASE ACTIVITY HIGH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3475F	DISEASE PROGN RA POOR DOCD	PRXOVR	DEF					NA	NA	NA	N
3475F	DISEASE PROGN RA POOR DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3476F	DISEASE PROGN RA GOOD DOCD	PRXOVR	DEF					NA	NA	NA	N
3476F	DISEASE PROGN RA GOOD DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3490F	HISTORY AIDS-DEFINING COND	PRXOVR	DEF					NA	NA	NA	N
3490F	HISTORY AIDS-DEFINING COND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3491F	HIV UNSURE BABY OF HIV+MOMS	PRXOVR	DEF					NA	NA	NA	N
3491F	HIV UNSURE BABY OF HIV+MOMS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3492F	HISTORY CD4+ CELL COUNT <350	PRXOVR	DEF					NA	NA	NA	N
3492F	HISTORY CD4+ CELL COUNT <350	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3493F	NO HIST CD4+ CELL COUNT <350	PRXOVR	DEF					NA	NA	NA	N
3493F	NO HIST CD4+ CELL COUNT <350	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3494F	CD4+CELL COUNT <200CELLS/MM3	PRXOVR	DEF					NA	NA	NA	N
3494F	CD4+CELL COUNT <200CELLS/MM3	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3495F	CD4+CELL CNT 200-499 CELLS	PRXOVR	DEF					NA	NA	NA	N
3495F	CD4+CELL CNT 200-499 CELLS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3496F	CD4+ CELL COUNT >= 500 CELLS	PRXOVR	DEF					NA	NA	NA	N
3496F	CD4+ CELL COUNT >= 500 CELLS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3497F	CD4+ CELL PERCENTAGE <15%	PRXOVR	DEF					NA	NA	NA	N
3497F	CD4+ CELL PERCENTAGE <15%	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3498F	CD4+ CELL >=15% (HIV)	PRXOVR	DEF					NA	NA	NA	N
3498F	CD4+ CELL >=15% (HIV)	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3500F	CD4+CELL CNT/% DOCD AS DONE	PRXOVR	DEF					NA	NA	NA	N
3500F	CD4+CELL CNT/% DOCD AS DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3502F	HIV RNA VRL LD <LMTS QUANTIF	PRXOVR	DEF					NA	NA	NA	N
3502F	HIV RNA VRL LD <LMTS QUANTIF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3503F	HIV RNA VRL LDNOT<LMTS QUNTF	PRXOVR	DEF					NA	NA	NA	N
3503F	HIV RNA VRL LDNOT<LMTS QUNTF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3510F	DOC TB SCRNG-RSLTS INTERPD	PRXOVR	DEF					NA	NA	NA	N
3510F	DOC TB SCRNG-RSLTS INTERPD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3511F	CHLMYD/GONRH TSTS DOCD DONE	PRXOVR	DEF					NA	NA	NA	N
3511F	CHLMYD/GONRH TSTS DOCD DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3512F	SYPH SCRNG DOCD AS DONE	PRXOVR	DEF					NA	NA	NA	N
3512F	SYPH SCRNG DOCD AS DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3513F	HEP B SCRNG DOCD AS DONE	PRXOVR	DEF					NA	NA	NA	N
3513F	HEP B SCRNG DOCD AS DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3514F	HEP C SCRNG DOCD AS DONE	PRXOVR	DEF					NA	NA	NA	N
3514F	HEP C SCRNG DOCD AS DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3515F	PT HAS DOCD IMMUN TO HEP C	PRXOVR	DEF					NA	NA	NA	N
3515F	PT HAS DOCD IMMUN TO HEP C	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3517F	HBV ASSESS&RESULTS INTRP 1YR	PRXOVR	DEF					NA	NA	NA	N
3517F	HBV ASSESS&RESULTS INTRP 1YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3520F	CDIFFICILE TESTING PERFORMED	PRXOVR	DEF					NA	NA	NA	N
3520F	CDIFFICILE TESTING PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3550F	LOW RSK THROMBOEMBOLISM	PRXOVR	DEF					NA	NA	NA	N
3550F	LOW RSK THROMBOEMBOLISM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3551F	INTRMED RSK THROMBOEMBOLISM	PRXOVR	DEF					NA	NA	NA	N
3551F	INTRMED RSK THROMBOEMBOLISM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3552F	HGH RISK FOR THROMBOEMBOLISM	PRXOVR	DEF					NA	NA	NA	N
3552F	HGH RISK FOR THROMBOEMBOLISM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3555F	PT INR MEASUREMENT PERFORMED	PRXOVR	DEF					NA	NA	NA	N
3555F	PT INR MEASUREMENT PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3570F	RPRT BONE SCINT XREF W XRAY	PRXOVR	DEF					NA	NA	NA	N
3570F	RPRT BONE SCINT XREF W XRAY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3572F	PT CONSID POSS RISK FX	PRXOVR	DEF					NA	NA	NA	N
3572F	PT CONSID POSS RISK FX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3573F	PT NOT CONSID POSS RISK FX	PRXOVR	DEF					NA	NA	NA	N
3573F	PT NOT CONSID POSS RISK FX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
36415	ROUTINE VENIPUNCTURE	PRXOVR	DEF					NA	NA	NA	N
36415	ROUTINE VENIPUNCTURE	MAXFEE	DEF					2.25	1/1/2018	12/31/2299	N
3650F	EEG ORDERED RVWD REQSTD	PRXOVR	DEF					NA	NA	NA	N
3650F	EEG ORDERED RVWD REQSTD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3700F	PSYCH DISORDERS ASSESSED	PRXOVR	DEF					NA	NA	NA	N
3700F	PSYCH DISORDERS ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3720F	COGNIT IMPAIRMENT ASSESSED	PRXOVR	DEF					NA	NA	NA	N
3720F	COGNIT IMPAIRMENT ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3725F	SCREEN DEPRESSION PERFORMED	PRXOVR	DEF					NA	NA	NA	N
3725F	SCREEN DEPRESSION PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3750F	PTNOTRCVNGSTEROID>=10MG/DAY	PRXOVR	DEF					NA	NA	NA	N
3750F	PTNOTRCVNGSTEROID>=10MG/DAY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3751F	ELECTRODIAG POLYNEURO 6 MN	PRXOVR	DEF					NA	NA	NA	N
3751F	ELECTRODIAG POLYNEURO 6 MN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3752F	NO ELECTRODIAG POLYNEURO 6MN	PRXOVR	DEF					NA	NA	NA	N
3752F	NO ELECTRODIAG POLYNEURO 6MN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3753F	PT HAS SYMP&SIGNS NEUROPATHY	PRXOVR	DEF					NA	NA	NA	N
3753F	PT HAS SYMP&SIGNS NEUROPATHY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3754F	SCREENING TESTS DM DONE	PRXOVR	DEF					NA	NA	NA	N
3754F	SCREENING TESTS DM DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3755F	COG&BEHAV IMPRMNT SCRNG DONE	PRXOVR	DEF					NA	NA	NA	N
3755F	COG&BEHAV IMPRMNT SCRNG DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3756F	PT W/PSEUDOBULB AFFECT/ALS	PRXOVR	DEF					NA	NA	NA	N
3756F	PT W/PSEUDOBULB AFFECT/ALS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3757F	PT W/O PSEUDOBULBAFFECT/ALS	PRXOVR	DEF					NA	NA	NA	N
3757F	PT W/O PSEUDOBULBAFFECT/ALS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3758F	PT REF PULM FX TEST/PEAKFLOW	PRXOVR	DEF					NA	NA	NA	N
3758F	PT REF PULM FX TEST/PEAKFLOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3759F	PT SCRN DYSPHAG/WT LOSS/NUTR	PRXOVR	DEF					NA	NA	NA	N
3759F	PT SCRN DYSPHAG/WT LOSS/NUTR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3760F	PT W/DYSPHAG/WT LOSS/NUTR	PRXOVR	DEF					NA	NA	NA	N
3760F	PT W/DYSPHAG/WT LOSS/NUTR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3761F	PT W/O DYSPHAG/WT LOSS/NUTR	PRXOVR	DEF					NA	NA	NA	N
3761F	PT W/O DYSPHAG/WT LOSS/NUTR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3762F	PATIENT IS DYSARTHRIC	PRXOVR	DEF					NA	NA	NA	N
3762F	PATIENT IS DYSARTHRIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3763F	PATIENT IS NOT DYSARTHRIC	PRXOVR	DEF					NA	NA	NA	N
3763F	PATIENT IS NOT DYSARTHRIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3775F	ADENOMA DETECTED SCREENING	PRXOVR	DEF					NA	NA	NA	N
3775F	ADENOMA DETECTED SCREENING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3776F	ADENOMA NOT DETECT SCREENING	PRXOVR	DEF					NA	NA	NA	N
3776F	ADENOMA NOT DETECT SCREENING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4000F	TOBACCO USE TXMNT COUNSELING	PRXOVR	DEF					NA	NA	NA	N
4000F	TOBACCO USE TXMNT COUNSELING	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
4001F	TOBACCO USE TXMNT PHARMACOL	PRXOVR	DEF					NA	NA	NA	N
4001F	TOBACCO USE TXMNT PHARMACOL	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
4002F	STATIN THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4002F	STATIN THERAPY RX	MAXFEE	DEF					NA			N
4003F	PT ED WRITE/ORAL PTS W/ HF	PRXOVR	DEF					NA	NA	NA	N
4003F	PT ED WRITE/ORAL PTS W/ HF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4004F	PT TOBACCO SCREEN RCVD TLK	PRXOVR	DEF					NA	NA	NA	N
4004F	PT TOBACCO SCREEN RCVD TLK	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
4005F	PHARM THX FOR OP RXD	PRXOVR	DEF					NA	NA	NA	N
4005F	PHARM THX FOR OP RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4006F	BETA-BLOCKER THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4006F	BETA-BLOCKER THERAPY RX	MAXFEE	DEF					NA			N
4007F	AREDS/ANITOX VIT/MIN RX'D	PRXOVR	DEF					NA	NA	NA	N
4007F	AREDS/ANITOX VIT/MIN RX'D	MAXFEE	DEF					NA			N
4008F	BETA-BLOCKER THERAPY RXD/TKN	PRXOVR	DEF					NA	NA	NA	N
4008F	BETA-BLOCKER THERAPY RXD/TKN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4009F	ACE/ARB INHIBITOR THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4009F	ACE/ARB INHIBITOR THERAPY RX	MAXFEE	DEF					NA			N
4010F	ACE/ARB THERAPY RXD/TAKEN	PRXOVR	DEF					NA	NA	NA	N
4010F	ACE/ARB THERAPY RXD/TAKEN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4011F	ORAL ANTIPLATELET THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4011F	ORAL ANTIPLATELET THERAPY RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4012F	WARFARIN THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4012F	WARFARIN THERAPY RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4013F	STATIN THERAPY/CURRENTLY TKN	PRXOVR	DEF					NA	NA	NA	N
4013F	STATIN THERAPY/CURRENTLY TKN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4014F	WRITTEN DISCHARGE INSTR PRVD	PRXOVR	DEF					NA	NA	NA	N
4014F	WRITTEN DISCHARGE INSTR PRVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4015F	PERSIST ASTHMA MEDICINE CTRL	PRXOVR	DEF					NA	NA	NA	N
4015F	PERSIST ASTHMA MEDICINE CTRL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4016F	ANTI-INFLM/ANLGSC AGENT RX	PRXOVR	DEF					NA	NA	NA	N
4016F	ANTI-INFLM/ANLGSC AGENT RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4017F	GI PROPHYLAXIS FOR NSAID RX	PRXOVR	DEF					NA	NA	NA	N
4017F	GI PROPHYLAXIS FOR NSAID RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4018F	THERAPY EXERCISE JOINT RX	PRXOVR	DEF					NA	NA	NA	N
4018F	THERAPY EXERCISE JOINT RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4019F	DOC RECPT COUNSL VIT D/CALC+	PRXOVR	DEF					NA	NA	NA	N
4019F	DOC RECPT COUNSL VIT D/CALC+	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4025F	INHALED BRONCHODILATOR RX	PRXOVR	DEF					NA	NA	NA	N
4025F	INHALED BRONCHODILATOR RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4030F	OXYGEN THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4030F	OXYGEN THERAPY RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4033F	PULMONARY REHAB REC	PRXOVR	DEF					NA	NA	NA	N
4033F	PULMONARY REHAB REC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4035F	INFLUENZA IMM REC	PRXOVR	DEF					NA	NA	NA	N
4035F	INFLUENZA IMM REC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4037F	INFLUENZA IMM ORDER/ADMIN	PRXOVR	DEF					NA	NA	NA	N
4037F	INFLUENZA IMM ORDER/ADMIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4040F	PNEUMOC VAC/ADMIN/RCVD	PRXOVR	DEF					NA	NA	NA	N
4040F	PNEUMOC VAC/ADMIN/RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4041F	DOC ORDER CEFAZOLIN/CEFUROX	PRXOVR	DEF					NA	NA	NA	N
4041F	DOC ORDER CEFAZOLIN/CEFUROX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4042F	DOC ANTIBIO NOT GIVEN	PRXOVR	DEF					NA	NA	NA	N
4042F	DOC ANTIBIO NOT GIVEN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4043F	DOC ORDER GIVEN STOP ANTIBIO	PRXOVR	DEF					NA	NA	NA	N
4043F	DOC ORDER GIVEN STOP ANTIBIO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4044F	DOC ORDER GIVEN VTE PROPHYLX	PRXOVR	DEF					NA	NA	NA	N
4044F	DOC ORDER GIVEN VTE PROPHYLX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4045F	EMPIRIC ANTIBIOTIC RX	PRXOVR	DEF					NA	NA	NA	N
4045F	EMPIRIC ANTIBIOTIC RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4046F	DOC ANTIBIO GIVEN B/4 SURG	PRXOVR	DEF					NA	NA	NA	N
4046F	DOC ANTIBIO GIVEN B/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4047F	DOC ANTIBIO GIVEN B/4 SURG	PRXOVR	DEF					NA	NA	NA	N
4047F	DOC ANTIBIO GIVEN B/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4048F	DOC ANTIBIO GIVEN B/4 SURG	PRXOVR	DEF					NA	NA	NA	N
4048F	DOC ANTIBIO GIVEN B/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4049F	DOC ORDER GIVEN STOP ANTIBIO	PRXOVR	DEF					NA	NA	NA	N
4049F	DOC ORDER GIVEN STOP ANTIBIO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4050F	HT CARE PLAN DOC	PRXOVR	DEF					NA	NA	NA	N
4050F	HT CARE PLAN DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4051F	REFERRED FOR AN AV FISTULA	PRXOVR	DEF					NA	NA	NA	N
4051F	REFERRED FOR AN AV FISTULA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4052F	HEMODIALYSIS VIA AV FISTULA	PRXOVR	DEF					NA	NA	NA	N
4052F	HEMODIALYSIS VIA AV FISTULA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4053F	HEMODIALYSIS VIA AV GRAFT	PRXOVR	DEF					NA	NA	NA	N
4053F	HEMODIALYSIS VIA AV GRAFT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4054F	HEMODIALYSIS VIA CATHETER	PRXOVR	DEF					NA	NA	NA	N
4054F	HEMODIALYSIS VIA CATHETER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4055F	PT RCVNG PERITON DIALYSIS	PRXOVR	DEF					NA	NA	NA	N
4055F	PT RCVNG PERITON DIALYSIS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4056F	APPROP ORAL REHYD RECOMMD	PRXOVR	DEF					NA	NA	NA	N
4056F	APPROP ORAL REHYD RECOMMD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4058F	PED GASTRO ED GIVEN CAREGVR	PRXOVR	DEF					NA	NA	NA	N
4058F	PED GASTRO ED GIVEN CAREGVR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4060F	PSYCH SVCS PROVIDED	PRXOVR	DEF					NA	NA	NA	N
4060F	PSYCH SVCS PROVIDED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4062F	PT REFERRAL PSYCH DOCD	PRXOVR	DEF					NA	NA	NA	N
4062F	PT REFERRAL PSYCH DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4063F	ANTIDEPRES RXTHXPY NOT RXD	PRXOVR	DEF					NA	NA	NA	N
4063F	ANTIDEPRES RXTHXPY NOT RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4064F	ANTIDEPRESSANT RX	PRXOVR	DEF					NA	NA	NA	N
4064F	ANTIDEPRESSANT RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4065F	ANTIPSYCHOTIC RX	PRXOVR	DEF					NA	NA	NA	N
4065F	ANTIPSYCHOTIC RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4066F	ECT PROVIDED	PRXOVR	DEF					NA	NA	NA	N
4066F	ECT PROVIDED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4067F	PT REFERRAL FOR ECT DOCD	PRXOVR	DEF					NA	NA	NA	N
4067F	PT REFERRAL FOR ECT DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4069F	VTE PROPHYLAXIS RCVD	PRXOVR	DEF					NA	NA	NA	N
4069F	VTE PROPHYLAXIS RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4070F	DVT PROPHYLX RECVD DAY 2	PRXOVR	DEF					NA	NA	NA	N
4070F	DVT PROPHYLX RECVD DAY 2	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4073F	ORAL ANTIPLAT THX RX DISCHRG	PRXOVR	DEF					NA	NA	NA	N
4073F	ORAL ANTIPLAT THX RX DISCHRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4075F	ANTICOAG THX RX AT DISCHRG	PRXOVR	DEF					NA	NA	NA	N
4075F	ANTICOAG THX RX AT DISCHRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4077F	DOC T-PA ADMIN CONSIDERED	PRXOVR	DEF					NA	NA	NA	N
4077F	DOC T-PA ADMIN CONSIDERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4079F	DOC REHAB SVCS CONSIDERED	PRXOVR	DEF					NA	NA	NA	N
4079F	DOC REHAB SVCS CONSIDERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4084F	ASPIRIN RECVD W/IN 24 HRS	PRXOVR	DEF					NA	NA	NA	N
4084F	ASPIRIN RECVD W/IN 24 HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4086F	ASPIRIN/CLOPIDOGREL RXD	PRXOVR	DEF					NA	NA	NA	N
4086F	ASPIRIN/CLOPIDOGREL RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4090F	PT RCVNG EPO THXPY	PRXOVR	DEF					NA	NA	NA	N
4090F	PT RCVNG EPO THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4095F	PT NOT RCVNG EPO THXPY	PRXOVR	DEF					NA	NA	NA	N
4095F	PT NOT RCVNG EPO THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4100F	BIPHOS THXPY VEIN ORD/RECVD	PRXOVR	DEF					NA	NA	NA	N
4100F	BIPHOS THXPY VEIN ORD/RECVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4110F	INT MAM ART USED FOR CABG	PRXOVR	DEF					NA	NA	NA	N
4110F	INT MAM ART USED FOR CABG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4115F	BETA BLCKR ADMIN W/IN 24 HRS	PRXOVR	DEF					NA	NA	NA	N
4115F	BETA BLCKR ADMIN W/IN 24 HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4120F	ANTIBIOT RXD/GIVEN	PRXOVR	DEF					NA	NA	NA	N
4120F	ANTIBIOT RXD/GIVEN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4124F	ANTIBIOT NOT RXD/GIVEN	PRXOVR	DEF					NA	NA	NA	N
4124F	ANTIBIOT NOT RXD/GIVEN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4130F	TOPICAL PREP RX AOE	PRXOVR	DEF					NA	NA	NA	N
4130F	TOPICAL PREP RX AOE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4131F	SYST ANTIMICROBIAL THX RX	PRXOVR	DEF					NA	NA	NA	N
4131F	SYST ANTIMICROBIAL THX RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4132F	NO SYST ANTIMICROBIAL THX RX	PRXOVR	DEF					NA	NA	NA	N
4132F	NO SYST ANTIMICROBIAL THX RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4133F	ANTIHIST/DECONG RX/RECOM	PRXOVR	DEF					NA	NA	NA	N
4133F	ANTIHIST/DECONG RX/RECOM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4134F	NO ANTIHIST/DECONG RX/RECOM	PRXOVR	DEF					NA	NA	NA	N
4134F	NO ANTIHIST/DECONG RX/RECOM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4135F	SYSTEMIC CORTICOSTEROIDS RX	PRXOVR	DEF					NA	NA	NA	N
4135F	SYSTEMIC CORTICOSTEROIDS RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4136F	SYST CORTICOSTEROIDS NOT RX	PRXOVR	DEF					NA	NA	NA	N
4136F	SYST CORTICOSTEROIDS NOT RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4140F	INHALED CORTICOSTEROIDS RXD	PRXOVR	DEF					NA	NA	NA	N
4140F	INHALED CORTICOSTEROIDS RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4142F	CORTICOSTER SPARNG THRPY RXD	PRXOVR	DEF					NA	NA	NA	N
4142F	CORTICOSTER SPARNG THRPY RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4144F	ALT LONG-TERM CNTRL MED RXD	PRXOVR	DEF					NA	NA	NA	N
4144F	ALT LONG-TERM CNTRL MED RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4145F	2+ ANTI-HYPRTNSV AGENTS TKN	PRXOVR	DEF					NA	NA	NA	N
4145F	2+ ANTI-HYPRTNSV AGENTS TKN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4148F	HEP A VAC INJXN ADMIN/RECVD	PRXOVR	DEF					NA	NA	NA	N
4148F	HEP A VAC INJXN ADMIN/RECVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4149F	HEP B VAC INJXN ADMIN/RECVD	PRXOVR	DEF					NA	NA	NA	N
4149F	HEP B VAC INJXN ADMIN/RECVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4150F	PT RECVNG ANTIVIR TXMNT HEPC	PRXOVR	DEF					NA	NA	NA	N
4150F	PT RECVNG ANTIVIR TXMNT HEPC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4151F	PT NOT RECVNG ANTIV HEP C	PRXOVR	DEF					NA	NA	NA	N
4151F	PT NOT RECVNG ANTIV HEP C	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4152F	DOC'D PEGINTF/RIB THXY CONSD	PRXOVR	DEF					NA	NA	NA	N
4152F	DOC'D PEGINTF/RIB THXY CONSD	MAXFEE	DEF					NA			N
4153F	COMBO PEGINTF/RIB RX	PRXOVR	DEF					NA	NA	NA	N
4153F	COMBO PEGINTF/RIB RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4154F	HEP A VAC SERIES RECOMMENDED	PRXOVR	DEF					NA	NA	NA	N
4154F	HEP A VAC SERIES RECOMMENDED	MAXFEE	DEF					NA			N
4155F	HEP A VAC SERIES PREV RECVD	PRXOVR	DEF					NA	NA	NA	N
4155F	HEP A VAC SERIES PREV RECVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4156F	HEP B VAC SERIES RECOMMENDED	PRXOVR	DEF					NA	NA	NA	N
4156F	HEP B VAC SERIES RECOMMENDED	MAXFEE	DEF					NA			N
4157F	HEP B VAC SERIES PREV RECVD	PRXOVR	DEF					NA	NA	NA	N
4157F	HEP B VAC SERIES PREV RECVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4158F	PT EDU RE ALCOH DRNKNG DONE	PRXOVR	DEF					NA	NA	NA	N
4158F	PT EDU RE ALCOH DRNKNG DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4159F	CONTRCP TALK B/4 ANTIV TXMNT	PRXOVR	DEF					NA	NA	NA	N
4159F	CONTRCP TALK B/4 ANTIV TXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4163F	PT COUNS 4 TXMNT OPT PROST	PRXOVR	DEF					NA	NA	NA	N
4163F	PT COUNS 4 TXMNT OPT PROST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4164F	ADJV HRMNL THXPY RXD	PRXOVR	DEF					NA	NA	NA	N
4164F	ADJV HRMNL THXPY RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4165F	3D-CRT/IMRT RECEIVED	PRXOVR	DEF					NA	NA	NA	N
4165F	3D-CRT/IMRT RECEIVED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4167F	HD BED TILTED 1ST DAY VENT	PRXOVR	DEF					NA	NA	NA	N
4167F	HD BED TILTED 1ST DAY VENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4168F	PT CARE ICU&VENT W/IN 24HRS	PRXOVR	DEF					NA	NA	NA	N
4168F	PT CARE ICU&VENT W/IN 24HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4169F	NO PT CARE ICU/VENT IN 24HRS	PRXOVR	DEF					NA	NA	NA	N
4169F	NO PT CARE ICU/VENT IN 24HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4171F	PT RCVNG ESA THXPY	PRXOVR	DEF					NA	NA	NA	N
4171F	PT RCVNG ESA THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4172F	PT NOT RCVNG ESA THXPY	PRXOVR	DEF					NA	NA	NA	N
4172F	PT NOT RCVNG ESA THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4174F	COUNS POTENT GLAUC IMPCT	PRXOVR	DEF					NA	NA	NA	N
4174F	COUNS POTENT GLAUC IMPCT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4175F	VIS 20/40/> W/IN 90 DAYS	PRXOVR	DEF					NA	NA	NA	N
4175F	VIS 20/40/> W/IN 90 DAYS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4176F	TALK RE UV LIGHT PT/CRGVR	PRXOVR	DEF					NA	NA	NA	N
4176F	TALK RE UV LIGHT PT/CRGVR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4177F	TALK PT/CRGVR RE AREDS PREV	PRXOVR	DEF					NA	NA	NA	N
4177F	TALK PT/CRGVR RE AREDS PREV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4178F	ANTID GLBLN RCVD W/IN 26WKS	PRXOVR	DEF					NA	NA	NA	N
4178F	ANTID GLBLN RCVD W/IN 26WKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4179F	TAMOXIFEN/AI PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
4179F	TAMOXIFEN/AI PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4180F	ADJV THXPYRXD/RCVD COLON CA	PRXOVR	DEF					NA	NA	NA	N
4180F	ADJV THXPYRXD/RCVD COLON CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4181F	CONFORMAL RADN THXPY RCVD	PRXOVR	DEF					NA	NA	NA	N
4181F	CONFORMAL RADN THXPY RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4182F	NO CONFORMAL RADN THXPY	PRXOVR	DEF					NA	NA	NA	N
4182F	NO CONFORMAL RADN THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4185F	CONTINUOUS PPI OR H2RA RCVD	PRXOVR	DEF					NA	NA	NA	N
4185F	CONTINUOUS PPI OR H2RA RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4186F	NO CONT PPI OR H2RA RCVD	PRXOVR	DEF					NA	NA	NA	N
4186F	NO CONT PPI OR H2RA RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4187F	ANTI RHEUM DRUGTHXPYRXD/GVN	PRXOVR	DEF					NA	NA	NA	N
4187F	ANTI RHEUM DRUGTHXPYRXD/GVN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4188F	APPROP ACE/ARB TSTNG DONE	PRXOVR	DEF					NA	NA	NA	N
4188F	APPROP ACE/ARB TSTNG DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4189F	APPROP DIGOXIN TSTNG DONE	PRXOVR	DEF					NA	NA	NA	N
4189F	APPROP DIGOXIN TSTNG DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4190F	APPROP DIURETIC TSTNG DONE	PRXOVR	DEF					NA	NA	NA	N
4190F	APPROP DIURETIC TSTNG DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4191F	APPROP ANTICONVULS TSTNG	PRXOVR	DEF					NA	NA	NA	N
4191F	APPROP ANTICONVULS TSTNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4192F	PT NOT RCVNG GLUCOCO THXPY	PRXOVR	DEF					NA	NA	NA	N
4192F	PT NOT RCVNG GLUCOCO THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4193F	PT RCV <10MG DAILY PREDNISO	PRXOVR	DEF					NA	NA	NA	N
4193F	PT RCV <10MG DAILY PREDNISO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4194F	PT RCV >=10MG DAILY PREDNISO	PRXOVR	DEF					NA	NA	NA	N
4194F	PT RCV >=10MG DAILY PREDNISO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4195F	PT RCVNG ANTI-RHEUM THXPY RA	PRXOVR	DEF					NA	NA	NA	N
4195F	PT RCVNG ANTI-RHEUM THXPY RA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4196F	PTNOT RCVNG ANTI-RHM THXPYRA	PRXOVR	DEF					NA	NA	NA	N
4196F	PTNOT RCVNG ANTI-RHM THXPYRA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4200F	EXTERNAL BEAM TO PROST ONLY	PRXOVR	DEF					NA	NA	NA	N
4200F	EXTERNAL BEAM TO PROST ONLY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4201F	EXTRNL BEAM OTHER THAN PROST	PRXOVR	DEF					NA	NA	NA	N
4201F	EXTRNL BEAM OTHER THAN PROST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4210F	ACE/ARB THXPY FOR MOS/>	PRXOVR	DEF					NA	NA	NA	N
4210F	ACE/ARB THXPY FOR MOS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4220F	DIGOXIN THXPY FOR 6 MOS/>	PRXOVR	DEF					NA	NA	NA	N
4220F	DIGOXIN THXPY FOR 6 MOS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4221F	DIURETIC THXPY FOR 6 MOS/>	PRXOVR	DEF					NA	NA	NA	N
4221F	DIURETIC THXPY FOR 6 MOS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4230F	ANTICONV THXPY FOR 6 MOS/>	PRXOVR	DEF					NA	NA	NA	N
4230F	ANTICONV THXPY FOR 6 MOS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4240F	INSTR XRCZ BACK PAIN 12 WKS	PRXOVR	DEF					NA	NA	NA	N
4240F	INSTR XRCZ BACK PAIN 12 WKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4242F	SPRVSD XRCZ BACK PN >12 WKS	PRXOVR	DEF					NA	NA	NA	N
4242F	SPRVSD XRCZ BACK PN >12 WKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4245F	PT INSTR NRML ACTIVITIES	PRXOVR	DEF					NA	NA	NA	N
4245F	PT INSTR NRML ACTIVITIES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4248F	PT INSTR NO BD REST 4 DAYS/>	PRXOVR	DEF					NA	NA	NA	N
4248F	PT INSTR NO BD REST 4 DAYS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4250F	WRMNG 4 SURG NORMOTHERMIA	PRXOVR	DEF					NA	NA	NA	N
4250F	WRMNG 4 SURG NORMOTHERMIA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4255F	ANESTH 60 MIN/> AS DOCD	PRXOVR	DEF					NA	NA	NA	N
4255F	ANESTH 60 MIN/> AS DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4256F	ANESTHE <60 MIN AS DOCD	PRXOVR	DEF					NA	NA	NA	N
4256F	ANESTHE <60 MIN AS DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4260F	WOUND SRFC CULTURETECH USED	PRXOVR	DEF					NA	NA	NA	N
4260F	WOUND SRFC CULTURETECH USED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4261F	TECH OTHER THAN SURFC CULTR	PRXOVR	DEF					NA	NA	NA	N
4261F	TECH OTHER THAN SURFC CULTR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4265F	WET-DRY DRESSINGS RX RECMD	PRXOVR	DEF					NA	NA	NA	N
4265F	WET-DRY DRESSINGS RX RECMD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4266F	NO WET-DRY DRSSINGS RX RECMD	PRXOVR	DEF					NA	NA	NA	N
4266F	NO WET-DRY DRSSINGS RX RECMD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4267F	COMPRSSION THXPY PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
4267F	COMPRSSION THXPY PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4268F	PT ED RE COMP THXPY RCVD	PRXOVR	DEF					NA	NA	NA	N
4268F	PT ED RE COMP THXPY RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4269F	APPROPOS MTHD OFFLOADING RXD	PRXOVR	DEF					NA	NA	NA	N
4269F	APPROPOS MTHD OFFLOADING RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4270F	PT RCVNG ANTI R-VIRAL THXPY	PRXOVR	DEF					NA	NA	NA	N
4270F	PT RCVNG ANTI R-VIRAL THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4271F	PT RCVNG ANTI R-VIRAL THXPY	PRXOVR	DEF					NA	NA	NA	N
4271F	PT RCVNG ANTI R-VIRAL THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4274F	FLU IMMUNO ADMIND RCVD	PRXOVR	DEF					NA	NA	NA	N
4274F	FLU IMMUNO ADMIND RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4275F	HEP B VAC INJ ADMIN/RCVD	PRXOVR	DEF					NA	NA	NA	N
4275F	HEP B VAC INJ ADMIN/RCVD	MAXFEE	DEF					NA			N
4276F	POTENT ANTIVIR THXPY RXD	PRXOVR	DEF					NA	NA	NA	N
4276F	POTENT ANTIVIR THXPY RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4279F	PCP PROPHYLAXIS RXD	PRXOVR	DEF					NA	NA	NA	N
4279F	PCP PROPHYLAXIS RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4280F	PCP PROPHYLAX RXD 3MON LOW %	PRXOVR	DEF					NA	NA	NA	N
4280F	PCP PROPHYLAX RXD 3MON LOW %	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4290F	PT SCRNED FOR INJ DRUG USE	PRXOVR	DEF					NA	NA	NA	N
4290F	PT SCRNED FOR INJ DRUG USE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4293F	PT SCRND HGH-RISK SEX BEHAV	PRXOVR	DEF					NA	NA	NA	N
4293F	PT SCRND HGH-RISK SEX BEHAV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4300F	PT RCVNG WARF THXPY	PRXOVR	DEF					NA	NA	NA	N
4300F	PT RCVNG WARF THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4301F	PT NOT RCVNG WARF THXPY	PRXOVR	DEF					NA	NA	NA	N
4301F	PT NOT RCVNG WARF THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4305F	PT ED RE FT CARE INSPCT RCVD	PRXOVR	DEF					NA	NA	NA	N
4305F	PT ED RE FT CARE INSPCT RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4306F	PT TLK PSYCH & RX OPD ADDIC	PRXOVR	DEF					NA	NA	NA	N
4306F	PT TLK PSYCH & RX OPD ADDIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4320F	PT TALK PSYCHSOC&RX OH DPND	PRXOVR	DEF					NA	NA	NA	N
4320F	PT TALK PSYCHSOC&RX OH DPND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4322F	CRGVR PROV W/ ED ADDL RSRCS	PRXOVR	DEF					NA	NA	NA	N
4322F	CRGVR PROV W/ ED ADDL RSRCS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4324F	PT QUERIED PRKNS COMPLIC	PRXOVR	DEF					NA	NA	NA	N
4324F	PT QUERIED PRKNS COMPLIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4325F	MED TXMNT OPTIONS RVWD W/PT	PRXOVR	DEF					NA	NA	NA	N
4325F	MED TXMNT OPTIONS RVWD W/PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4326F	PT ASKED RE SYMP AUTO DYSFXN	PRXOVR	DEF					NA	NA	NA	N
4326F	PT ASKED RE SYMP AUTO DYSFXN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4328F	PT ASKED RE SLEEP DISTURB	PRXOVR	DEF					NA	NA	NA	N
4328F	PT ASKED RE SLEEP DISTURB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4330F	CNSLNG EPI SPEC SFTY ISSUES	PRXOVR	DEF					NA	NA	NA	N
4330F	CNSLNG EPI SPEC SFTY ISSUES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4340F	CNSLNG CHLDBRNG WOMEN EPI	PRXOVR	DEF					NA	NA	NA	N
4340F	CNSLNG CHLDBRNG WOMEN EPI	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4350F	CNSLNG PROVIDED SYMP MNGMNT	PRXOVR	DEF					NA	NA	NA	N
4350F	CNSLNG PROVIDED SYMP MNGMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4400F	REHAB THXPY OPTIONS W/PT	PRXOVR	DEF					NA	NA	NA	N
4400F	REHAB THXPY OPTIONS W/PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4450F	SELF-CARE ED PROVIDED TO PT	PRXOVR	DEF					NA	NA	NA	N
4450F	SELF-CARE ED PROVIDED TO PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4470F	ICD COUNSELING PROVIDED	PRXOVR	DEF					NA	NA	NA	N
4470F	ICD COUNSELING PROVIDED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4480F	PT RCVNG ACE/ARB B-BLOCKERTX	PRXOVR	DEF					NA	NA	NA	N
4480F	PT RCVNG ACE/ARB B-BLOCKERTX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4481F	PT RCVNG ACE/ARB BLKER <3MOS	PRXOVR	DEF					NA	NA	NA	N
4481F	PT RCVNG ACE/ARB BLKER <3MOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4500F	REF TO OUTPT CARD REHAB PROG	PRXOVR	DEF					NA	NA	NA	N
4500F	REF TO OUTPT CARD REHAB PROG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4510F	PREV CARDREHAB QUALCARDEVENT	PRXOVR	DEF					NA	NA	NA	N
4510F	PREV CARDREHAB QUALCARDEVENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4525F	NEUROPSYCHIA INTERVEN ORDER	PRXOVR	DEF					NA	NA	NA	N
4525F	NEUROPSYCHIA INTERVEN ORDER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4526F	NEUROPSYCHIA INTERVEN RCVD	PRXOVR	DEF					NA	NA	NA	N
4526F	NEUROPSYCHIA INTERVEN RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4540F	DISEASE MODIF PHARMACOTHXPY	PRXOVR	DEF					NA	NA	NA	N
4540F	DISEASE MODIF PHARMACOTHXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4541F	PT OFFERED TX FOR PSEUDOBULB	PRXOVR	DEF					NA	NA	NA	N
4541F	PT OFFERED TX FOR PSEUDOBULB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4550F	NONINVAS RESP SUPPORT TALK	PRXOVR	DEF					NA	NA	NA	N
4550F	NONINVAS RESP SUPPORT TALK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4551F	NUTRITIONAL SUPPORT OFFERED	PRXOVR	DEF					NA	NA	NA	N
4551F	NUTRITIONAL SUPPORT OFFERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4552F	PT REF FOR SPEECH LANG PATH	PRXOVR	DEF					NA	NA	NA	N
4552F	PT REF FOR SPEECH LANG PATH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4553F	PT ASST RE END LIFE ISSUES	PRXOVR	DEF					NA	NA	NA	N
4553F	PT ASST RE END LIFE ISSUES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4554F	PT RECVD INHAL ANESTHETIC	PRXOVR	DEF					NA	NA	NA	N
4554F	PT RECVD INHAL ANESTHETIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4555F	PT RECVD NO INHAL ANESTHIC	PRXOVR	DEF					NA	NA	NA	N
4555F	PT RECVD NO INHAL ANESTHIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4556F	PT W/3+ POST-OP NAUSEA&VOM	PRXOVR	DEF					NA	NA	NA	N
4556F	PT W/3+ POST-OP NAUSEA&VOM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4557F	PT W/O 3+ POST-OPNAUSEA&VOM	PRXOVR	DEF					NA	NA	NA	N
4557F	PT W/O 3+ POST-OPNAUSEA&VOM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4558F	PT RECVD 2 RX ANTI-EMET AGT	PRXOVR	DEF					NA	NA	NA	N
4558F	PT RECVD 2 RX ANTI-EMET AGT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4559F	1 BODYTEMP >=35.5CW/IN 30MIN	PRXOVR	DEF					NA	NA	NA	N
4559F	1 BODYTEMP >=35.5CW/IN 30MIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4560F	ANESTH W/O GEN/NEURAX ANESTH	PRXOVR	DEF					NA	NA	NA	N
4560F	ANESTH W/O GEN/NEURAX ANESTH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4561F	PT W/ CORONARY ARTERY STENT	PRXOVR	DEF					NA	NA	NA	N
4561F	PT W/ CORONARY ARTERY STENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4562F	PT W/O CORONARY ARTERY STENT	PRXOVR	DEF					NA	NA	NA	N
4562F	PT W/O CORONARY ARTERY STENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4563F	PT RECVD ASPIRIN W/IN 24 HRS	PRXOVR	DEF					NA	NA	NA	N
4563F	PT RECVD ASPIRIN W/IN 24 HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5005F	PT COUNSLD ON EXAM FOR MOLES	PRXOVR	DEF					NA	NA	NA	N
5005F	PT COUNSLD ON EXAM FOR MOLES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5010F	MACUL RESULT PHY/QHP MNG DM	PRXOVR	DEF					NA	NA	NA	N
5010F	MACUL RESULT PHY/QHP MNG DM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5015F	DOC FX & TEST/TXMNT FOR OP	PRXOVR	DEF					NA	NA	NA	N
5015F	DOC FX & TEST/TXMNT FOR OP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5020F	TXMNTS 2 PHYS/QHP BY 1 MON	PRXOVR	DEF					NA	NA	NA	N
5020F	TXMNTS 2 PHYS/QHP BY 1 MON	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5050F	PLAN 2 MAIN DR BY 1 MONTH	PRXOVR	DEF					NA	NA	NA	N
5050F	PLAN 2 MAIN DR BY 1 MONTH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5060F	FNDNGS MAMMO 2PT W/IN 3 DAYS	PRXOVR	DEF					NA	NA	NA	N
5060F	FNDNGS MAMMO 2PT W/IN 3 DAYS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5062F	MAMMO RESULT COM TO PT 5 DAY	PRXOVR	DEF					NA	NA	NA	N
5062F	MAMMO RESULT COM TO PT 5 DAY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5100F	RSK FX REF W/N 24 HRS XRAY	PRXOVR	DEF					NA	NA	NA	N
5100F	RSK FX REF W/N 24 HRS XRAY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5200F	EVAL APPROS SURG THXPY EPI	PRXOVR	DEF					NA	NA	NA	N
5200F	EVAL APPROS SURG THXPY EPI	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5250F	ASTHMA DISCHARGE PLAN PRESNT	PRXOVR	DEF					NA	NA	NA	N
5250F	ASTHMA DISCHARGE PLAN PRESNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6005F	CARE LEVEL RATIONALE DOC	PRXOVR	DEF					NA	NA	NA	N
6005F	CARE LEVEL RATIONALE DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6010F	DYSPHAG TEST DONE B/4 EATING	PRXOVR	DEF					NA	NA	NA	N
6010F	DYSPHAG TEST DONE B/4 EATING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6015F	DYSPHAG TEST DONE B/4 EATING	PRXOVR	DEF					NA	NA	NA	N
6015F	DYSPHAG TEST DONE B/4 EATING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6020F	NPO (NOTHING-MOUTH) ORDERED	PRXOVR	DEF					NA	NA	NA	N
6020F	NPO (NOTHING-MOUTH) ORDERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6030F	MAX STERILE BARRIERS FLWD	PRXOVR	DEF					NA	NA	NA	N
6030F	MAX STERILE BARRIERS FLWD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6040F	APPRO RAD DS DVCS TECHS DOCD	PRXOVR	DEF					NA	NA	NA	N
6040F	APPRO RAD DS DVCS TECHS DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6045F	RADXPS IN END RPRT4FLURO PXD	PRXOVR	DEF					NA	NA	NA	N
6045F	RADXPS IN END RPRT4FLURO PXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6070F	PT ASKED/CNSLD AED EFFECTS	PRXOVR	DEF					NA	NA	NA	N
6070F	PT ASKED/CNSLD AED EFFECTS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6080F	PT/CAREGIVER QUERIED FALLS	PRXOVR	DEF					NA	NA	NA	N
6080F	PT/CAREGIVER QUERIED FALLS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6090F	PT/CAREGIVER COUNSEL SAFETY	PRXOVR	DEF					NA	NA	NA	N
6090F	PT/CAREGIVER COUNSEL SAFETY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6100F	VERIFY PT SITE PXD DOCD	PRXOVR	DEF					NA	NA	NA	N
6100F	VERIFY PT SITE PXD DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6101F	SAFETY COUNSELING DEMENTIA	PRXOVR	DEF					NA	NA	NA	N
6101F	SAFETY COUNSELING DEMENTIA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6102F	SAFETY COUNSELING DEM ORDER	PRXOVR	DEF					NA	NA	NA	N
6102F	SAFETY COUNSELING DEM ORDER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6110F	COUNSEL PROV DRIVING RISKS	PRXOVR	DEF					NA	NA	NA	N
6110F	COUNSEL PROV DRIVING RISKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6150F	PT NOTRCVNG1ST ANTITNF TXMNT	PRXOVR	DEF					NA	NA	NA	N
6150F	PT NOTRCVNG1ST ANTITNF TXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
7010F	PT INFO INTO RECALL SYSTEM	PRXOVR	DEF					NA	NA	NA	N
7010F	PT INFO INTO RECALL SYSTEM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
7020F	MAMMO ASSESS CAT IN DBASE	PRXOVR	DEF					NA	NA	NA	N
7020F	MAMMO ASSESS CAT IN DBASE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
7025F	PT INFOSYS ALARM 4 NXT MAMMO	PRXOVR	DEF					NA	NA	NA	N
7025F	PT INFOSYS ALARM 4 NXT MAMMO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
81025	URINE PREGNANCY TEST	PRXOVR	DEF					NA	NA	NA	N
81025	URINE PREGNANCY TEST	MAXFEE	DEF					6.46	4/1/2019	12/31/2299	N
82075	ASSAY OF BREATH ETHANOL	PRXOVR	AOD					NA	NA	NA	N
82075	ASSAY OF BREATH ETHANOL	MAXFEE	DEF					22.50	4/1/2019	12/31/2299	N
86580	TB INTRADERMAL TEST	PRXOVR	AOD					NA	NA	NA	N
86580	TB INTRADERMAL TEST	MAXFEE	DEF					5.72	4/1/2019	12/31/2299	N
9001F	AORTIC ANEURYSM<5CM DIAM CT	PRXOVR	DEF					NA	NA	NA	N
9001F	AORTIC ANEURYSM<5CM DIAM CT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9002F	AORTIC ANEURYSM 5-5.4CM DIAM	PRXOVR	DEF					NA	NA	NA	N
9002F	AORTIC ANEURYSM 5-5.4CM DIAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9003F	AORTIC ANRYSM5.5-5.9CM DIAM	PRXOVR	DEF					NA	NA	NA	N
9003F	AORTIC ANRYSM5.5-5.9CM DIAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9004F	AORTIC ANRYSM 6/> CM DIAM	PRXOVR	DEF					NA	NA	NA	N
9004F	AORTIC ANRYSM 6/> CM DIAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9005F	ASYMPT CAROT/VRTBRBAS STEN	PRXOVR	DEF					NA	NA	NA	N
9005F	ASYMPT CAROT/VRTBRBAS STEN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9006F	SYMPT STEN-TIA/STRK<120DAYS	PRXOVR	DEF					NA	NA	NA	N
9006F	SYMPT STEN-TIA/STRK<120DAYS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9007F	OTHER CAROT STEN 120 DAYS/>	PRXOVR	DEF					NA	NA	NA	N
9007F	OTHER CAROT STEN 120 DAYS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
90371	HEP B IG IM	PRXOVR	DEF					NA	NA	NA	N
90371	HEP B IG IM	MAXFEE	DEF					136.74	7/1/2023	12/31/2299	N
90377	RABIES IG HT&SOL HUMAN IM/SC	PRXOVR	DEF					NA	NA	NA	N
90377	RABIES IG HT&SOL HUMAN IM/SC	MAXFEE	DEF					234.09	7/1/2023	12/31/2299	N
90460	IM ADMIN 1ST/ONLY COMPONENT	PRXOVR	DEF					NA	NA	NA	N
90460	IM ADMIN 1ST/ONLY COMPONENT	MAXFEE	DEF					15	1/1/2016	12/31/2299	N
90471	IMMUNIZATION ADMIN	MAXFLT	DEF					NA	NA	NA	N
90471	IMMUNIZATION ADMIN	PRXOVR	DEF					NA	NA	NA	N
90472	IMMUNIZATION ADMIN EACH ADD	PRXOVR	DEF					NA	NA	NA	N
90472	IMMUNIZATION ADMIN EACH ADD	MAXFEE	DEF					9.85	1/1/2022	12/31/2299	N
90473	IMMUNE ADMIN ORAL/NASAL	MAXFLT	DEF					NA	NA	NA	N
90473	IMMUNE ADMIN ORAL/NASAL	PRXOVR	DEF					NA	NA	NA	N
90474	IMMUNE ADMIN ORAL/NASAL ADDL	PRXOVR	DEF					NA	NA	NA	N
90474	IMMUNE ADMIN ORAL/NASAL ADDL	MAXFEE	DEF					9.85	1/1/2022	12/31/2299	N
90611	SMALLPOX&MONKEYPOX VAC 0.5ML	PRXOVR	DEF					NA	NA	NA	N
90611	SMALLPOX&MONKEYPOX VAC 0.5ML	MAXFEE	DEF					0.01	7/26/2022	12/31/2299	N
90619	MENACWY-TT VACCINE IM	PRXOVR	DEF					NA	NA	NA	N
90619	MENACWY-TT VACCINE IM	MAXFEE	VFC					0	10/1/2021	12/31/2299	N
90619	MENACWY-TT VACCINE IM	MAXFEE	DEF					150.53	10/1/2021	12/31/2299	N
90622	VACCINIA VRS VAC 0.3 ML PERQ	PRXOVR	DEF					NA	NA	NA	N
90622	VACCINIA VRS VAC 0.3 ML PERQ	MAXFEE	DEF					0.01	7/26/2022	12/31/2299	N
90632	HEPA VACCINE ADULT IM	PRXOVR	DEF					NA	NA	NA	N
90632	HEPA VACCINE ADULT IM	MAXFEE	DEF					71.85	7/1/2023	12/31/2299	N
90633	HEPA VACC PED/ADOL 2 DOSE IM	PRXOVR	DEF					NA	NA	NA	N
90633	HEPA VACC PED/ADOL 2 DOSE IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90633	HEPA VACC PED/ADOL 2 DOSE IM	MAXFEE	DEF					74.60	10/1/2021	12/31/2299	N
90634	HEPA VACC PED/ADOL 3 DOSE	PRXOVR	DEF					NA	NA	NA	N
90634	HEPA VACC PED/ADOL 3 DOSE	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90634	HEPA VACC PED/ADOL 3 DOSE	MAXFEE	DEF					61.64	9/1/2013	12/31/2299	N
90644	HIB-MENCY VACC 6WK-18M0 IM	PRXOVR	DEF					NA	NA	NA	N
90644	HIB-MENCY VACC 6WK-18M0 IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90649	4VHPV VACCINE 3 DOSE IM	PRXOVR	DEF					NA	NA	NA	N
90649	4VHPV VACCINE 3 DOSE IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90649	4VHPV VACCINE 3 DOSE IM	MAXFEE	DEF					144.43	9/1/2013	12/31/2299	N
90650	2VHPV VACCINE 3 DOSE IM	PRXOVR	DEF					NA	NA	NA	N
90650	2VHPV VACCINE 3 DOSE IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90650	2VHPV VACCINE 3 DOSE IM	MAXFEE	DEF					136.96	9/1/2013	12/31/2299	N
90654	FLU VACC IIV3 NO PRESERV ID	PRXOVR	DEF					NA	NA	NA	N
90654	FLU VACC IIV3 NO PRESERV ID	MAXFEE	DEF					18.92	11/1/2013	12/31/2299	N
90658	IIV3 VACCINE SPLT 0.5 ML IM	PRXOVR	DEF					NA	NA	NA	N
90658	IIV3 VACCINE SPLT 0.5 ML IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90658	IIV3 VACCINE SPLT 0.5 ML IM	MAXFEE	DEF					10.39	9/1/2013	12/31/2299	N
90660	LAIV3 VACCINE INTRANASAL	PRXOVR	DEF					NA	NA	NA	N
90660	LAIV3 VACCINE INTRANASAL	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90660	LAIV3 VACCINE INTRANASAL	MAXFEE	DEF					23.46	9/1/2013	12/31/2299	N
90670	PCV13 VACCINE IM	PRXOVR	DEF					NA	NA	NA	N
90670	PCV13 VACCINE IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90670	PCV13 VACCINE IM	MAXFEE	DEF					257.99	4/1/2022	12/31/2299	N
90671	PCV15 VACCINE IM	PRXOVR	DEF					NA	NA	NA	N
90671	PCV15 VACCINE IM	MAXFEE	DEF					246.20	1/1/2022	12/31/2299	N
90677	PCV20 VACCINE IM	PRXOVR	DEF					NA	NA	NA	N
90677	PCV20 VACCINE IM	MAXFEE	DEF					288.66	4/1/2023	12/31/2299	N
90680	RV5 VACC 3 DOSE LIVE ORAL	PRXOVR	DEF					NA	NA	NA	N
90680	RV5 VACC 3 DOSE LIVE ORAL	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90681	RV1 VACC 2 DOSE LIVE ORAL	PRXOVR	DEF					NA	NA	NA	N
90681	RV1 VACC 2 DOSE LIVE ORAL	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90696	DTAP-IPV VACCINE 4-6 YRS IM	PRXOVR	DEF					NA	NA	NA	N
90696	DTAP-IPV VACCINE 4-6 YRS IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90697	DTAP-IPV-HIB-HEPB VACCINE IM	PRXOVR	DEF					NA	NA	NA	N
90697	DTAP-IPV-HIB-HEPB VACCINE IM	MAXFEE	VFC					0	10/1/2021	12/31/2299	N
90698	DTAP-IPV/HIB VACCINE IM	PRXOVR	DEF					NA	NA	NA	N
90698	DTAP-IPV/HIB VACCINE IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90698	DTAP-IPV/HIB VACCINE IM	MAXFEE	DEF					85.33	11/1/2015	12/31/2299	N
90707	MMR VACCINE SC	PRXOVR	DEF					NA	NA	NA	N
90707	MMR VACCINE SC	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90707	MMR VACCINE SC	MAXFEE	DEF					93.75	10/1/2022	12/31/2299	N
90710	MMRV VACCINE SC	PRXOVR	DEF					NA	NA	NA	N
90710	MMRV VACCINE SC	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90710	MMRV VACCINE SC	MAXFEE	DEF					277.52	10/1/2022	12/31/2299	N
90713	POLIOVIRUS IPV SC/IM	PRXOVR	DEF					NA	NA	NA	N
90713	POLIOVIRUS IPV SC/IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90714	TD VACC NO PRESV 7 YRS+ IM	PRXOVR	DEF					NA	NA	NA	N
90714	TD VACC NO PRESV 7 YRS+ IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90714	TD VACC NO PRESV 7 YRS+ IM	MAXFEE	DEF					31.05	7/1/2023	12/31/2299	N
90715	TDAP VACCINE 7 YRS/> IM	PRXOVR	DEF					NA	NA	NA	N
90715	TDAP VACCINE 7 YRS/> IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90715	TDAP VACCINE 7 YRS/> IM	MAXFEE	DEF					38.75	7/1/2023	12/31/2299	N
90716	VAR VACCINE LIVE SUBQ	PRXOVR	DEF					NA	NA	NA	N
90716	VAR VACCINE LIVE SUBQ	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90716	VAR VACCINE LIVE SUBQ	MAXFEE	DEF					170.39	10/1/2022	12/31/2299	N
90732	PPSV23 VACC 2 YRS+ SUBQ/IM	PRXOVR	DEF					NA	NA	NA	N
90732	PPSV23 VACC 2 YRS+ SUBQ/IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90732	PPSV23 VACC 2 YRS+ SUBQ/IM	MAXFEE	DEF					133.47	1/1/2022	12/31/2299	N
90733	MPSV4 VACCINE SUBQ	PRXOVR	DEF					NA	NA	NA	N
90733	MPSV4 VACCINE SUBQ	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90733	MPSV4 VACCINE SUBQ	MAXFEE	DEF					126.39	2/1/2015	12/31/2299	N
90734	MENACWYD/MENACWYCRM VACC IM	PRXOVR	DEF					NA	NA	NA	N
90734	MENACWYD/MENACWYCRM VACC IM	MAXFEE	VFC					0	1/1/2016	12/31/2299	N
90734	MENACWYD/MENACWYCRM VACC IM	MAXFEE	DEF					115.88	2/1/2015	12/31/2299	N
90736	HZV VACCINE LIVE SUBQ	PRXOVR	DEF					NA	NA	NA	N
90736	HZV VACCINE LIVE SUBQ	MAXFEE	DEF					210.93	5/1/2015	12/31/2299	N
90740	HEPB VACC 3 DOSE IMMUNSUP IM	PRXOVR	DEF					NA	NA	NA	N
90740	HEPB VACC 3 DOSE IMMUNSUP IM	MAXFEE	DEF					152.12	4/1/2023	12/31/2299	N
90746	HEPB VACCINE 3 DOSE ADULT IM	PRXOVR	DEF					NA	NA	NA	N
90746	HEPB VACCINE 3 DOSE ADULT IM	MAXFEE	DEF					70.38	7/1/2022	12/31/2299	N
90747	HEPB VACC 4 DOSE IMMUNSUP IM	PRXOVR	DEF					NA	NA	NA	N
90747	HEPB VACC 4 DOSE IMMUNSUP IM	MAXFEE	DEF					140.75	7/1/2023	12/31/2299	N
90750	HZV VACC RECOMBINANT IM	PRXOVR	DEF					NA	NA	NA	N
90750	HZV VACC RECOMBINANT IM	MAXFEE	DEF					149.80	1/1/2018	12/31/2299	N
90759	HEP B VAC 3AG 10MCG 3 DOS IM	PRXOVR	DEF					NA	NA	NA	N
90759	HEP B VAC 3AG 10MCG 3 DOS IM	MAXFEE	VFC					0	1/1/2022	12/31/2299	N
90759	HEP B VAC 3AG 10MCG 3 DOS IM	MAXFEE	DEF					73.82	10/1/2022	12/31/2299	N
90785	PSYTX COMPLEX INTERACTIVE	MAXFEE	AOD					13.81	1/1/2018	12/31/2299	N
90785	PSYTX COMPLEX INTERACTIVE	PRXOVR	AOD					NA	NA	NA	N
90785	PSYTX COMPLEX INTERACTIVE	MXSUPV	AOD					NA	NA	NA	N
90785	PSYTX COMPLEX INTERACTIVE	MXPSYA	AOD					NA	NA	NA	N
90791	PSYCH DIAGNOSTIC EVALUATION	MAXFEE	AOD					130.72	1/1/2018	12/31/2299	R
90791	PSYCH DIAGNOSTIC EVALUATION	PRXOVR	AOD					NA	NA	NA	R
90791	PSYCH DIAGNOSTIC EVALUATION	MXSUPV	AOD					NA	NA	NA	R
90791	PSYCH DIAGNOSTIC EVALUATION	MXPSYA	AOD					NA	NA	NA	R
90792	PSYCH DIAG EVAL W/MED SRVCS	MAXFEE	AOD					144.35	1/1/2018	12/31/2299	R
90792	PSYCH DIAG EVAL W/MED SRVCS	PRXOVR	AOD					NA	NA	NA	R
90832	PSYTX W PT 30 MINUTES	MAXFEE	AOD					63.11	1/1/2018	12/31/2299	N
90832	PSYTX W PT 30 MINUTES	PRXOVR	AOD					NA	NA	NA	N
90832	PSYTX W PT 30 MINUTES	MXSUPV	AOD					NA	NA	NA	N
90832	PSYTX W PT 30 MINUTES	MXPSYA	AOD					NA	NA	NA	N
90833	PSYTX W PT W E/M 30 MIN	MAXFEE	AOD					65.37	1/1/2018	12/31/2299	R
90833	PSYTX W PT W E/M 30 MIN	PRXOVR	AOD					NA	NA	NA	R
90834	PSYTX W PT 45 MINUTES	MAXFEE	AOD					82.05	1/1/2018	12/31/2299	R
90834	PSYTX W PT 45 MINUTES	PRXOVR	AOD					NA	NA	NA	R
90834	PSYTX W PT 45 MINUTES	MXSUPV	AOD					NA	NA	NA	R
90834	PSYTX W PT 45 MINUTES	MXPSYA	AOD					NA	NA	NA	R
90836	PSYTX W PT W E/M 45 MIN	MAXFEE	AOD					83.03	1/1/2018	12/31/2299	R
90836	PSYTX W PT W E/M 45 MIN	PRXOVR	AOD					NA	NA	NA	R
90837	PSYTX W PT 60 MINUTES	MAXFEE	AOD					120.36	1/1/2018	12/31/2299	R
90837	PSYTX W PT 60 MINUTES	PRXOVR	AOD					NA	NA	NA	R
90837	PSYTX W PT 60 MINUTES	MXSUPV	AOD					NA	NA	NA	R
90837	PSYTX W PT 60 MINUTES	MXPSYA	AOD					NA	NA	NA	R
90838	PSYTX W PT W E/M 60 MIN	MAXFEE	AOD					109.53	1/1/2018	12/31/2299	R
90838	PSYTX W PT W E/M 60 MIN	PRXOVR	AOD					NA	NA	NA	R
90839	PSYTX CRISIS INITIAL 60 MIN	MAXFEE	AOD					171.70	8/1/2019	12/31/2299	N
90839	PSYTX CRISIS INITIAL 60 MIN	PRXOVR	AOD					NA	NA	NA	N
90839	PSYTX CRISIS INITIAL 60 MIN	MXSUPV	AOD					NA	NA	NA	N
90839	PSYTX CRISIS INITIAL 60 MIN	MXPSYA	AOD					NA	NA	NA	N
90840	PSYTX CRISIS EA ADDL 30 MIN	MAXFEE	AOD					81.95	8/1/2019	12/31/2299	N
90840	PSYTX CRISIS EA ADDL 30 MIN	PRXOVR	AOD					NA	NA	NA	N
90840	PSYTX CRISIS EA ADDL 30 MIN	MXSUPV	AOD					NA	NA	NA	N
90840	PSYTX CRISIS EA ADDL 30 MIN	MXPSYA	AOD					NA	NA	NA	N
90846	FAMILY PSYTX W/O PT 50 MIN	MAXFEE	AOD					102.28	1/1/2018	12/31/2299	R
90846	FAMILY PSYTX W/O PT 50 MIN	PRXOVR	AOD					NA	NA	NA	R
90846	FAMILY PSYTX W/O PT 50 MIN	MXSUPV	AOD					NA	NA	NA	R
90846	FAMILY PSYTX W/O PT 50 MIN	MXPSYA	AOD					NA	NA	NA	R
90847	FAMILY PSYTX W/PT 50 MIN	MAXFEE	AOD					100.72	1/1/2018	12/31/2299	R
90847	FAMILY PSYTX W/PT 50 MIN	PRXOVR	AOD					NA	NA	NA	R
90847	FAMILY PSYTX W/PT 50 MIN	MXSUPV	AOD					NA	NA	NA	R
90847	FAMILY PSYTX W/PT 50 MIN	MXPSYA	AOD					NA	NA	NA	R
90849	MULTIPLE FAMILY GROUP PSYTX	MAXFEE	AOD					40.66	8/1/2019	12/31/2299	R
90849	MULTIPLE FAMILY GROUP PSYTX	PRXOVR	AOD					NA	NA	NA	R
90849	MULTIPLE FAMILY GROUP PSYTX	MXSUPV	AOD					NA	NA	NA	R
90849	MULTIPLE FAMILY GROUP PSYTX	MXPSYA	AOD					NA	NA	NA	R
90853	GROUP PSYCHOTHERAPY	MAXFEE	AOD					33.09	8/1/2019	12/31/2299	R
90853	GROUP PSYCHOTHERAPY	PRXOVR	AOD					NA	NA	NA	R
90853	GROUP PSYCHOTHERAPY	MXSUPV	AOD					NA	NA	NA	R
90853	GROUP PSYCHOTHERAPY	MXPSYA	AOD					NA	NA	NA	R
91300	SARSCOV2 VAC 30MCG/0.3ML IM	PRXOVR	DEF					NA	NA	NA	N
91300	SARSCOV2 VAC 30MCG/0.3ML IM	MAXFEE	DEF					0.01	12/11/2020	12/31/2299	N
91301	SARSCOV2 VAC 100MCG/0.5ML IM	PRXOVR	DEF					NA	NA	NA	N
91301	SARSCOV2 VAC 100MCG/0.5ML IM	MAXFEE	DEF					0.01	12/18/2020	12/31/2299	N
91304	SARSCOV2 VAC 5MCG/0.5ML IM	PRXOVR	DEF					NA	NA	NA	N
91304	SARSCOV2 VAC 5MCG/0.5ML IM	MAXFEE	DEF					0.01	7/13/2022	12/31/2299	N
91305	SARSCOV2 VAC 30 MCG TRS-SUCR	PRXOVR	DEF					NA	NA	NA	N
91305	SARSCOV2 VAC 30 MCG TRS-SUCR	MAXFEE	DEF					0.01	1/3/2022	12/31/2299	N
91306	SARSCOV2 VAC 50MCG/0.25ML IM	PRXOVR	DEF					NA	NA	NA	N
91306	SARSCOV2 VAC 50MCG/0.25ML IM	MAXFEE	DEF					0.01	10/20/2021	12/31/2299	N
91307	SARSCOV2 VAC 10 MCG TRS-SUCR	PRXOVR	DEF					NA	NA	NA	N
91307	SARSCOV2 VAC 10 MCG TRS-SUCR	MAXFEE	DEF					0.01	10/29/2021	12/31/2299	N
91308	SARSCOV2 VAC 3 MCG TRS-SUCR	PRXOVR	DEF					NA	NA	NA	N
91308	SARSCOV2 VAC 3 MCG TRS-SUCR	MAXFEE	DEF					0.01	6/17/2022	12/31/2299	N
91309	SARSCOV2 VAC 50MCG/0.5ML IM	PRXOVR	DEF					NA	NA	NA	N
91309	SARSCOV2 VAC 50MCG/0.5ML IM	MAXFEE	DEF					0.01	3/29/2022	12/31/2299	N
91311	SARSCOV2 VAC 25MCG/0.25ML IM	PRXOVR	DEF					NA	NA	NA	N
91311	SARSCOV2 VAC 25MCG/0.25ML IM	MAXFEE	DEF					0.01	6/17/2022	12/31/2299	N
91312	SARSCOV2 VAC BVL 30MCG/0.3ML	PRXOVR	DEF					NA	NA	NA	N
91312	SARSCOV2 VAC BVL 30MCG/0.3ML	MAXFEE	DEF					0.01	8/31/2022	12/31/2299	N
91313	SARSCOV2 VAC BVL 50MCG/0.5ML	PRXOVR	DEF					NA	NA	NA	N
91313	SARSCOV2 VAC BVL 50MCG/0.5ML	MAXFEE	DEF					0.01	8/31/2022	12/31/2299	N
91314	SARSCOV2 VAC BVL 25MCG/.25ML	PRXOVR	DEF					NA	NA	NA	N
91314	SARSCOV2 VAC BVL 25MCG/.25ML	MAXFEE	DEF					0.01	10/12/2022	12/31/2299	N
91315	SARSCOV2 VAC BVL 10MCG/0.2ML	PRXOVR	DEF					NA	NA	NA	N
91315	SARSCOV2 VAC BVL 10MCG/0.2ML	MAXFEE	DEF					0.01	10/12/2022	12/31/2299	N
91316	SARSCOV2 VAC BVL 10MCG/0.2ML	PRXOVR	DEF					NA	NA	NA	N
91316	SARSCOV2 VAC BVL 10MCG/0.2ML	MAXFEE	DEF					0.01	12/8/2022	12/31/2299	N
91317	SARSCOV2 VAC BVL 3MCG/0.2ML	PRXOVR	DEF					NA	NA	NA	N
91317	SARSCOV2 VAC BVL 3MCG/0.2ML	MAXFEE	DEF					0.01	12/8/2022	12/31/2299	N
93000	ELECTROCARDIOGRAM COMPLETE	PRXOVR	DEF					NA	NA	NA	N
93000	ELECTROCARDIOGRAM COMPLETE	MAXFEE	DEF					15.90	9/1/2013	12/31/2299	N
93005	ELECTROCARDIOGRAM TRACING	PRXOVR	DEF					NA	NA	NA	N
93005	ELECTROCARDIOGRAM TRACING	MAXFEE	DEF					6.90	12/31/2014	12/31/2299	N
93010	ELECTROCARDIOGRAM REPORT	PRXOVR	DEF					NA	NA	NA	N
93010	ELECTROCARDIOGRAM REPORT	MAXFEE	DEF					7.90	1/1/2010	12/31/2299	N
96101	PSYCHO TESTING BY PSYCH/PHYS	MAXFEE	AOD					NA			S
96101	PSYCHO TESTING BY PSYCH/PHYS	PRXOVR	AOD					NA	NA	NA	S
96111	DEVELOPMENTAL TEST EXTEND	MAXFEE	AOD					NA			S
96111	DEVELOPMENTAL TEST EXTEND	PRXOVR	AOD					NA	NA	NA	S
96112	DEVEL TST PHYS/QHP 1ST HR	MAXFEE	AOD					56.11	1/1/2019	12/31/2299	S
96112	DEVEL TST PHYS/QHP 1ST HR	PRXOVR	AOD					NA	NA	NA	S
96113	DEVEL TST PHYS/QHP EA ADDL	MAXFEE	AOD					28.06	1/1/2019	12/31/2299	S
96113	DEVEL TST PHYS/QHP EA ADDL	PRXOVR	AOD					NA	NA	NA	S
96116	NUBHVL XM PHYS/QHP 1ST HR	MAXFEE	AOD					64.10	1/1/2018	12/31/2299	S
96116	NUBHVL XM PHYS/QHP 1ST HR	PRXOVR	AOD					NA	NA	NA	S
96118	NEUROPSYCH TST BY PSYCH/PHYS	MAXFEE	AOD					NA			S
96118	NEUROPSYCH TST BY PSYCH/PHYS	PRXOVR	AOD					NA	NA	NA	S
96121	NUBHVL XM PHY/QHP EA ADDL HR	MAXFEE	AOD					64.10	1/1/2019	12/31/2299	S
96121	NUBHVL XM PHY/QHP EA ADDL HR	PRXOVR	AOD					NA	NA	NA	S
96130	PSYCL TST EVAL PHYS/QHP 1ST	MAXFEE	AOD					59.26	1/1/2019	12/31/2299	S
96130	PSYCL TST EVAL PHYS/QHP 1ST	PRXOVR	AOD					NA	NA	NA	S
96131	PSYCL TST EVAL PHYS/QHP EA	MAXFEE	AOD					59.26	1/1/2019	12/31/2299	S
96131	PSYCL TST EVAL PHYS/QHP EA	PRXOVR	AOD					NA	NA	NA	S
96132	NRPSYC TST EVAL PHYS/QHP 1ST	MAXFEE	AOD					97.37	1/1/2019	12/31/2299	S
96132	NRPSYC TST EVAL PHYS/QHP 1ST	PRXOVR	AOD					NA	NA	NA	S
96133	NRPSYC TST EVAL PHYS/QHP EA	MAXFEE	AOD					78.31	1/1/2019	12/31/2299	S
96133	NRPSYC TST EVAL PHYS/QHP EA	PRXOVR	AOD					NA	NA	NA	S
96136	PSYCL/NRPSYC TST PHY/QHP 1ST	MAXFEE	AOD					30.86	1/1/2019	12/31/2299	S
96136	PSYCL/NRPSYC TST PHY/QHP 1ST	PRXOVR	AOD					NA	NA	NA	S
96137	PSYCL/NRPSYC TST PHY/QHP EA	MAXFEE	AOD					28.39	1/1/2019	12/31/2299	S
96137	PSYCL/NRPSYC TST PHY/QHP EA	PRXOVR	AOD					NA	NA	NA	S
96372	THER/PROPH/DIAG INJ SC/IM	MAXFEE	AOD					21.39	1/1/2017	12/31/2299	N
96372	THER/PROPH/DIAG INJ SC/IM	PRXOVR	AOD					NA	NA	NA	N
99201	OFFICE/OUTPATIENT VISIT NEW	MAXFEE	AOD					49.38	1/1/2018	12/31/2299	N
99201	OFFICE/OUTPATIENT VISIT NEW	PRXOVR	AOD					NA	NA	NA	N
99201	OFFICE/OUTPATIENT VISIT NEW	MAXFEE	FAC					11.56	1/1/2016	12/31/2299	N
99201	OFFICE/OUTPATIENT VISIT NEW	MAXFEE	NFF					23.55	1/1/2016	12/31/2299	N
99202	OFFICE O/P NEW SF 15-29 MIN	MAXFEE	AOD					84.67	1/1/2018	12/31/2299	N
99202	OFFICE O/P NEW SF 15-29 MIN	PRXOVR	AOD					NA	NA	NA	N
99202	OFFICE O/P NEW SF 15-29 MIN	MAXFEE	FAC					20.84	1/1/2016	12/31/2299	N
99202	OFFICE O/P NEW SF 15-29 MIN	MAXFEE	NFF					38.93	1/1/2016	12/31/2299	N
99203	OFFICE O/P NEW LOW 30-44 MIN	MAXFEE	AOD					122.93	1/1/2018	12/31/2299	N
99203	OFFICE O/P NEW LOW 30-44 MIN	PRXOVR	AOD					NA	NA	NA	N
99203	OFFICE O/P NEW LOW 30-44 MIN	MAXFEE	FAC					32.94	1/1/2016	12/31/2299	N
99203	OFFICE O/P NEW LOW 30-44 MIN	MAXFEE	NFF					57.76	1/1/2016	12/31/2299	N
99204	OFFICE O/P NEW MOD 45-59 MIN	MAXFEE	AOD					188.51	1/1/2018	12/31/2299	N
99204	OFFICE O/P NEW MOD 45-59 MIN	PRXOVR	AOD					NA	NA	NA	N
99205	OFFICE O/P NEW HI 60-74 MIN	MAXFEE	AOD					236.92	1/1/2018	12/31/2299	N
99205	OFFICE O/P NEW HI 60-74 MIN	PRXOVR	AOD					NA	NA	NA	N
99211	OFF/OP EST MAY X REQ PHY/QHP	MAXFEE	AOD					22.31	1/1/2018	12/31/2299	N
99211	OFF/OP EST MAY X REQ PHY/QHP	PRXOVR	AOD					NA	NA	NA	N
99211	OFF/OP EST MAY X REQ PHY/QHP	MAXFEE	FAC					5.55	1/1/2016	12/31/2299	N
99211	OFF/OP EST MAY X REQ PHY/QHP	MAXFEE	NFF					14.50	1/1/2016	12/31/2299	N
99212	OFFICE O/P EST SF 10-19 MIN	MAXFEE	AOD					48.97	1/1/2018	12/31/2299	N
99212	OFFICE O/P EST SF 10-19 MIN	PRXOVR	AOD					NA	NA	NA	N
99212	OFFICE O/P EST SF 10-19 MIN	MAXFEE	FAC					12.81	1/1/2016	12/31/2299	N
99212	OFFICE O/P EST SF 10-19 MIN	MAXFEE	NFF					26.73	1/1/2016	12/31/2299	N
99213	OFFICE O/P EST LOW 20-29 MIN	MAXFEE	AOD					82.85	1/1/2018	12/31/2299	N
99213	OFFICE O/P EST LOW 20-29 MIN	PRXOVR	AOD					NA	NA	NA	N
99213	OFFICE O/P EST LOW 20-29 MIN	MAXFEE	FAC					24.85	1/1/2016	12/31/2299	N
99213	OFFICE O/P EST LOW 20-29 MIN	MAXFEE	NFF					43.61	1/1/2016	12/31/2299	N
99214	OFFICE O/P EST MOD 30-39 MIN	MAXFEE	AOD					122.27	1/1/2018	12/31/2299	N
99214	OFFICE O/P EST MOD 30-39 MIN	PRXOVR	AOD					NA	NA	NA	N
99215	OFFICE O/P EST HI 40-54 MIN	MAXFEE	AOD					165.15	1/1/2018	12/31/2299	N
99215	OFFICE O/P EST HI 40-54 MIN	PRXOVR	AOD					NA	NA	NA	N
99341	HOME/RES VST NEW SF MDM 15	MAXFEE	AOD					63.65	1/1/2018	12/31/2299	N
99341	HOME/RES VST NEW SF MDM 15	PRXOVR	AOD					NA	NA	NA	N
99342	HOME/RES VST NEW LOW MDM 30	MAXFEE	AOD					91.90	1/1/2018	12/31/2299	N
99342	HOME/RES VST NEW LOW MDM 30	PRXOVR	AOD					NA	NA	NA	N
99343	HOME VISIT NEW PATIENT	MAXFEE	AOD					NA			N
99343	HOME VISIT NEW PATIENT	PRXOVR	AOD					NA	NA	NA	N
99344	HOME/RES VST NEW MOD MDM 60	MAXFEE	AOD					210.78	1/1/2018	12/31/2299	N
99344	HOME/RES VST NEW MOD MDM 60	PRXOVR	AOD					NA	NA	NA	N
99345	HOME/RES VST NEW HIGH MDM 75	MAXFEE	AOD					255.57	1/1/2018	12/31/2299	N
99345	HOME/RES VST NEW HIGH MDM 75	PRXOVR	AOD					NA	NA	NA	N
99347	HOME/RES VST EST SF MDM 20	MAXFEE	AOD					64	1/1/2018	12/31/2299	N
99347	HOME/RES VST EST SF MDM 20	PRXOVR	AOD					NA	NA	NA	N
99348	HOME/RES VST EST LOW MDM 30	MAXFEE	AOD					97.38	1/1/2018	12/31/2299	N
99348	HOME/RES VST EST LOW MDM 30	PRXOVR	AOD					NA	NA	NA	N
99349	HOME/RES VST EST MOD MDM 40	MAXFEE	AOD					148.16	1/1/2018	12/31/2299	N
99349	HOME/RES VST EST MOD MDM 40	PRXOVR	AOD					NA	NA	NA	N
99350	HOME/RES VST EST HIGH MDM 60	MAXFEE	AOD					205.79	1/1/2018	12/31/2299	N
99350	HOME/RES VST EST HIGH MDM 60	PRXOVR	AOD					NA	NA	NA	N
99354	PROLNG SVC O/P 1ST HOUR	MAXFEE	AOD					NA			N
99354	PROLNG SVC O/P 1ST HOUR	PRXOVR	AOD					NA	NA	NA	N
99354	PROLNG SVC O/P 1ST HOUR	MXSUPV	AOD					NA	NA	NA	N
99354	PROLNG SVC O/P 1ST HOUR	MXPSYA	AOD					NA	NA	NA	N
99355	PROLNG SVC O/P EA ADDL 30	MAXFEE	AOD					NA			N
99355	PROLNG SVC O/P EA ADDL 30	PRXOVR	AOD					NA	NA	NA	N
99355	PROLNG SVC O/P EA ADDL 30	MXSUPV	AOD					NA	NA	NA	N
99355	PROLNG SVC O/P EA ADDL 30	MXPSYA	AOD					NA	NA	NA	N
99401	PREVENTIVE COUNSELING INDIV	PRXOVR	DEF					NA	NA	NA	N
99401	PREVENTIVE COUNSELING INDIV	MAXFEE	FAC					17.69	1/1/2014	12/31/2299	N
99401	PREVENTIVE COUNSELING INDIV	MAXFEE	NFF					26.21	1/1/2014	12/31/2299	N
99402	PREVENTIVE COUNSELING INDIV	PRXOVR	DEF					NA	NA	NA	N
99402	PREVENTIVE COUNSELING INDIV	MAXFEE	FAC					28.87	1/1/2014	12/31/2299	N
99402	PREVENTIVE COUNSELING INDIV	MAXFEE	NFF					39.90	1/1/2014	12/31/2299	N
99406	BEHAV CHNG SMOKING 3-10 MIN	MAXFEE	AOD					9.43	8/1/2019	12/31/2299	N
99406	BEHAV CHNG SMOKING 3-10 MIN	PRXOVR	AOD					NA	NA	NA	N
99406	BEHAV CHNG SMOKING 3-10 MIN	MXSUPV	AOD					NA	NA	NA	N
99406	BEHAV CHNG SMOKING 3-10 MIN	MXPSYA	AOD					NA	NA	NA	N
99407	BEHAV CHNG SMOKING > 10 MIN	MAXFEE	AOD					19	8/1/2019	12/31/2299	N
99407	BEHAV CHNG SMOKING > 10 MIN	PRXOVR	AOD					NA	NA	NA	N
99407	BEHAV CHNG SMOKING > 10 MIN	MXSUPV	AOD					NA	NA	NA	N
99407	BEHAV CHNG SMOKING > 10 MIN	MXPSYA	AOD					NA	NA	NA	N
99415	PROLNG CLIN STAFF SVC 1ST HR	MAXFEE	AOD					10.94	1/1/2022	12/31/2299	N
99415	PROLNG CLIN STAFF SVC 1ST HR	PRXOVR	AOD					NA	NA	NA	N
99416	PROLNG CLIN STAFF SVC EA ADD	MAXFEE	AOD					5.62	1/1/2022	12/31/2299	N
99416	PROLNG CLIN STAFF SVC EA ADD	PRXOVR	AOD					NA	NA	NA	N
99417	PROLNG OP E/M EACH 15 MIN	MAXFEE	AOD					38.53	1/1/2022	12/31/2299	N
99417	PROLNG OP E/M EACH 15 MIN	PRXOVR	AOD					NA	NA	NA	N
G0312	IMMUNIZE COUNS < 21YR 5-15 M	PRXOVR	DEF					NA	NA	NA	N
G0312	IMMUNIZE COUNS < 21YR 5-15 M	MAXFEE	DEF					26.21	6/8/2022	12/31/2299	N
G0313	IMMUNIZE COUNS < 21YR 6-30 M	PRXOVR	DEF					NA	NA	NA	N
G0313	IMMUNIZE COUNS < 21YR 6-30 M	MAXFEE	DEF					39.90	6/8/2022	12/31/2299	N
G0913	IMPROVE VISUAL FUNCT	PRXOVR	DEF					NA	NA	NA	N
G0913	IMPROVE VISUAL FUNCT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G0914	SURVEY NOT COMPLETE	PRXOVR	DEF					NA	NA	NA	N
G0914	SURVEY NOT COMPLETE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G0915	NO IMPROVE VISUAL FUNCT	PRXOVR	DEF					NA	NA	NA	N
G0915	NO IMPROVE VISUAL FUNCT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G0916	SATISFY WITH CARE	PRXOVR	DEF					NA	NA	NA	N
G0916	SATISFY WITH CARE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G0917	CARE SURVEY NOT COMPLETE	PRXOVR	DEF					NA	NA	NA	N
G0917	CARE SURVEY NOT COMPLETE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G0918	NO SATISFY WITH CARE	PRXOVR	DEF					NA	NA	NA	N
G0918	NO SATISFY WITH CARE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G2212	PROLONG OUTPT/OFFICE VIS	MAXFEE	AOD					38.53	1/1/2022	12/31/2299	N
G2212	PROLONG OUTPT/OFFICE VIS	PRXOVR	AOD					NA	NA	NA	N
G8395	LVEF>=40% DOC NORMAL OR MILD	PRXOVR	DEF					NA	NA	NA	N
G8395	LVEF>=40% DOC NORMAL OR MILD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8396	LVEF NOT PERFORMED	PRXOVR	DEF					NA	NA	NA	N
G8396	LVEF NOT PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8397	DIL MACULA/FUNDUS EXAM/W DOC	PRXOVR	DEF					NA	NA	NA	N
G8397	DIL MACULA/FUNDUS EXAM/W DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8398	DIL MACULAR/FUNDUS NOT PERFO	PRXOVR	DEF					NA	NA	NA	N
G8398	DIL MACULAR/FUNDUS NOT PERFO	MAXFEE	DEF					NA			N
G8399	PT W/DXA RESULTS DOCUMENT	PRXOVR	DEF					NA	NA	NA	N
G8399	PT W/DXA RESULTS DOCUMENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8400	PT W/DXA NO RESULTS DOC	PRXOVR	DEF					NA	NA	NA	N
G8400	PT W/DXA NO RESULTS DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8404	LOW EXTEMITY NEUR EXAM DOCUM	PRXOVR	DEF					NA	NA	NA	N
G8404	LOW EXTEMITY NEUR EXAM DOCUM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8405	LOW EXTEMITY NEUR NOT PERFOR	PRXOVR	DEF					NA	NA	NA	N
G8405	LOW EXTEMITY NEUR NOT PERFOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8410	EVAL ON FOOT DOCUMENTED	PRXOVR	DEF					NA	NA	NA	N
G8410	EVAL ON FOOT DOCUMENTED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8415	EVAL ON FOOT NOT PERFORMED	PRXOVR	DEF					NA	NA	NA	N
G8415	EVAL ON FOOT NOT PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8416	PT INELIG FOOTWEAR EVALUATIO	PRXOVR	DEF					NA	NA	NA	N
G8416	PT INELIG FOOTWEAR EVALUATIO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8417	CALC BMI ABV UP PARAM F/U	PRXOVR	DEF					NA	NA	NA	N
G8417	CALC BMI ABV UP PARAM F/U	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8418	CALC BMI BLW LOW PARAM F/U	PRXOVR	DEF					NA	NA	NA	N
G8418	CALC BMI BLW LOW PARAM F/U	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8419	CALC BMI OUT NRM PARAM NOF/U	PRXOVR	DEF					NA	NA	NA	N
G8419	CALC BMI OUT NRM PARAM NOF/U	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8420	CALC BMI NORM PARAMETERS	PRXOVR	DEF					NA	NA	NA	N
G8420	CALC BMI NORM PARAMETERS	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8421	BMI NOT CALCULATED	PRXOVR	DEF					NA	NA	NA	N
G8421	BMI NOT CALCULATED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8422	PT INELIG BMI CALCULATION	PRXOVR	DEF					NA	NA	NA	N
G8422	PT INELIG BMI CALCULATION	MAXFEE	DEF					NA			N
G8427	DOCREV CUR MEDS BY ELIG CLIN	PRXOVR	DEF					NA	NA	NA	N
G8427	DOCREV CUR MEDS BY ELIG CLIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8428	CUR MEDS NOT DOCUMENT	PRXOVR	DEF					NA	NA	NA	N
G8428	CUR MEDS NOT DOCUMENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8430	DOC MED RSN NO MEDREC	PRXOVR	DEF					NA	NA	NA	N
G8430	DOC MED RSN NO MEDREC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8431	POS CLIN DEPRES SCRN F/U DOC	PRXOVR	DEF					NA	NA	NA	N
G8431	POS CLIN DEPRES SCRN F/U DOC	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8432	DEP SCR NOT DOC; RNG	PRXOVR	DEF					NA	NA	NA	N
G8432	DEP SCR NOT DOC; RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8433	SCR FOR DEP NOT CPT DOC RSN	PRXOVR	DEF					NA	NA	NA	N
G8433	SCR FOR DEP NOT CPT DOC RSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8442	DOC PAIN AS NT PERF; NOT ELG	PRXOVR	DEF					NA	NA	NA	N
G8442	DOC PAIN AS NT PERF; NOT ELG	MAXFEE	DEF					NA			N
G8450	BETA-BLOC RX PT W/ABN LVEF	PRXOVR	DEF					NA	NA	NA	N
G8450	BETA-BLOC RX PT W/ABN LVEF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8451	PT W/ABN LVEF INELIG B-BLOC	PRXOVR	DEF					NA	NA	NA	N
G8451	PT W/ABN LVEF INELIG B-BLOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8452	PT W/ABN LVEF B-BLOC NO RX	PRXOVR	DEF					NA	NA	NA	N
G8452	PT W/ABN LVEF B-BLOC NO RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8465	HIGH RISK RECURRENCE PRO CA	PRXOVR	DEF					NA	NA	NA	N
G8465	HIGH RISK RECURRENCE PRO CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8473	ACE/ARB THXPY RX'D	PRXOVR	DEF					NA	NA	NA	N
G8473	ACE/ARB THXPY RX'D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8474	ACE/ARB NOT RX'D; DOC REAS	PRXOVR	DEF					NA	NA	NA	N
G8474	ACE/ARB NOT RX'D; DOC REAS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8475	ACE/ARB THXPY NOT RX'D	PRXOVR	DEF					NA	NA	NA	N
G8475	ACE/ARB THXPY NOT RX'D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8476	BP SYS <140 AND DIAS <90	PRXOVR	DEF					NA	NA	NA	N
G8476	BP SYS <140 AND DIAS <90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8477	BP SYS>=140 AND/OR DIAS >=90	PRXOVR	DEF					NA	NA	NA	N
G8477	BP SYS>=140 AND/OR DIAS >=90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8478	BP NOT PERFORMED/DOC	PRXOVR	DEF					NA	NA	NA	N
G8478	BP NOT PERFORMED/DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8482	FLU IMMUNIZE ORDER/ADMIN	PRXOVR	DEF					NA	NA	NA	N
G8482	FLU IMMUNIZE ORDER/ADMIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8483	FLU IMM NO ADMIN DOC REA	PRXOVR	DEF					NA	NA	NA	N
G8483	FLU IMM NO ADMIN DOC REA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8484	FLU IMMUNIZE NO ADMIN	PRXOVR	DEF					NA	NA	NA	N
G8484	FLU IMMUNIZE NO ADMIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8506	PT REC ACE/ARB	PRXOVR	DEF					NA	NA	NA	N
G8506	PT REC ACE/ARB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8509	POS PAIN ASSESS NO F/U DOC	PRXOVR	DEF					NA	NA	NA	N
G8509	POS PAIN ASSESS NO F/U DOC	MAXFEE	DEF					NA			N
G8510	SCR DEP NEG; NO PLAN REQD	PRXOVR	DEF					NA	NA	NA	N
G8510	SCR DEP NEG; NO PLAN REQD	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8511	SCR DEP POS; NO PLAN DOC RNG	PRXOVR	DEF					NA	NA	NA	N
G8511	SCR DEP POS; NO PLAN DOC RNG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8535	ELD MALTREATMENT NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G8535	ELD MALTREATMENT NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8536	NO DOC ELDER MAL SCRN	PRXOVR	DEF					NA	NA	NA	N
G8536	NO DOC ELDER MAL SCRN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8539	DOC FUNCT AND CARE PLAN	PRXOVR	DEF					NA	NA	NA	N
G8539	DOC FUNCT AND CARE PLAN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8540	FOA NOT DOC AS BEING PERF	PRXOVR	DEF					NA	NA	NA	N
G8540	FOA NOT DOC AS BEING PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8541	NO DOC CUR FUNCT ASSESS	PRXOVR	DEF					NA	NA	NA	N
G8541	NO DOC CUR FUNCT ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8542	DOC FUNCT NO DEFICIENCIES	PRXOVR	DEF					NA	NA	NA	N
G8542	DOC FUNCT NO DEFICIENCIES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8543	CUR FUNCT ASSES; NO CARE PLN	PRXOVR	DEF					NA	NA	NA	N
G8543	CUR FUNCT ASSES; NO CARE PLN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8569	PROL INTUBATION REQ	PRXOVR	DEF					NA	NA	NA	N
G8569	PROL INTUBATION REQ	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8570	NO PROL INTUB REQ	PRXOVR	DEF					NA	NA	NA	N
G8570	NO PROL INTUB REQ	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8571	STER WD IFX 30 D POSTOP	PRXOVR	DEF					NA	NA	NA	N
G8571	STER WD IFX 30 D POSTOP	MAXFEE	DEF					NA			N
G8572	NO STER WD IFX	PRXOVR	DEF					NA	NA	NA	N
G8572	NO STER WD IFX	MAXFEE	DEF					NA			N
G8573	STK CABG	PRXOVR	DEF					NA	NA	NA	N
G8573	STK CABG	MAXFEE	DEF					NA			N
G8574	NO STRK CABG	PRXOVR	DEF					NA	NA	NA	N
G8574	NO STRK CABG	MAXFEE	DEF					NA			N
G8575	POSTOP REN FAIL	PRXOVR	DEF					NA	NA	NA	N
G8575	POSTOP REN FAIL	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8576	NO POSTOP REN FAIL	PRXOVR	DEF					NA	NA	NA	N
G8576	NO POSTOP REN FAIL	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8577	REOP REQ BLD GRFT OTH	PRXOVR	DEF					NA	NA	NA	N
G8577	REOP REQ BLD GRFT OTH	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8578	NO REOP REQ BLD GRFT OTH	PRXOVR	DEF					NA	NA	NA	N
G8578	NO REOP REQ BLD GRFT OTH	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8598	ASA/ANTIPLAT THER USED	PRXOVR	DEF					NA	NA	NA	N
G8598	ASA/ANTIPLAT THER USED	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8599	NO ASA/ANTIPLAT THER USE RNG	PRXOVR	DEF					NA	NA	NA	N
G8599	NO ASA/ANTIPLAT THER USE RNG	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8600	TPA INITI W/IN 4.5 HR	PRXOVR	DEF					NA	NA	NA	N
G8600	TPA INITI W/IN 4.5 HR	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8601	NO ELIG TPA INIT W/IN 4.5 HR	PRXOVR	DEF					NA	NA	NA	N
G8601	NO ELIG TPA INIT W/IN 4.5 HR	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8602	NO TPA INIT W/IN 4.5 HR	PRXOVR	DEF					NA	NA	NA	N
G8602	NO TPA INIT W/IN 4.5 HR	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8627	SURG PROC W/IN 30 DAYS	PRXOVR	DEF					NA	NA	NA	N
G8627	SURG PROC W/IN 30 DAYS	MAXFEE	DEF					NA			N
G8628	NO SURG PROC W/IN 30 DAYS	PRXOVR	DEF					NA	NA	NA	N
G8628	NO SURG PROC W/IN 30 DAYS	MAXFEE	DEF					NA			N
G8633	PHARM THER OSTEO RX	PRXOVR	DEF					NA	NA	NA	N
G8633	PHARM THER OSTEO RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8635	NO PHARM THER OSTEO RX	PRXOVR	DEF					NA	NA	NA	N
G8635	NO PHARM THER OSTEO RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8647	RAFSCRS KI SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8647	RAFSCRS KI SCOR >= 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8648	RAFSCRS KI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8648	RAFSCRS KI SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8649	RAFSCRS KI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8649	RAFSCRS KI NO SCOR	MAXFEE	DEF					NA			N
G8650	RAFS CRS KI NO SCOR NO RSN	PRXOVR	DEF					NA	NA	NA	N
G8650	RAFS CRS KI NO SCOR NO RSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8651	RAFSCRS HI SCOR >=0	PRXOVR	DEF					NA	NA	NA	N
G8651	RAFSCRS HI SCOR >=0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8652	RAFSCRS HI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8652	RAFSCRS HI SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8653	RAFSCRS HI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8653	RAFSCRS HI NO SCOR	MAXFEE	DEF					NA			N
G8654	RAFS CRS HI NO SCOR NO SURV	PRXOVR	DEF					NA	NA	NA	N
G8654	RAFS CRS HI NO SCOR NO SURV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8655	RAFSCRS LLFAI SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8655	RAFSCRS LLFAI SCOR >= 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8656	RAFSCRS LLFAI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8656	RAFSCRS LLFAI SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8657	RAFSCRS LLFAI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8657	RAFSCRS LLFAI NO SCOR	MAXFEE	DEF					NA			N
G8658	RAFSCRS LLFAI NO SCOR + SURV	PRXOVR	DEF					NA	NA	NA	N
G8658	RAFSCRS LLFAI NO SCOR + SURV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8659	RAFSCRS LBI SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8659	RAFSCRS LBI SCOR >= 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8660	RAFSCRS LBI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8660	RAFSCRS LBI SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8661	RAFSCRS LBI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8661	RAFSCRS LBI NO SCOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8662	RAFS CRS LBI NO SCOR NO SURV	PRXOVR	DEF					NA	NA	NA	N
G8662	RAFS CRS LBI NO SCOR NO SURV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8663	RAFSCRS SI SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8663	RAFSCRS SI SCOR >= 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8664	RAFSCRS SI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8664	RAFSCRS SI SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8665	RAFSCRS SI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8665	RAFSCRS SI NO SCOR	MAXFEE	DEF					NA			N
G8666	RAFS CRS SI NO SCOR NO SURV	PRXOVR	DEF					NA	NA	NA	N
G8666	RAFS CRS SI NO SCOR NO SURV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8667	RAFSCRS EWH SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8667	RAFSCRS EWH SCOR >= 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8668	RAFSCRS EWH SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8668	RAFSCRS EWH SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8669	RAFSCRS	PRXOVR	DEF					NA	NA	NA	N
G8669	RAFSCRS	MAXFEE	DEF					NA			N
G8670	RAFS CRS EWH NO SCOR NO SURV	PRXOVR	DEF					NA	NA	NA	N
G8670	RAFS CRS EWH NO SCOR NO SURV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8671	RAFSCRS GOI SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8671	RAFSCRS GOI SCOR >= 0	MAXFEE	DEF					NA			N
G8672	RAFSCRS GOI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8672	RAFSCRS GOI SCOR < 0	MAXFEE	DEF					NA			N
G8673	RAFSCRS GOI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8673	RAFSCRS GOI NO SCOR	MAXFEE	DEF					NA			N
G8674	RAFSCRS NECK; NO MSR/NO FOTO	PRXOVR	DEF					NA	NA	NA	N
G8674	RAFSCRS NECK; NO MSR/NO FOTO	MAXFEE	DEF					NA			N
G8694	LVEF <=40%	PRXOVR	DEF					NA	NA	NA	N
G8694	LVEF <=40%	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8708	ANTIBIOTIC NOT PRES	PRXOVR	DEF					NA	NA	NA	N
G8708	ANTIBIOTIC NOT PRES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8709	URI EP COMPETE DIAG	PRXOVR	DEF					NA	NA	NA	N
G8709	URI EP COMPETE DIAG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8710	PT PRES ANTIBIOTIC	PRXOVR	DEF					NA	NA	NA	N
G8710	PT PRES ANTIBIOTIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8711	PRES ANTIBX ON/WITHIN 3 DAY	PRXOVR	DEF					NA	NA	NA	N
G8711	PRES ANTIBX ON/WITHIN 3 DAY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8712	NOT PRES ANTIBIOTIC	PRXOVR	DEF					NA	NA	NA	N
G8712	NOT PRES ANTIBIOTIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8721	PT; PN; HIST GRADE DOC	PRXOVR	DEF					NA	NA	NA	N
G8721	PT; PN; HIST GRADE DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8722	MED REAS PT; PN; NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G8722	MED REAS PT; PN; NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8723	SPEC SIT NOT PRIM TUMOR	PRXOVR	DEF					NA	NA	NA	N
G8723	SPEC SIT NOT PRIM TUMOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8724	PT; PN; HIST GRADE NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G8724	PT; PN; HIST GRADE NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8730	PAIN DOC POS AND PLAN	PRXOVR	DEF					NA	NA	NA	N
G8730	PAIN DOC POS AND PLAN	MAXFEE	DEF					NA			N
G8731	PAIN NEG NO PLAN	PRXOVR	DEF					NA	NA	NA	N
G8731	PAIN NEG NO PLAN	MAXFEE	DEF					NA			N
G8732	NO DOC OF PAIN	PRXOVR	DEF					NA	NA	NA	N
G8732	NO DOC OF PAIN	MAXFEE	DEF					NA			N
G8733	DOC POS ELDER MAL SCRN PLAN	PRXOVR	DEF					NA	NA	NA	N
G8733	DOC POS ELDER MAL SCRN PLAN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8734	DOC NEG ELD REQ	PRXOVR	DEF					NA	NA	NA	N
G8734	DOC NEG ELD REQ	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8735	ELD MAL SCRN POS NO PLAN	PRXOVR	DEF					NA	NA	NA	N
G8735	ELD MAL SCRN POS NO PLAN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8749	NO SIGNS MELANOMA	PRXOVR	DEF					NA	NA	NA	N
G8749	NO SIGNS MELANOMA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8752	SYS BP LESS 140	PRXOVR	DEF					NA	NA	NA	N
G8752	SYS BP LESS 140	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8753	SYS BP > OR = 140	PRXOVR	DEF					NA	NA	NA	N
G8753	SYS BP > OR = 140	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8754	DIAS BP LESS 90	PRXOVR	DEF					NA	NA	NA	N
G8754	DIAS BP LESS 90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8755	DIAS BP > OR = 90	PRXOVR	DEF					NA	NA	NA	N
G8755	DIAS BP > OR = 90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8756	NO BP MEASURE DOC	PRXOVR	DEF					NA	NA	NA	N
G8756	NO BP MEASURE DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8783	BP SCRN PERF REC INTERVAL	PRXOVR	DEF					NA	NA	NA	N
G8783	BP SCRN PERF REC INTERVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8785	BP SCRN NO PERF AT INTERVAL	PRXOVR	DEF					NA	NA	NA	N
G8785	BP SCRN NO PERF AT INTERVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8797	SPECIMEN SITE NOT ESOPHAGUS	PRXOVR	DEF					NA	NA	NA	N
G8797	SPECIMEN SITE NOT ESOPHAGUS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8798	SPECIMEN SITE NOT PROSTATE	PRXOVR	DEF					NA	NA	NA	N
G8798	SPECIMEN SITE NOT PROSTATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8806	PERF ULTRSND TO LCT PREG DOC	PRXOVR	DEF					NA	NA	NA	N
G8806	PERF ULTRSND TO LCT PREG DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8807	NO TA TV ULTRASND	PRXOVR	DEF					NA	NA	NA	N
G8807	NO TA TV ULTRASND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8808	ULTRASOUND NOT PERF; RNG	PRXOVR	DEF					NA	NA	NA	N
G8808	ULTRASOUND NOT PERF; RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8809	RH-IMMUNOGLOBULIN ORDER	PRXOVR	DEF					NA	NA	NA	N
G8809	RH-IMMUNOGLOBULIN ORDER	MAXFEE	DEF					NA			N
G8810	DOC REAS NO RH-IMMUNO	PRXOVR	DEF					NA	NA	NA	N
G8810	DOC REAS NO RH-IMMUNO	MAXFEE	DEF					NA			N
G8811	NO RH-IMMUNOGLOBULIN ORDER	PRXOVR	DEF					NA	NA	NA	N
G8811	NO RH-IMMUNOGLOBULIN ORDER	MAXFEE	DEF					NA			N
G8815	DOC REAS NO STATIN THERAPY	PRXOVR	DEF					NA	NA	NA	N
G8815	DOC REAS NO STATIN THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8816	STATIN MED PRES AT DISCH	PRXOVR	DEF					NA	NA	NA	N
G8816	STATIN MED PRES AT DISCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8817	DOC REAS NO STATIN MED DISCH	PRXOVR	DEF					NA	NA	NA	N
G8817	DOC REAS NO STATIN MED DISCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8818	PT DISCH TO HOME BY DAY#7	PRXOVR	DEF					NA	NA	NA	N
G8818	PT DISCH TO HOME BY DAY#7	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8825	PT NOT DISCH TO HOME DAY#7	PRXOVR	DEF					NA	NA	NA	N
G8825	PT NOT DISCH TO HOME DAY#7	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8826	PT DISCH HOME DAY #2 EVAR	PRXOVR	DEF					NA	NA	NA	N
G8826	PT DISCH HOME DAY #2 EVAR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8833	PT NOT DISCH HOME DAY#2 EVAR	PRXOVR	DEF					NA	NA	NA	N
G8833	PT NOT DISCH HOME DAY#2 EVAR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8834	PT DISCH HOME DAY #2 CEA	PRXOVR	DEF					NA	NA	NA	N
G8834	PT DISCH HOME DAY #2 CEA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8838	NOT DISCH HOME BY DAY #2	PRXOVR	DEF					NA	NA	NA	N
G8838	NOT DISCH HOME BY DAY #2	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8839	SLEEP APNEA ASSESS	PRXOVR	DEF					NA	NA	NA	N
G8839	SLEEP APNEA ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8840	DOC REAS NO SLEEP APNEA	PRXOVR	DEF					NA	NA	NA	N
G8840	DOC REAS NO SLEEP APNEA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8841	NO SLEEP APNEA ASSESS	PRXOVR	DEF					NA	NA	NA	N
G8841	NO SLEEP APNEA ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8842	AHI OR RDI INITIAL DX	PRXOVR	DEF					NA	NA	NA	N
G8842	AHI OR RDI INITIAL DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8843	DOC REAS NO AHI OR RDI	PRXOVR	DEF					NA	NA	NA	N
G8843	DOC REAS NO AHI OR RDI	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8844	NO AHI OR RDI INITIAL DX	PRXOVR	DEF					NA	NA	NA	N
G8844	NO AHI OR RDI INITIAL DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8845	POS AIRWAY PRESS PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
G8845	POS AIRWAY PRESS PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8846	MOD OR SEVERE OSA	PRXOVR	DEF					NA	NA	NA	N
G8846	MOD OR SEVERE OSA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8849	DOC REAS NO POS AIR PRESS	PRXOVR	DEF					NA	NA	NA	N
G8849	DOC REAS NO POS AIR PRESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8850	NO PAP PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
G8850	NO PAP PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8851	ADHERE POS AIR PRESS THERAPY	PRXOVR	DEF					NA	NA	NA	N
G8851	ADHERE POS AIR PRESS THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8852	POS AIR PRESS PRESCRIBE	PRXOVR	DEF					NA	NA	NA	N
G8852	POS AIR PRESS PRESCRIBE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8854	REAS NO ADHERE POS AIR PRES	PRXOVR	DEF					NA	NA	NA	N
G8854	REAS NO ADHERE POS AIR PRES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8855	POS AIR PRESS ADHERE NO PERF	PRXOVR	DEF					NA	NA	NA	N
G8855	POS AIR PRESS ADHERE NO PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8856	REF FOR OTO EVAL	PRXOVR	DEF					NA	NA	NA	N
G8856	REF FOR OTO EVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8857	NO ELIG REF FOR OTO EVAL	PRXOVR	DEF					NA	NA	NA	N
G8857	NO ELIG REF FOR OTO EVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8858	NOT REF FOR OTO EVAL	PRXOVR	DEF					NA	NA	NA	N
G8858	NOT REF FOR OTO EVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8861	DXA ORDERED FOR OSTEO	PRXOVR	DEF					NA	NA	NA	N
G8861	DXA ORDERED FOR OSTEO	MAXFEE	DEF					NA			N
G8863	NO ASSESS BONE LOSS	PRXOVR	DEF					NA	NA	NA	N
G8863	NO ASSESS BONE LOSS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8864	PNEUMOCOCCAL VACCINE ADMIN	PRXOVR	DEF					NA	NA	NA	N
G8864	PNEUMOCOCCAL VACCINE ADMIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8865	DOC MED REAS NO PNEUMOCOCCAL	PRXOVR	DEF					NA	NA	NA	N
G8865	DOC MED REAS NO PNEUMOCOCCAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8866	DOC PT REAS NO PNEUMOCOCCAL	PRXOVR	DEF					NA	NA	NA	N
G8866	DOC PT REAS NO PNEUMOCOCCAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8867	NO PNEUMOCOCCAL ADMIN	PRXOVR	DEF					NA	NA	NA	N
G8867	NO PNEUMOCOCCAL ADMIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8869	DOC IMMUNE HEP B ANTITNF	PRXOVR	DEF					NA	NA	NA	N
G8869	DOC IMMUNE HEP B ANTITNF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8872	INTRAOP IMAGE CONFIRM EXCISE	PRXOVR	DEF					NA	NA	NA	N
G8872	INTRAOP IMAGE CONFIRM EXCISE	MAXFEE	DEF					NA			N
G8873	SPECIMEN NOT INTRAOP IMAGE	PRXOVR	DEF					NA	NA	NA	N
G8873	SPECIMEN NOT INTRAOP IMAGE	MAXFEE	DEF					NA			N
G8874	TISSUE NOT IMAGE INTRAOP	PRXOVR	DEF					NA	NA	NA	N
G8874	TISSUE NOT IMAGE INTRAOP	MAXFEE	DEF					NA			N
G8875	BREAST CANCER DX MIN INVSIVE	PRXOVR	DEF					NA	NA	NA	N
G8875	BREAST CANCER DX MIN INVSIVE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8876	DOC REAS NO MIN INV DX	PRXOVR	DEF					NA	NA	NA	N
G8876	DOC REAS NO MIN INV DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8877	NO BRST CNCR DX MIN INVASIVE	PRXOVR	DEF					NA	NA	NA	N
G8877	NO BRST CNCR DX MIN INVASIVE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8878	SENT LYMPH NODE BIOPSY	PRXOVR	DEF					NA	NA	NA	N
G8878	SENT LYMPH NODE BIOPSY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8880	SEN LYM P NODE BIOP NOT PERF	PRXOVR	DEF					NA	NA	NA	N
G8880	SEN LYM P NODE BIOP NOT PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8881	BRST CNCR STAGE > T1N0M0	PRXOVR	DEF					NA	NA	NA	N
G8881	BRST CNCR STAGE > T1N0M0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8882	NO SENT LYMPH NODE BIOPSY	PRXOVR	DEF					NA	NA	NA	N
G8882	NO SENT LYMPH NODE BIOPSY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8883	REV; COMM; TRACK; DOC BIOPSY	PRXOVR	DEF					NA	NA	NA	N
G8883	REV; COMM; TRACK; DOC BIOPSY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8884	DOC REAS BIOPSY NOT REVIEW	PRXOVR	DEF					NA	NA	NA	N
G8884	DOC REAS BIOPSY NOT REVIEW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8885	NO REV; COMM; TRACK BIOPSY	PRXOVR	DEF					NA	NA	NA	N
G8885	NO REV; COMM; TRACK BIOPSY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8923	LVEF <= 40% OR LVSD	PRXOVR	DEF					NA	NA	NA	N
G8923	LVEF <= 40% OR LVSD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8924	SPIR FEV1/FVC<70%;FEV<60%	PRXOVR	DEF					NA	NA	NA	N
G8924	SPIR FEV1/FVC<70%;FEV<60%	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8925	SPIR FEV1/FVC>=60% & NO COPD	PRXOVR	DEF					NA	NA	NA	N
G8925	SPIR FEV1/FVC>=60% & NO COPD	MAXFEE	DEF					NA			N
G8926	SPIRO NO PERF OR DOC	PRXOVR	DEF					NA	NA	NA	N
G8926	SPIRO NO PERF OR DOC	MAXFEE	DEF					NA			N
G8934	LVEF <=40% OR DEP LV SYS FCN	PRXOVR	DEF					NA	NA	NA	N
G8934	LVEF <=40% OR DEP LV SYS FCN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8935	RX ACE OR ARB THERAPY	PRXOVR	DEF					NA	NA	NA	N
G8935	RX ACE OR ARB THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8936	PT NOT ELIGIBLE ACE/ARB	PRXOVR	DEF					NA	NA	NA	N
G8936	PT NOT ELIGIBLE ACE/ARB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8937	NO RX ACE/ARB THERAPY	PRXOVR	DEF					NA	NA	NA	N
G8937	NO RX ACE/ARB THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8938	BMI DOC ONL FUP NT DOC	PRXOVR	DEF					NA	NA	NA	N
G8938	BMI DOC ONL FUP NT DOC	MAXFEE	DEF					NA			N
G8939	PAIN AS DOC POSITIVE; NO F/U	PRXOVR	DEF					NA	NA	NA	N
G8939	PAIN AS DOC POSITIVE; NO F/U	MAXFEE	DEF					NA			N
G8941	ELD MALTREATMENT DOC AS POS	PRXOVR	DEF					NA	NA	NA	N
G8941	ELD MALTREATMENT DOC AS POS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8942	DOC FCN/CARE PLAN W/30 DAYS	PRXOVR	DEF					NA	NA	NA	N
G8942	DOC FCN/CARE PLAN W/30 DAYS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8944	AJCC MEL CNR STG 0 - IIC	PRXOVR	DEF					NA	NA	NA	N
G8944	AJCC MEL CNR STG 0 - IIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8946	MIBM BUT NO DX OF BREAST CA	PRXOVR	DEF					NA	NA	NA	N
G8946	MIBM BUT NO DX OF BREAST CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8950	PRE-HTN OR HTN DOC; F/U INDC	PRXOVR	DEF					NA	NA	NA	N
G8950	PRE-HTN OR HTN DOC; F/U INDC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8952	PRE-HTN/HTN; NO F/U; NOT GVN	PRXOVR	DEF					NA	NA	NA	N
G8952	PRE-HTN/HTN; NO F/U; NOT GVN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8955	MOST RECENT ASSESS VOL MGMT	PRXOVR	DEF					NA	NA	NA	N
G8955	MOST RECENT ASSESS VOL MGMT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8956	PT RCV HEDIA OUTPT DYLS FAC	PRXOVR	DEF					NA	NA	NA	N
G8956	PT RCV HEDIA OUTPT DYLS FAC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8958	ASSESS VOL MGMT NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G8958	ASSESS VOL MGMT NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8959	CLIN TX MDD COMM TO TX CLIN	PRXOVR	DEF					NA	NA	NA	N
G8959	CLIN TX MDD COMM TO TX CLIN	MAXFEE	DEF					NA			N
G8960	CLIN TX MDD NOT COMM	PRXOVR	DEF					NA	NA	NA	N
G8960	CLIN TX MDD NOT COMM	MAXFEE	DEF					NA			N
G8961	CSIT LOWRISK SURG PTS PREOP	PRXOVR	DEF					NA	NA	NA	N
G8961	CSIT LOWRISK SURG PTS PREOP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8962	CSIT ON PT ANY REAS 30 DAYS	PRXOVR	DEF					NA	NA	NA	N
G8962	CSIT ON PT ANY REAS 30 DAYS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8963	CSI PER ASX PT W/PCI 2 YRS	PRXOVR	DEF					NA	NA	NA	N
G8963	CSI PER ASX PT W/PCI 2 YRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8964	CSI ANY OTHER THAN PCI 2 YR	PRXOVR	DEF					NA	NA	NA	N
G8964	CSI ANY OTHER THAN PCI 2 YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8965	CSIT PERF ON LOW CHD RSK	PRXOVR	DEF					NA	NA	NA	N
G8965	CSIT PERF ON LOW CHD RSK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8966	CSIT PERF SX OR HIGH CHD RSK	PRXOVR	DEF					NA	NA	NA	N
G8966	CSIT PERF SX OR HIGH CHD RSK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8967	WARF OR OTHER FDA DRUG PRESC	PRXOVR	DEF					NA	NA	NA	N
G8967	WARF OR OTHER FDA DRUG PRESC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8968	DOC MED NOT PRESB	PRXOVR	DEF					NA	NA	NA	N
G8968	DOC MED NOT PRESB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8969	DOC PT RSN NO PRESC WARF/FDA	PRXOVR	DEF					NA	NA	NA	N
G8969	DOC PT RSN NO PRESC WARF/FDA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8970	NO RSK FAC OR 1 MOD RISK TE	PRXOVR	DEF					NA	NA	NA	N
G8970	NO RSK FAC OR 1 MOD RISK TE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8973	MST RCNT HBB < 10G/DL	PRXOVR	DEF					NA	NA	NA	N
G8973	MST RCNT HBB < 10G/DL	MAXFEE	DEF					NA			N
G8974	HGB NOT DOC RNS NOT GVN	PRXOVR	DEF					NA	NA	NA	N
G8974	HGB NOT DOC RNS NOT GVN	MAXFEE	DEF					NA			N
G8975	HGB <10G/DL; MED RSN	PRXOVR	DEF					NA	NA	NA	N
G8975	HGB <10G/DL; MED RSN	MAXFEE	DEF					NA			N
G8976	HGB >= 10 G/DL	PRXOVR	DEF					NA	NA	NA	N
G8976	HGB >= 10 G/DL	MAXFEE	DEF					NA			N
G9063	ONC DX NSCLC STGI NO PROGRES	PRXOVR	DEF					NA	NA	NA	N
G9063	ONC DX NSCLC STGI NO PROGRES	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9064	ONC DX NSCLC STG2 NO PROGRES	PRXOVR	DEF					NA	NA	NA	N
G9064	ONC DX NSCLC STG2 NO PROGRES	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9065	ONC DX NSCLC STG3A NO PROGRE	PRXOVR	DEF					NA	NA	NA	N
G9065	ONC DX NSCLC STG3A NO PROGRE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9066	ONC DX NSCLC STG3B-4 METASTA	PRXOVR	DEF					NA	NA	NA	N
G9066	ONC DX NSCLC STG3B-4 METASTA	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9067	ONC DX NSCLC DX UNKNOWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9067	ONC DX NSCLC DX UNKNOWN NOS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9068	ONC DX SCLC/NSCLC LIMITED	PRXOVR	DEF					NA	NA	NA	N
G9068	ONC DX SCLC/NSCLC LIMITED	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9069	ONC DX SCLC/NSCLC EXT AT DX	PRXOVR	DEF					NA	NA	NA	N
G9069	ONC DX SCLC/NSCLC EXT AT DX	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9070	ONC DX SCLC/NSCLC EXT UNKNWN	PRXOVR	DEF					NA	NA	NA	N
G9070	ONC DX SCLC/NSCLC EXT UNKNWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9071	ONC DX BRST STG1-2B HR;NOPRO	PRXOVR	DEF					NA	NA	NA	N
G9071	ONC DX BRST STG1-2B HR;NOPRO	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9072	ONC DX BRST STG1-2 NOPROGRES	PRXOVR	DEF					NA	NA	NA	N
G9072	ONC DX BRST STG1-2 NOPROGRES	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9073	ONC DX BRST STG3-HR; NO PRO	PRXOVR	DEF					NA	NA	NA	N
G9073	ONC DX BRST STG3-HR; NO PRO	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9074	ONC DX BRST STG3-NOPROGRESS	PRXOVR	DEF					NA	NA	NA	N
G9074	ONC DX BRST STG3-NOPROGRESS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9075	ONC DX BRST METASTIC/ RECUR	PRXOVR	DEF					NA	NA	NA	N
G9075	ONC DX BRST METASTIC/ RECUR	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9077	ONC DX PROSTATE T1NO PROGRES	PRXOVR	DEF					NA	NA	NA	N
G9077	ONC DX PROSTATE T1NO PROGRES	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9078	ONC DX PROSTATE T2NO PROGRES	PRXOVR	DEF					NA	NA	NA	N
G9078	ONC DX PROSTATE T2NO PROGRES	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9079	ONC DX PROSTATE T3B-T4NOPROG	PRXOVR	DEF					NA	NA	NA	N
G9079	ONC DX PROSTATE T3B-T4NOPROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9080	ONC DX PROSTATE W/RISE PSA	PRXOVR	DEF					NA	NA	NA	N
G9080	ONC DX PROSTATE W/RISE PSA	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9083	ONC DX PROSTATE UNKNWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9083	ONC DX PROSTATE UNKNWN NOS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9084	ONC DX COLON T1-3;N1-2;NO PR	PRXOVR	DEF					NA	NA	NA	N
G9084	ONC DX COLON T1-3;N1-2;NO PR	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9085	ONC DX COLON T4; N0 W/O PROG	PRXOVR	DEF					NA	NA	NA	N
G9085	ONC DX COLON T4; N0 W/O PROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9086	ONC DX COLON T1-4 NO DX PROG	PRXOVR	DEF					NA	NA	NA	N
G9086	ONC DX COLON T1-4 NO DX PROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9087	ONC DX COLON METAS EVID DX	PRXOVR	DEF					NA	NA	NA	N
G9087	ONC DX COLON METAS EVID DX	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9088	ONC DX COLON METAS NOEVID DX	PRXOVR	DEF					NA	NA	NA	N
G9088	ONC DX COLON METAS NOEVID DX	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9089	ONC DX COLON EXTENT UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9089	ONC DX COLON EXTENT UNKNOWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9090	ONC DX RECTAL T1-2 NO PROGR	PRXOVR	DEF					NA	NA	NA	N
G9090	ONC DX RECTAL T1-2 NO PROGR	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9091	ONC DX RECTAL T3 N0 NO PROG	PRXOVR	DEF					NA	NA	NA	N
G9091	ONC DX RECTAL T3 N0 NO PROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9092	ONC DX RECTAL T1-3;N1-2NOPRG	PRXOVR	DEF					NA	NA	NA	N
G9092	ONC DX RECTAL T1-3;N1-2NOPRG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9093	ONC DX RECTAL T4;N;M0 NO PRG	PRXOVR	DEF					NA	NA	NA	N
G9093	ONC DX RECTAL T4;N;M0 NO PRG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9094	ONC DX RECTAL M1 W/METS PROG	PRXOVR	DEF					NA	NA	NA	N
G9094	ONC DX RECTAL M1 W/METS PROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9095	ONC DX RECTAL EXTENT UNKNWN	PRXOVR	DEF					NA	NA	NA	N
G9095	ONC DX RECTAL EXTENT UNKNWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9096	ONC DX ESOPHAG T1-T3 NOPROG	PRXOVR	DEF					NA	NA	NA	N
G9096	ONC DX ESOPHAG T1-T3 NOPROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9097	ONC DX ESOPHAGEAL T4 NO PROG	PRXOVR	DEF					NA	NA	NA	N
G9097	ONC DX ESOPHAGEAL T4 NO PROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9098	ONC DX ESOPHAGEAL METS RECUR	PRXOVR	DEF					NA	NA	NA	N
G9098	ONC DX ESOPHAGEAL METS RECUR	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9099	ONC DX ESOPHAGEAL UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9099	ONC DX ESOPHAGEAL UNKNOWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9100	ONC DX GASTRIC NO RECURRENCE	PRXOVR	DEF					NA	NA	NA	N
G9100	ONC DX GASTRIC NO RECURRENCE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9101	ONC DX GASTRIC P R1-R2NOPROG	PRXOVR	DEF					NA	NA	NA	N
G9101	ONC DX GASTRIC P R1-R2NOPROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9102	ONC DX GASTRIC UNRESECTABLE	PRXOVR	DEF					NA	NA	NA	N
G9102	ONC DX GASTRIC UNRESECTABLE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9103	ONC DX GASTRIC RECURRENT	PRXOVR	DEF					NA	NA	NA	N
G9103	ONC DX GASTRIC RECURRENT	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9104	ONC DX GASTRIC UNKNOWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9104	ONC DX GASTRIC UNKNOWN NOS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9105	ONC DX PANCREATC P R0 RES NO	PRXOVR	DEF					NA	NA	NA	N
G9105	ONC DX PANCREATC P R0 RES NO	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9106	ONC DX PANCREATC P R1/R2 NO	PRXOVR	DEF					NA	NA	NA	N
G9106	ONC DX PANCREATC P R1/R2 NO	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9107	ONC DX PANCREATIC UNRESECTAB	PRXOVR	DEF					NA	NA	NA	N
G9107	ONC DX PANCREATIC UNRESECTAB	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9108	ONC DX PANCREATIC UNKNWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9108	ONC DX PANCREATIC UNKNWN NOS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9109	ONC DX HEAD/NECK T1-T2NO PRG	PRXOVR	DEF					NA	NA	NA	N
G9109	ONC DX HEAD/NECK T1-T2NO PRG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9110	ONC DX HEAD/NECK T3-4 NOPROG	PRXOVR	DEF					NA	NA	NA	N
G9110	ONC DX HEAD/NECK T3-4 NOPROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9111	ONC DX HEAD/NECK M1 METS REC	PRXOVR	DEF					NA	NA	NA	N
G9111	ONC DX HEAD/NECK M1 METS REC	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9112	ONC DX HEAD/NECK EXT UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9112	ONC DX HEAD/NECK EXT UNKNOWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9113	ONC DX OVARIAN STG1A-B NO PR	PRXOVR	DEF					NA	NA	NA	N
G9113	ONC DX OVARIAN STG1A-B NO PR	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9114	ONC DX OVARIAN STG1A-B OR 2	PRXOVR	DEF					NA	NA	NA	N
G9114	ONC DX OVARIAN STG1A-B OR 2	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9115	ONC DX OVARIAN STG3/4 NOPROG	PRXOVR	DEF					NA	NA	NA	N
G9115	ONC DX OVARIAN STG3/4 NOPROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9116	ONC DX OVARIAN RECURRENCE	PRXOVR	DEF					NA	NA	NA	N
G9116	ONC DX OVARIAN RECURRENCE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9117	ONC DX OVARIAN UNKNOWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9117	ONC DX OVARIAN UNKNOWN NOS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9123	ONC DX CML CHRONIC PHASE	PRXOVR	DEF					NA	NA	NA	N
G9123	ONC DX CML CHRONIC PHASE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9124	ONC DX CML ACCELER PHASE	PRXOVR	DEF					NA	NA	NA	N
G9124	ONC DX CML ACCELER PHASE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9125	ONC DX CML BLAST PHASE	PRXOVR	DEF					NA	NA	NA	N
G9125	ONC DX CML BLAST PHASE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9126	ONC DX CML REMISSION	PRXOVR	DEF					NA	NA	NA	N
G9126	ONC DX CML REMISSION	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9128	ONC DX MULTI MYELOMA STAGE I	PRXOVR	DEF					NA	NA	NA	N
G9128	ONC DX MULTI MYELOMA STAGE I	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9129	ONC DX MULT MYELOMA STG2 HIG	PRXOVR	DEF					NA	NA	NA	N
G9129	ONC DX MULT MYELOMA STG2 HIG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9130	ONC DX MULTI MYELOMA UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9130	ONC DX MULTI MYELOMA UNKNOWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9131	ONC DX BRST UNKNOWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9131	ONC DX BRST UNKNOWN NOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9132	ONC DX PROSTATE METS NO CAST	PRXOVR	DEF					NA	NA	NA	N
G9132	ONC DX PROSTATE METS NO CAST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9133	ONC DX PROSTATE CLINICAL MET	PRXOVR	DEF					NA	NA	NA	N
G9133	ONC DX PROSTATE CLINICAL MET	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9134	ONC NHLSTG 1-2 NO RELAP NO	PRXOVR	DEF					NA	NA	NA	N
G9134	ONC NHLSTG 1-2 NO RELAP NO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9135	ONC DX NHL STG 3-4 NOT RELAP	PRXOVR	DEF					NA	NA	NA	N
G9135	ONC DX NHL STG 3-4 NOT RELAP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9136	ONC DX NHL TRANS TO LG BCELL	PRXOVR	DEF					NA	NA	NA	N
G9136	ONC DX NHL TRANS TO LG BCELL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9137	ONC DX NHL RELAPSE/REFRACTOR	PRXOVR	DEF					NA	NA	NA	N
G9137	ONC DX NHL RELAPSE/REFRACTOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9138	ONC DX NHL STG UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9138	ONC DX NHL STG UNKNOWN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9139	ONC DX CML DX STATUS UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9139	ONC DX CML DX STATUS UNKNOWN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9188	BETA NOT GIVEN NO REASON	PRXOVR	DEF					NA	NA	NA	N
G9188	BETA NOT GIVEN NO REASON	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9189	BETA PRES OR ALREADY TAKING	PRXOVR	DEF					NA	NA	NA	N
G9189	BETA PRES OR ALREADY TAKING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9190	MEDICAL REASON FOR NO BETA	PRXOVR	DEF					NA	NA	NA	N
G9190	MEDICAL REASON FOR NO BETA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9191	PT REASON FOR NO BETA	PRXOVR	DEF					NA	NA	NA	N
G9191	PT REASON FOR NO BETA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9192	SYSTEM REASON FOR NO BETA	PRXOVR	DEF					NA	NA	NA	N
G9192	SYSTEM REASON FOR NO BETA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9196	MED REASON FOR NO CEPH	PRXOVR	DEF					NA	NA	NA	N
G9196	MED REASON FOR NO CEPH	MAXFEE	DEF					NA			N
G9197	ORDER FOR CEPH	PRXOVR	DEF					NA	NA	NA	N
G9197	ORDER FOR CEPH	MAXFEE	DEF					NA			N
G9198	NO ORDER FOR CEPH NO REASON	PRXOVR	DEF					NA	NA	NA	N
G9198	NO ORDER FOR CEPH NO REASON	MAXFEE	DEF					NA			N
G9212	DOC OF DSM-IV INIT EVAL	PRXOVR	DEF					NA	NA	NA	N
G9212	DOC OF DSM-IV INIT EVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9213	NO DOC OF DSM-IV	PRXOVR	DEF					NA	NA	NA	N
G9213	NO DOC OF DSM-IV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9223	PJP PROPH ORDERED CD4 LOW	PRXOVR	DEF					NA	NA	NA	N
G9223	PJP PROPH ORDERED CD4 LOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9225	NORSN NO FOOT EXAM	PRXOVR	DEF					NA	NA	NA	N
G9225	NORSN NO FOOT EXAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9226	3 COMP FOOT EXAM COMPLETED	PRXOVR	DEF					NA	NA	NA	N
G9226	3 COMP FOOT EXAM COMPLETED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9227	FOA DOC; CARE PLAN NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G9227	FOA DOC; CARE PLAN NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9228	GC CHL SYP DOCUMENTED	PRXOVR	DEF					NA	NA	NA	N
G9228	GC CHL SYP DOCUMENTED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9229	PTRSN NO GC CHL SYP TEST	PRXOVR	DEF					NA	NA	NA	N
G9229	PTRSN NO GC CHL SYP TEST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9230	NORSN FOR GC CHL SYP TEST	PRXOVR	DEF					NA	NA	NA	N
G9230	NORSN FOR GC CHL SYP TEST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9231	DOC ESRD DIA TRANS PREG	PRXOVR	DEF					NA	NA	NA	N
G9231	DOC ESRD DIA TRANS PREG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9232	PTRSN NO COMM COMORBID	PRXOVR	DEF					NA	NA	NA	N
G9232	PTRSN NO COMM COMORBID	MAXFEE	DEF					NA			N
G9239	DOC RSN HEMOD & CATH ACC	PRXOVR	DEF					NA	NA	NA	N
G9239	DOC RSN HEMOD & CATH ACC	MAXFEE	DEF					NA			N
G9240	DOC PT W CATH MAINT DIA	PRXOVR	DEF					NA	NA	NA	N
G9240	DOC PT W CATH MAINT DIA	MAXFEE	DEF					NA			N
G9241	DOC PT W OUT CATH MAINT DIA	PRXOVR	DEF					NA	NA	NA	N
G9241	DOC PT W OUT CATH MAINT DIA	MAXFEE	DEF					NA			N
G9242	DOC VIRAL LOAD >=200	PRXOVR	DEF					NA	NA	NA	N
G9242	DOC VIRAL LOAD >=200	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9243	DOC VIRAL LOAD <200	PRXOVR	DEF					NA	NA	NA	N
G9243	DOC VIRAL LOAD <200	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9246	NO MED VISIT IN 24MO	PRXOVR	DEF					NA	NA	NA	N
G9246	NO MED VISIT IN 24MO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9247	1 MED VISIT IN 24MO	PRXOVR	DEF					NA	NA	NA	N
G9247	1 MED VISIT IN 24MO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9250	DOC OF PAIN COMFORT 48HR	PRXOVR	DEF					NA	NA	NA	N
G9250	DOC OF PAIN COMFORT 48HR	MAXFEE	DEF					NA			N
G9251	DOC NO PAIN COMFORT 48HR	PRXOVR	DEF					NA	NA	NA	N
G9251	DOC NO PAIN COMFORT 48HR	MAXFEE	DEF					NA			N
G9254	DOC PT DISCHG >2D	PRXOVR	DEF					NA	NA	NA	N
G9254	DOC PT DISCHG >2D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9255	DOC PT DISCHG <=2D	PRXOVR	DEF					NA	NA	NA	N
G9255	DOC PT DISCHG <=2D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9256	DOC OF PAT DEATH AFTER CAS	PRXOVR	DEF					NA	NA	NA	N
G9256	DOC OF PAT DEATH AFTER CAS	MAXFEE	DEF					NA			N
G9257	DOC OF PAT STROKE AFTER CAS	PRXOVR	DEF					NA	NA	NA	N
G9257	DOC OF PAT STROKE AFTER CAS	MAXFEE	DEF					NA			N
G9258	DOC OF PAT STROKE AFTER CEA	PRXOVR	DEF					NA	NA	NA	N
G9258	DOC OF PAT STROKE AFTER CEA	MAXFEE	DEF					NA			N
G9259	SURVIVE/NO STROKE POST CAS	PRXOVR	DEF					NA	NA	NA	N
G9259	SURVIVE/NO STROKE POST CAS	MAXFEE	DEF					NA			N
G9260	DOC OF PAT DEATH AFTER CEA	PRXOVR	DEF					NA	NA	NA	N
G9260	DOC OF PAT DEATH AFTER CEA	MAXFEE	DEF					NA			N
G9261	SURVIVE/NO STROKE POST CEA	PRXOVR	DEF					NA	NA	NA	N
G9261	SURVIVE/NO STROKE POST CEA	MAXFEE	DEF					NA			N
G9262	DOC OF DEATH POST-AAA REPAIR	PRXOVR	DEF					NA	NA	NA	N
G9262	DOC OF DEATH POST-AAA REPAIR	MAXFEE	DEF					NA			N
G9263	DOC OF DISCH POST-AAA REPAIR	PRXOVR	DEF					NA	NA	NA	N
G9263	DOC OF DISCH POST-AAA REPAIR	MAXFEE	DEF					NA			N
G9264	DOC RSN HEMOD W/CATH >=90D	PRXOVR	DEF					NA	NA	NA	N
G9264	DOC RSN HEMOD W/CATH >=90D	MAXFEE	DEF					NA			N
G9265	DOC CATH >90D FOR MAINT DIA	PRXOVR	DEF					NA	NA	NA	N
G9265	DOC CATH >90D FOR MAINT DIA	MAXFEE	DEF					NA			N
G9266	NORSN PT CATH >=90D	PRXOVR	DEF					NA	NA	NA	N
G9266	NORSN PT CATH >=90D	MAXFEE	DEF					NA			N
G9267	DOC COMP OR MORT W IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9267	DOC COMP OR MORT W IN 30D	MAXFEE	DEF					NA			N
G9268	DOC COMP OR MORT W IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9268	DOC COMP OR MORT W IN 90D	MAXFEE	DEF					NA			N
G9269	DOC NO COMP OR MORT W IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9269	DOC NO COMP OR MORT W IN 30D	MAXFEE	DEF					NA			N
G9270	DOC NO COMP OR MORT W IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9270	DOC NO COMP OR MORT W IN 90D	MAXFEE	DEF					NA			N
G9273	SYS<140 AND DIA<90	PRXOVR	DEF					NA	NA	NA	N
G9273	SYS<140 AND DIA<90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9274	BP OUT OF NRML LIMITS	PRXOVR	DEF					NA	NA	NA	N
G9274	BP OUT OF NRML LIMITS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9275	DOC OF NON TOBACCO USER	PRXOVR	DEF					NA	NA	NA	N
G9275	DOC OF NON TOBACCO USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9276	DOC OF TOBACCO USER	PRXOVR	DEF					NA	NA	NA	N
G9276	DOC OF TOBACCO USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9277	DOC DAILY ASPIRIN OR CONTRA	PRXOVR	DEF					NA	NA	NA	N
G9277	DOC DAILY ASPIRIN OR CONTRA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9278	DOC NO DAILY ASPIRIN	PRXOVR	DEF					NA	NA	NA	N
G9278	DOC NO DAILY ASPIRIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9279	PNE SCRN DONE DOC VAC DONE	PRXOVR	DEF					NA	NA	NA	N
G9279	PNE SCRN DONE DOC VAC DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9280	PNE NOT GIVEN NORSN	PRXOVR	DEF					NA	NA	NA	N
G9280	PNE NOT GIVEN NORSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9281	PNE SCRN DONE DOC NOT IND	PRXOVR	DEF					NA	NA	NA	N
G9281	PNE SCRN DONE DOC NOT IND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9282	DOC MEDRSN NO HISTO TYPE	PRXOVR	DEF					NA	NA	NA	N
G9282	DOC MEDRSN NO HISTO TYPE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9283	HIST TYPE DOC ON REPORT	PRXOVR	DEF					NA	NA	NA	N
G9283	HIST TYPE DOC ON REPORT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9284	NO HIST TYPE DOC ON REPORT	PRXOVR	DEF					NA	NA	NA	N
G9284	NO HIST TYPE DOC ON REPORT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9285	SITE NOT SMALL CELL LUNG CA	PRXOVR	DEF					NA	NA	NA	N
G9285	SITE NOT SMALL CELL LUNG CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9286	ANTIBIO RX W IN 10D OF SYMPT	PRXOVR	DEF					NA	NA	NA	N
G9286	ANTIBIO RX W IN 10D OF SYMPT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9287	NO ANTIBIO W IN 10D OF SYMPT	PRXOVR	DEF					NA	NA	NA	N
G9287	NO ANTIBIO W IN 10D OF SYMPT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9288	DOC MEDRSN NO HIST TYPE RPT	PRXOVR	DEF					NA	NA	NA	N
G9288	DOC MEDRSN NO HIST TYPE RPT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9289	DOC TYPE NSM LUNG CA	PRXOVR	DEF					NA	NA	NA	N
G9289	DOC TYPE NSM LUNG CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9290	NO DOC TYPE NSM LUNG CA	PRXOVR	DEF					NA	NA	NA	N
G9290	NO DOC TYPE NSM LUNG CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9291	NOT NSM LUNG CA	PRXOVR	DEF					NA	NA	NA	N
G9291	NOT NSM LUNG CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9292	MEDRSN NO PT CATEGORY	PRXOVR	DEF					NA	NA	NA	N
G9292	MEDRSN NO PT CATEGORY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9293	NO PT CATEGORY ON REPORT	PRXOVR	DEF					NA	NA	NA	N
G9293	NO PT CATEGORY ON REPORT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9294	PT CAT AND THCK ON REPORT	PRXOVR	DEF					NA	NA	NA	N
G9294	PT CAT AND THCK ON REPORT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9295	NON CUTANEOUS LOC	PRXOVR	DEF					NA	NA	NA	N
G9295	NON CUTANEOUS LOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9296	DOC SHARE DEC PRIOR PROC	PRXOVR	DEF					NA	NA	NA	N
G9296	DOC SHARE DEC PRIOR PROC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9297	NO DOC SHARE DEC PRIOR PROC	PRXOVR	DEF					NA	NA	NA	N
G9297	NO DOC SHARE DEC PRIOR PROC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9298	EVAL RISK VTE CARD 30D PRIOR	PRXOVR	DEF					NA	NA	NA	N
G9298	EVAL RISK VTE CARD 30D PRIOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9299	NO EVAL RISK VTE CARD PRIOR	PRXOVR	DEF					NA	NA	NA	N
G9299	NO EVAL RISK VTE CARD PRIOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9300	DOC MEDRSN NO COMPL ANTIBIO	PRXOVR	DEF					NA	NA	NA	N
G9300	DOC MEDRSN NO COMPL ANTIBIO	MAXFEE	DEF					NA			N
G9301	DOC COMPL INF ANTIBIO	PRXOVR	DEF					NA	NA	NA	N
G9301	DOC COMPL INF ANTIBIO	MAXFEE	DEF					NA			N
G9302	NORSN INCOMP INF ANTIBIO	PRXOVR	DEF					NA	NA	NA	N
G9302	NORSN INCOMP INF ANTIBIO	MAXFEE	DEF					NA			N
G9303	NORSN NO PROS INFO OP RPT	PRXOVR	DEF					NA	NA	NA	N
G9303	NORSN NO PROS INFO OP RPT	MAXFEE	DEF					NA			N
G9304	PROS INFO OP RPT	PRXOVR	DEF					NA	NA	NA	N
G9304	PROS INFO OP RPT	MAXFEE	DEF					NA			N
G9305	NO INTERV REQ FOR LEAK	PRXOVR	DEF					NA	NA	NA	N
G9305	NO INTERV REQ FOR LEAK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9306	INTERV REQ FOR LEAK	PRXOVR	DEF					NA	NA	NA	N
G9306	INTERV REQ FOR LEAK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9307	NO RET FOR SURG W IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9307	NO RET FOR SURG W IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9308	UNPL RET OR W/COMPL W/IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9308	UNPL RET OR W/COMPL W/IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9309	NO UNPLND HOSP READM IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9309	NO UNPLND HOSP READM IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9310	UNPLND HOSP READM IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9310	UNPLND HOSP READM IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9311	NO SURG SITE INFECTION	PRXOVR	DEF					NA	NA	NA	N
G9311	NO SURG SITE INFECTION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9312	SURGICAL SITE INFECTION	PRXOVR	DEF					NA	NA	NA	N
G9312	SURGICAL SITE INFECTION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9313	AMOXIC NOT PRESC AS 1ST LINE	PRXOVR	DEF					NA	NA	NA	N
G9313	AMOXIC NOT PRESC AS 1ST LINE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9314	NORSN NOT FIRST LINE AMOX	PRXOVR	DEF					NA	NA	NA	N
G9314	NORSN NOT FIRST LINE AMOX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9315	AMOX W/WO CLAV RX	PRXOVR	DEF					NA	NA	NA	N
G9315	AMOX W/WO CLAV RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9316	DOC COMM RISK CALC	PRXOVR	DEF					NA	NA	NA	N
G9316	DOC COMM RISK CALC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9317	NO DOC COMM RISK CALC	PRXOVR	DEF					NA	NA	NA	N
G9317	NO DOC COMM RISK CALC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9318	IMAGE STD NOMENCLATURE	PRXOVR	DEF					NA	NA	NA	N
G9318	IMAGE STD NOMENCLATURE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9319	IMAGE NOT STD NOMENCLATURE	PRXOVR	DEF					NA	NA	NA	N
G9319	IMAGE NOT STD NOMENCLATURE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9321	DOC COUNT OF CT IN 12MO	PRXOVR	DEF					NA	NA	NA	N
G9321	DOC COUNT OF CT IN 12MO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9322	NO DOC COUNT OF CT IN 12MO	PRXOVR	DEF					NA	NA	NA	N
G9322	NO DOC COUNT OF CT IN 12MO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9326	CT DONE NO RAD DS INDEX; NRG	PRXOVR	DEF					NA	NA	NA	N
G9326	CT DONE NO RAD DS INDEX; NRG	MAXFEE	DEF					NA			N
G9327	CT DONE RAD DS INDEX	PRXOVR	DEF					NA	NA	NA	N
G9327	CT DONE RAD DS INDEX	MAXFEE	DEF					NA			N
G9329	NORSN NO DICOM FORMAT DOC	PRXOVR	DEF					NA	NA	NA	N
G9329	NORSN NO DICOM FORMAT DOC	MAXFEE	DEF					NA			N
G9340	DICOM FORMAT DOC ON RPT	PRXOVR	DEF					NA	NA	NA	N
G9340	DICOM FORMAT DOC ON RPT	MAXFEE	DEF					NA			N
G9341	SRCH FOR CT W IN 12 MOS	PRXOVR	DEF					NA	NA	NA	N
G9341	SRCH FOR CT W IN 12 MOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9342	NO SRCH FOR CT IN 12MO NORSN	PRXOVR	DEF					NA	NA	NA	N
G9342	NO SRCH FOR CT IN 12MO NORSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9344	SYSRSN NO DICOM SRCH	PRXOVR	DEF					NA	NA	NA	N
G9344	SYSRSN NO DICOM SRCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9345	FOLLOW UP PULM NOD	PRXOVR	DEF					NA	NA	NA	N
G9345	FOLLOW UP PULM NOD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9347	NO FOLLOW UP PULM NOD NORSN	PRXOVR	DEF					NA	NA	NA	N
G9347	NO FOLLOW UP PULM NOD NORSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9348	DOC RSN FOR ORD CT SCAN	PRXOVR	DEF					NA	NA	NA	N
G9348	DOC RSN FOR ORD CT SCAN	MAXFEE	DEF					NA			N
G9349	CT WITHIN 28 DAYS	PRXOVR	DEF					NA	NA	NA	N
G9349	CT WITHIN 28 DAYS	MAXFEE	DEF					NA			N
G9350	NO DOC SINUS CT 28D OR DX	PRXOVR	DEF					NA	NA	NA	N
G9350	NO DOC SINUS CT 28D OR DX	MAXFEE	DEF					NA			N
G9351	DOC >1 SINUS CT W 90D DX	PRXOVR	DEF					NA	NA	NA	N
G9351	DOC >1 SINUS CT W 90D DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9352	NOT >1 SINUS CT W 90D DX	PRXOVR	DEF					NA	NA	NA	N
G9352	NOT >1 SINUS CT W 90D DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9353	MEDRSN >1 SINUS CT W 90D DX	PRXOVR	DEF					NA	NA	NA	N
G9353	MEDRSN >1 SINUS CT W 90D DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9354	1 OR NO CT SINUS W/IN 90D DX	PRXOVR	DEF					NA	NA	NA	N
G9354	1 OR NO CT SINUS W/IN 90D DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9355	NO EARLY IND/DELIVERY	PRXOVR	DEF					NA	NA	NA	N
G9355	NO EARLY IND/DELIVERY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9356	EARLY IND/DELIVERY	PRXOVR	DEF					NA	NA	NA	N
G9356	EARLY IND/DELIVERY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9357	PP EVAL/EDU PERF	PRXOVR	DEF					NA	NA	NA	N
G9357	PP EVAL/EDU PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9358	PP EVAL/EDU NOT PERF	PRXOVR	DEF					NA	NA	NA	N
G9358	PP EVAL/EDU NOT PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9359	NEG MGD POS TB NOTACT	PRXOVR	DEF					NA	NA	NA	N
G9359	NEG MGD POS TB NOTACT	MAXFEE	DEF					NA			N
G9360	NO DOC OF NEG OR MAN POS TB	PRXOVR	DEF					NA	NA	NA	N
G9360	NO DOC OF NEG OR MAN POS TB	MAXFEE	DEF					NA			N
G9361	DOC RSN ELECT C-SEC/INDUCT	PRXOVR	DEF					NA	NA	NA	N
G9361	DOC RSN ELECT C-SEC/INDUCT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9364	SINUS CAUS BAC INX	PRXOVR	DEF					NA	NA	NA	N
G9364	SINUS CAUS BAC INX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9365	1HIGH RISK MED ORD	PRXOVR	DEF					NA	NA	NA	N
G9365	1HIGH RISK MED ORD	MAXFEE	DEF					NA			N
G9366	1HIGH RISK NO ORD	PRXOVR	DEF					NA	NA	NA	N
G9366	1HIGH RISK NO ORD	MAXFEE	DEF					NA			N
G9367	>= 2 SAME HI-RSK MED ORD	PRXOVR	DEF					NA	NA	NA	N
G9367	>= 2 SAME HI-RSK MED ORD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9368	>= 2 SAME HI-RSK MED NOT ORD	PRXOVR	DEF					NA	NA	NA	N
G9368	>= 2 SAME HI-RSK MED NOT ORD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9380	OFF ASSIS EOL ISS	PRXOVR	DEF					NA	NA	NA	N
G9380	OFF ASSIS EOL ISS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9382	NO OFF ASSIS EOL	PRXOVR	DEF					NA	NA	NA	N
G9382	NO OFF ASSIS EOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9383	RECD SCRN HCV INFEC	PRXOVR	DEF					NA	NA	NA	N
G9383	RECD SCRN HCV INFEC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9384	DOC MED RSN NO HCV SCRN	PRXOVR	DEF					NA	NA	NA	N
G9384	DOC MED RSN NO HCV SCRN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9385	DOC PT REAS NOT REC HCV SRN	PRXOVR	DEF					NA	NA	NA	N
G9385	DOC PT REAS NOT REC HCV SRN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9386	SCRN HCV INFEC NOT RECD	PRXOVR	DEF					NA	NA	NA	N
G9386	SCRN HCV INFEC NOT RECD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9389	UNPLN RUP POST CAP	PRXOVR	DEF					NA	NA	NA	N
G9389	UNPLN RUP POST CAP	MAXFEE	DEF					NA			N
G9390	NO UNPLN RUP POST CAP	PRXOVR	DEF					NA	NA	NA	N
G9390	NO UNPLN RUP POST CAP	MAXFEE	DEF					NA			N
G9393	INI PHQ9 >9 REMISS <5	PRXOVR	DEF					NA	NA	NA	N
G9393	INI PHQ9 >9 REMISS <5	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9394	DX BIPOL; DEATH; NHRES; HOSP	PRXOVR	DEF					NA	NA	NA	N
G9394	DX BIPOL; DEATH; NHRES; HOSP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9395	INI PHQ9 >9 NO REMISS >=5	PRXOVR	DEF					NA	NA	NA	N
G9395	INI PHQ9 >9 NO REMISS >=5	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9396	INI PHQ9 >9 NOT ASSESS	PRXOVR	DEF					NA	NA	NA	N
G9396	INI PHQ9 >9 NOT ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9399	DOC DISC TX CHOICES	PRXOVR	DEF					NA	NA	NA	N
G9399	DOC DISC TX CHOICES	MAXFEE	DEF					NA			N
G9400	DOC REAS NO DISC TX OPT	PRXOVR	DEF					NA	NA	NA	N
G9400	DOC REAS NO DISC TX OPT	MAXFEE	DEF					NA			N
G9401	NO DISC TX CHOICES	PRXOVR	DEF					NA	NA	NA	N
G9401	NO DISC TX CHOICES	MAXFEE	DEF					NA			N
G9402	RECD F/U W/IN 30D DISCH	PRXOVR	DEF					NA	NA	NA	N
G9402	RECD F/U W/IN 30D DISCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9403	DOC REAS NO 30 DAY F/U	PRXOVR	DEF					NA	NA	NA	N
G9403	DOC REAS NO 30 DAY F/U	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9404	NO 30 DAY F/U	PRXOVR	DEF					NA	NA	NA	N
G9404	NO 30 DAY F/U	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9405	RECD F/U W/IN 7D DC	PRXOVR	DEF					NA	NA	NA	N
G9405	RECD F/U W/IN 7D DC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9406	DOC REAS NO 7D F/U	PRXOVR	DEF					NA	NA	NA	N
G9406	DOC REAS NO 7D F/U	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9407	NO 7D F/U	PRXOVR	DEF					NA	NA	NA	N
G9407	NO 7D F/U	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9408	CARD TAMP W/IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9408	CARD TAMP W/IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9409	NO CARD TAMP E/IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9409	NO CARD TAMP E/IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9410	ADMIT W/IN 180D REQ REMOV	PRXOVR	DEF					NA	NA	NA	N
G9410	ADMIT W/IN 180D REQ REMOV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9411	NO ADMIT W/IN 180D REQ REMOV	PRXOVR	DEF					NA	NA	NA	N
G9411	NO ADMIT W/IN 180D REQ REMOV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9412	ADMIT W/IN 180D REQ SURG REV	PRXOVR	DEF					NA	NA	NA	N
G9412	ADMIT W/IN 180D REQ SURG REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9413	NO ADMIT REQ SURG REV	PRXOVR	DEF					NA	NA	NA	N
G9413	NO ADMIT REQ SURG REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9414	1DOSE MENIG VAC BTWN 11 & 13	PRXOVR	DEF					NA	NA	NA	N
G9414	1DOSE MENIG VAC BTWN 11 & 13	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9415	NO 1DOSE MENI VAC BTWN 11&13	PRXOVR	DEF					NA	NA	NA	N
G9415	NO 1DOSE MENI VAC BTWN 11&13	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9416	PT 1 TDAP BETW 10-13 YRS	PRXOVR	DEF					NA	NA	NA	N
G9416	PT 1 TDAP BETW 10-13 YRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9417	PT NOT 1 TDAP BETW 10-13 YRS	PRXOVR	DEF					NA	NA	NA	N
G9417	PT NOT 1 TDAP BETW 10-13 YRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9418	LUNGCX BX RPT DOCS CLASS	PRXOVR	DEF					NA	NA	NA	N
G9418	LUNGCX BX RPT DOCS CLASS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9419	MED REAS NOT INCL HISTO TYPE	PRXOVR	DEF					NA	NA	NA	N
G9419	MED REAS NOT INCL HISTO TYPE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9420	SPEC SITE NO LUNG	PRXOVR	DEF					NA	NA	NA	N
G9420	SPEC SITE NO LUNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9421	LUNG CX BX RPT NO DOC CLASS	PRXOVR	DEF					NA	NA	NA	N
G9421	LUNG CX BX RPT NO DOC CLASS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9422	RPT DOC CLASS HISTO TYPE	PRXOVR	DEF					NA	NA	NA	N
G9422	RPT DOC CLASS HISTO TYPE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9423	MED REAS RPT NO HISTO TYPE	PRXOVR	DEF					NA	NA	NA	N
G9423	MED REAS RPT NO HISTO TYPE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9424	SITE NO LUNG OR LUNG CX	PRXOVR	DEF					NA	NA	NA	N
G9424	SITE NO LUNG OR LUNG CX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9425	SPEC RPT NO DOC CLASS HISTO	PRXOVR	DEF					NA	NA	NA	N
G9425	SPEC RPT NO DOC CLASS HISTO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9426	IMPR MED TIME EDARR PAIN MED	PRXOVR	DEF					NA	NA	NA	N
G9426	IMPR MED TIME EDARR PAIN MED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9427	NO IMPRO MED TIME PAIN MED	PRXOVR	DEF					NA	NA	NA	N
G9427	NO IMPRO MED TIME PAIN MED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9428	PATHO RPT INCL PT CTG	PRXOVR	DEF					NA	NA	NA	N
G9428	PATHO RPT INCL PT CTG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9429	DOC MED RSN NO PT CAT	PRXOVR	DEF					NA	NA	NA	N
G9429	DOC MED RSN NO PT CAT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9430	SPEC SITE NO CUTANEOUS	PRXOVR	DEF					NA	NA	NA	N
G9430	SPEC SITE NO CUTANEOUS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9431	PATHO RPT NO PT CTG	PRXOVR	DEF					NA	NA	NA	N
G9431	PATHO RPT NO PT CTG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9432	ASTH CONTROLLED	PRXOVR	DEF					NA	NA	NA	N
G9432	ASTH CONTROLLED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9434	ASTH NOT CONTROLLED	PRXOVR	DEF					NA	NA	NA	N
G9434	ASTH NOT CONTROLLED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9448	BORN 1945-1965	PRXOVR	DEF					NA	NA	NA	N
G9448	BORN 1945-1965	MAXFEE	DEF					NA			N
G9449	HX BLD TRANSF B/F 1992	PRXOVR	DEF					NA	NA	NA	N
G9449	HX BLD TRANSF B/F 1992	MAXFEE	DEF					NA			N
G9450	HX INJEC DRUG USE	PRXOVR	DEF					NA	NA	NA	N
G9450	HX INJEC DRUG USE	MAXFEE	DEF					NA			N
G9451	1X SCRN HCV INFECT	PRXOVR	DEF					NA	NA	NA	N
G9451	1X SCRN HCV INFECT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9452	DOC MED REAS NO SCRN HCV	PRXOVR	DEF					NA	NA	NA	N
G9452	DOC MED REAS NO SCRN HCV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9453	PT REAS NO HCV INFECT	PRXOVR	DEF					NA	NA	NA	N
G9453	PT REAS NO HCV INFECT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9454	NO SCR HCV INF 12 MTH RP	PRXOVR	DEF					NA	NA	NA	N
G9454	NO SCR HCV INF 12 MTH RP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9455	ABD IMAG W/US; CT OR MRI	PRXOVR	DEF					NA	NA	NA	N
G9455	ABD IMAG W/US; CT OR MRI	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9456	DOC MED PT REAS NO HCC SCRN	PRXOVR	DEF					NA	NA	NA	N
G9456	DOC MED PT REAS NO HCC SCRN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9457	PT NO ABD IMG NO DOC RSN	PRXOVR	DEF					NA	NA	NA	N
G9457	PT NO ABD IMG NO DOC RSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9458	TOB USER RECD CESS INTERV	PRXOVR	DEF					NA	NA	NA	N
G9458	TOB USER RECD CESS INTERV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9459	TOB NON-USER	PRXOVR	DEF					NA	NA	NA	N
G9459	TOB NON-USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9460	NO TOB ASSESS OR CESS INTER	PRXOVR	DEF					NA	NA	NA	N
G9460	NO TOB ASSESS OR CESS INTER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9468	NO RECD CORTICO>=10MG/D >60D	PRXOVR	DEF					NA	NA	NA	N
G9468	NO RECD CORTICO>=10MG/D >60D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9469	REC CORTICO>90D OR 1RX 900MG	PRXOVR	DEF					NA	NA	NA	N
G9469	REC CORTICO>90D OR 1RX 900MG	MAXFEE	DEF					NA			N
G9470	NO REC CORTICO>60D 1RX 600MG	PRXOVR	DEF					NA	NA	NA	N
G9470	NO REC CORTICO>60D 1RX 600MG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9471	W/IN 2YR DXA NOT ORDER	PRXOVR	DEF					NA	NA	NA	N
G9471	W/IN 2YR DXA NOT ORDER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9472	NO DXA NO MED HX NO RV SX	PRXOVR	DEF					NA	NA	NA	N
G9472	NO DXA NO MED HX NO RV SX	MAXFEE	DEF					NA			N
G9497	REC INST NO SMOKE DAY SURG	PRXOVR	DEF					NA	NA	NA	N
G9497	REC INST NO SMOKE DAY SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9498	ABX REG PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
G9498	ABX REG PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9500	RAD EXPOS IND/EXP TM DOC	PRXOVR	DEF					NA	NA	NA	N
G9500	RAD EXPOS IND/EXP TM DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9501	RAD EXPOS IND/EXP TM NO DOC	PRXOVR	DEF					NA	NA	NA	N
G9501	RAD EXPOS IND/EXP TM NO DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9502	MED REAS NO PERF FOOT EXAM	PRXOVR	DEF					NA	NA	NA	N
G9502	MED REAS NO PERF FOOT EXAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9503	PT TK TAMS HCL	PRXOVR	DEF					NA	NA	NA	N
G9503	PT TK TAMS HCL	MAXFEE	DEF					NA			N
G9504	DOC RSN HEP B STAT NOT ASSES	PRXOVR	DEF					NA	NA	NA	N
G9504	DOC RSN HEP B STAT NOT ASSES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9505	ABX PRES W/IN 10 DYS OF SYMP	PRXOVR	DEF					NA	NA	NA	N
G9505	ABX PRES W/IN 10 DYS OF SYMP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9506	BIO IMM RESP MOD PRESC	PRXOVR	DEF					NA	NA	NA	N
G9506	BIO IMM RESP MOD PRESC	MAXFEE	DEF					NA			N
G9507	DOC REAS ON STATIN OR CONTRA	PRXOVR	DEF					NA	NA	NA	N
G9507	DOC REAS ON STATIN OR CONTRA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9508	DOC PT NOT ON STATIN	PRXOVR	DEF					NA	NA	NA	N
G9508	DOC PT NOT ON STATIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9509	ADIT MDD DYS REM 12 MNTHS	PRXOVR	DEF					NA	NA	NA	N
G9509	ADIT MDD DYS REM 12 MNTHS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9510	REMIS12M NOT PHQ-9 SCORE <5	PRXOVR	DEF					NA	NA	NA	N
G9510	REMIS12M NOT PHQ-9 SCORE <5	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9511	IDX EVT DTE PHQ>9 DOC 12 MO	PRXOVR	DEF					NA	NA	NA	N
G9511	IDX EVT DTE PHQ>9 DOC 12 MO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9512	INDIV PDC > 0.8	PRXOVR	DEF					NA	NA	NA	N
G9512	INDIV PDC > 0.8	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9513	INDIV PDC NOT > 0.8	PRXOVR	DEF					NA	NA	NA	N
G9513	INDIV PDC NOT > 0.8	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9514	REQ RET OR W/IN 90D OF SURG	PRXOVR	DEF					NA	NA	NA	N
G9514	REQ RET OR W/IN 90D OF SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9515	NO REAS; NO RET OR W/IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9515	NO REAS; NO RET OR W/IN 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9516	IMPR VIS ACUIT W/IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9516	IMPR VIS ACUIT W/IN 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9517	NO IMPR VIS ACUIT W/IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9517	NO IMPR VIS ACUIT W/IN 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9518	DOC ACTIVE INJ DRUG USE	PRXOVR	DEF					NA	NA	NA	N
G9518	DOC ACTIVE INJ DRUG USE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9519	FINAL REF +/- 1.0 W/IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9519	FINAL REF +/- 1.0 W/IN 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9520	REFRACT NOT +/- 1.0 W/IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9520	REFRACT NOT +/- 1.0 W/IN 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9521	ER AND IP HOSP <2 IN 12 MOS	PRXOVR	DEF					NA	NA	NA	N
G9521	ER AND IP HOSP <2 IN 12 MOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9522	ER/IP HOSP =/>2 IN 12 MOS	PRXOVR	DEF					NA	NA	NA	N
G9522	ER/IP HOSP =/>2 IN 12 MOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9523	D/C HEMO OR PERIT DIALYSIS	PRXOVR	DEF					NA	NA	NA	N
G9523	D/C HEMO OR PERIT DIALYSIS	MAXFEE	DEF					NA			N
G9524	REFER TO HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9524	REFER TO HOSPICE	MAXFEE	DEF					NA			N
G9525	DOC PT REAS NO HOSPICE REFER	PRXOVR	DEF					NA	NA	NA	N
G9525	DOC PT REAS NO HOSPICE REFER	MAXFEE	DEF					NA			N
G9526	NO REASON; NO REFER HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9526	NO REASON; NO REFER HOSPICE	MAXFEE	DEF					NA			N
G9529	MINOR BLUNT TRAUMA W/HEAD CT	PRXOVR	DEF					NA	NA	NA	N
G9529	MINOR BLUNT TRAUMA W/HEAD CT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9530	PT MBHT HD CT ORD EC PROV	PRXOVR	DEF					NA	NA	NA	N
G9530	PT MBHT HD CT ORD EC PROV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9531	PT DOC	PRXOVR	DEF					NA	NA	NA	N
G9531	PT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9532	PT HD CT ORD	PRXOVR	DEF					NA	NA	NA	N
G9532	PT HD CT ORD	MAXFEE	DEF					NA			N
G9533	INDIC FOR HEAD CT NOT VALID	PRXOVR	DEF					NA	NA	NA	N
G9533	INDIC FOR HEAD CT NOT VALID	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9534	ADV BRAIN IMAGE NOT ORDERED	PRXOVR	DEF					NA	NA	NA	N
G9534	ADV BRAIN IMAGE NOT ORDERED	MAXFEE	DEF					NA			N
G9535	NORMAL NEURO EXAM	PRXOVR	DEF					NA	NA	NA	N
G9535	NORMAL NEURO EXAM	MAXFEE	DEF					NA			N
G9536	DOC MED REAS ADV BRAIN IMAGE	PRXOVR	DEF					NA	NA	NA	N
G9536	DOC MED REAS ADV BRAIN IMAGE	MAXFEE	DEF					NA			N
G9537	IMG HD CLIN TRIAL	PRXOVR	DEF					NA	NA	NA	N
G9537	IMG HD CLIN TRIAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9538	ADV BRAIN IMAGE ORDERED	PRXOVR	DEF					NA	NA	NA	N
G9538	ADV BRAIN IMAGE ORDERED	MAXFEE	DEF					NA			N
G9539	INTENT POT REMV TIME PLACEMT	PRXOVR	DEF					NA	NA	NA	N
G9539	INTENT POT REMV TIME PLACEMT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9540	PT ALIVE 3 MOS POST PROC	PRXOVR	DEF					NA	NA	NA	N
G9540	PT ALIVE 3 MOS POST PROC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9541	FILTER REM 3 MON PLMT	PRXOVR	DEF					NA	NA	NA	N
G9541	FILTER REM 3 MON PLMT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9542	DOC REASS APPR REMO FILT 3MS	PRXOVR	DEF					NA	NA	NA	N
G9542	DOC REASS APPR REMO FILT 3MS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9543	DOC 2X RE-ASSESS FILT REMOV	PRXOVR	DEF					NA	NA	NA	N
G9543	DOC 2X RE-ASSESS FILT REMOV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9544	NO FILT REMOV W/IN 3MOS PLCM	PRXOVR	DEF					NA	NA	NA	N
G9544	NO FILT REMOV W/IN 3MOS PLCM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9547	CYS REN LES OR ADREN	PRXOVR	DEF					NA	NA	NA	N
G9547	CYS REN LES OR ADREN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9548	NO F/U REC IMAGE STUDY	PRXOVR	DEF					NA	NA	NA	N
G9548	NO F/U REC IMAGE STUDY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9549	DOC MED RSN FOR F/U IMAG	PRXOVR	DEF					NA	NA	NA	N
G9549	DOC MED RSN FOR F/U IMAG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9550	IMAG REC	PRXOVR	DEF					NA	NA	NA	N
G9550	IMAG REC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9551	IMAG NO LES	PRXOVR	DEF					NA	NA	NA	N
G9551	IMAG NO LES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9552	INC THYR NODE <1.0 IN RPT	PRXOVR	DEF					NA	NA	NA	N
G9552	INC THYR NODE <1.0 IN RPT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9553	PRIOR THYROID DISE DX	PRXOVR	DEF					NA	NA	NA	N
G9553	PRIOR THYROID DISE DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9554	CT/CTA/MRI/A CHST FOLL REC	PRXOVR	DEF					NA	NA	NA	N
G9554	CT/CTA/MRI/A CHST FOLL REC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9555	DOC MED RSN FOR FOLLUP IMAGE	PRXOVR	DEF					NA	NA	NA	N
G9555	DOC MED RSN FOR FOLLUP IMAGE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9556	CT/CTA/MRI/A NO FOLLUP IMAG	PRXOVR	DEF					NA	NA	NA	N
G9556	CT/CTA/MRI/A NO FOLLUP IMAG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9557	CT/CTA/MRI/A NO THYR <1.0CM	PRXOVR	DEF					NA	NA	NA	N
G9557	CT/CTA/MRI/A NO THYR <1.0CM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9558	TX BETA-LACTAM ABX THERAPY	PRXOVR	DEF					NA	NA	NA	N
G9558	TX BETA-LACTAM ABX THERAPY	MAXFEE	DEF					NA			N
G9559	DOC MED REAS NO ABX THERAPY	PRXOVR	DEF					NA	NA	NA	N
G9559	DOC MED REAS NO ABX THERAPY	MAXFEE	DEF					NA			N
G9560	NO BETA-LACTAM ABX THER; RNG	PRXOVR	DEF					NA	NA	NA	N
G9560	NO BETA-LACTAM ABX THER; RNG	MAXFEE	DEF					NA			N
G9561	PRESC OPIATES >6 WKS	PRXOVR	DEF					NA	NA	NA	N
G9561	PRESC OPIATES >6 WKS	MAXFEE	DEF					NA			N
G9562	FOLL-UP EVAL Q3MO OPIOD TX	PRXOVR	DEF					NA	NA	NA	N
G9562	FOLL-UP EVAL Q3MO OPIOD TX	MAXFEE	DEF					NA			N
G9563	NO F/U EVAL Q3MO OPIOD TX	PRXOVR	DEF					NA	NA	NA	N
G9563	NO F/U EVAL Q3MO OPIOD TX	MAXFEE	DEF					NA			N
G9573	ADL PT MD OR DYS REM 6 MON	PRXOVR	DEF					NA	NA	NA	N
G9573	ADL PT MD OR DYS REM 6 MON	MAXFEE	DEF					NA			N
G9574	ADL PT MD DYS NO REM 6 MON	PRXOVR	DEF					NA	NA	NA	N
G9574	ADL PT MD DYS NO REM 6 MON	MAXFEE	DEF					NA			N
G9577	PRESC OPIATES >6 WKS	PRXOVR	DEF					NA	NA	NA	N
G9577	PRESC OPIATES >6 WKS	MAXFEE	DEF					NA			N
G9578	DOC OPIOID TX 1X DURING THER	PRXOVR	DEF					NA	NA	NA	N
G9578	DOC OPIOID TX 1X DURING THER	MAXFEE	DEF					NA			N
G9579	NO DOC OPIOID TX 1X AT THER	PRXOVR	DEF					NA	NA	NA	N
G9579	NO DOC OPIOID TX 1X AT THER	MAXFEE	DEF					NA			N
G9580	DOOR TO PUNC TIME <2HRS	PRXOVR	DEF					NA	NA	NA	N
G9580	DOOR TO PUNC TIME <2HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9582	DOOR TO PUNC TIME >2HR; NRG	PRXOVR	DEF					NA	NA	NA	N
G9582	DOOR TO PUNC TIME >2HR; NRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9583	PRESC OPIATES >6 WKS	PRXOVR	DEF					NA	NA	NA	N
G9583	PRESC OPIATES >6 WKS	MAXFEE	DEF					NA			N
G9584	EVAL OPIOID USE INSTR/PT INT	PRXOVR	DEF					NA	NA	NA	N
G9584	EVAL OPIOID USE INSTR/PT INT	MAXFEE	DEF					NA			N
G9585	NO EVAL OPI USE INSTR/INTV	PRXOVR	DEF					NA	NA	NA	N
G9585	NO EVAL OPI USE INSTR/INTV	MAXFEE	DEF					NA			N
G9593	LOW PECARN PED HEAD TRAUMA	PRXOVR	DEF					NA	NA	NA	N
G9593	LOW PECARN PED HEAD TRAUMA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9594	PT MBHT HD CT ORD EC PROV	PRXOVR	DEF					NA	NA	NA	N
G9594	PT MBHT HD CT ORD EC PROV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9595	DOC SHNT/TUM/COAG	PRXOVR	DEF					NA	NA	NA	N
G9595	DOC SHNT/TUM/COAG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9596	PED PT HD CT ORD	PRXOVR	DEF					NA	NA	NA	N
G9596	PED PT HD CT ORD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9597	NO LOW PECARN PED HEAD TRAUM	PRXOVR	DEF					NA	NA	NA	N
G9597	NO LOW PECARN PED HEAD TRAUM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9598	AOR ANE 5.5-5.9 CM MAX DIAM	PRXOVR	DEF					NA	NA	NA	N
G9598	AOR ANE 5.5-5.9 CM MAX DIAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9599	AOR ANE >=6.0 CM MAX DIAM	PRXOVR	DEF					NA	NA	NA	N
G9599	AOR ANE >=6.0 CM MAX DIAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9600	SYMP AAA URGENT REPAIR	PRXOVR	DEF					NA	NA	NA	N
G9600	SYMP AAA URGENT REPAIR	MAXFEE	DEF					NA			N
G9601	PT DCHG HOME POST OP DAY 7	PRXOVR	DEF					NA	NA	NA	N
G9601	PT DCHG HOME POST OP DAY 7	MAXFEE	DEF					NA			N
G9602	PT NO DCHG HOME POSTOP DAY 7	PRXOVR	DEF					NA	NA	NA	N
G9602	PT NO DCHG HOME POSTOP DAY 7	MAXFEE	DEF					NA			N
G9603	PT SURV IMPROV BSLINE TX	PRXOVR	DEF					NA	NA	NA	N
G9603	PT SURV IMPROV BSLINE TX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9604	PT SURV RESULTS NOT AVAIL	PRXOVR	DEF					NA	NA	NA	N
G9604	PT SURV RESULTS NOT AVAIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9605	SURV SCORE NO IMPROV W/TX	PRXOVR	DEF					NA	NA	NA	N
G9605	SURV SCORE NO IMPROV W/TX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9606	INTRAOP CYST EVAL TRAC INJ	PRXOVR	DEF					NA	NA	NA	N
G9606	INTRAOP CYST EVAL TRAC INJ	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9607	DOC MED RSN NOT PERF CYSTOSC	PRXOVR	DEF					NA	NA	NA	N
G9607	DOC MED RSN NOT PERF CYSTOSC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9608	INTRAOP CYST EVAL NOT DONE	PRXOVR	DEF					NA	NA	NA	N
G9608	INTRAOP CYST EVAL NOT DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9609	DOC ORDER ANTI-PLAT	PRXOVR	DEF					NA	NA	NA	N
G9609	DOC ORDER ANTI-PLAT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9610	DOC MD RSN NO ANTIPLA	PRXOVR	DEF					NA	NA	NA	N
G9610	DOC MD RSN NO ANTIPLA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9611	NO DOC ORDER ANTI-PLAT RNG	PRXOVR	DEF					NA	NA	NA	N
G9611	NO DOC ORDER ANTI-PLAT RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9612	PHODOC 2 MR CEC LNDMK	PRXOVR	DEF					NA	NA	NA	N
G9612	PHODOC 2 MR CEC LNDMK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9613	DOC POST SURG ANATOMY	PRXOVR	DEF					NA	NA	NA	N
G9613	DOC POST SURG ANATOMY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9614	PHOTODOC < 2 CEC LNDMK	PRXOVR	DEF					NA	NA	NA	N
G9614	PHOTODOC < 2 CEC LNDMK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9615	PRE-OP ASST DOC	PRXOVR	DEF					NA	NA	NA	N
G9615	PRE-OP ASST DOC	MAXFEE	DEF					NA			N
G9616	DOC RSN NO PREOP ASSMT	PRXOVR	DEF					NA	NA	NA	N
G9616	DOC RSN NO PREOP ASSMT	MAXFEE	DEF					NA			N
G9617	PRE-OP ASST NOT DOC; RNG	PRXOVR	DEF					NA	NA	NA	N
G9617	PRE-OP ASST NOT DOC; RNG	MAXFEE	DEF					NA			N
G9618	DOC SCR UTER MAL OR US/SAMP	PRXOVR	DEF					NA	NA	NA	N
G9618	DOC SCR UTER MAL OR US/SAMP	MAXFEE	DEF					NA			N
G9620	NO SCR UTR MALIG/US/SAMP RNG	PRXOVR	DEF					NA	NA	NA	N
G9620	NO SCR UTR MALIG/US/SAMP RNG	MAXFEE	DEF					NA			N
G9621	SCR UNHEAL ETOH W/COUNSEL	PRXOVR	DEF					NA	NA	NA	N
G9621	SCR UNHEAL ETOH W/COUNSEL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9622	NO UNHEAL ETOH USER	PRXOVR	DEF					NA	NA	NA	N
G9622	NO UNHEAL ETOH USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9623	DOC MED RSN NO SCR ETOH USE	PRXOVR	DEF					NA	NA	NA	N
G9623	DOC MED RSN NO SCR ETOH USE	MAXFEE	DEF					NA			N
G9624	PT NOT SCRN OR NO COUNSELING	PRXOVR	DEF					NA	NA	NA	N
G9624	PT NOT SCRN OR NO COUNSELING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9625	PT BL SRG 30 DAY PST SRG	PRXOVR	DEF					NA	NA	NA	N
G9625	PT BL SRG 30 DAY PST SRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9626	MED RSN NO RPT BLADDER INJ	PRXOVR	DEF					NA	NA	NA	N
G9626	MED RSN NO RPT BLADDER INJ	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9627	PT NO BL SRG 30 DAY PST SRG	PRXOVR	DEF					NA	NA	NA	N
G9627	PT NO BL SRG 30 DAY PST SRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9628	PT BWLI SRG 30 DAY PST SRG	PRXOVR	DEF					NA	NA	NA	N
G9628	PT BWLI SRG 30 DAY PST SRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9629	MED RSN NO RPT BOWEL INJ	PRXOVR	DEF					NA	NA	NA	N
G9629	MED RSN NO RPT BOWEL INJ	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9630	PT NO BWLI SRG 30 DAY SRG	PRXOVR	DEF					NA	NA	NA	N
G9630	PT NO BWLI SRG 30 DAY SRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9631	PT UI SRG 30 DAY PST SRG	PRXOVR	DEF					NA	NA	NA	N
G9631	PT UI SRG 30 DAY PST SRG	MAXFEE	DEF					NA			N
G9632	MED RSN FOR NO RPT URET INJ	PRXOVR	DEF					NA	NA	NA	N
G9632	MED RSN FOR NO RPT URET INJ	MAXFEE	DEF					NA			N
G9633	PT NO UI SRG 30 DAY PST SRG	PRXOVR	DEF					NA	NA	NA	N
G9633	PT NO UI SRG 30 DAY PST SRG	MAXFEE	DEF					NA			N
G9634	QUAL LIFE TOOL 2X SAME/IMPR	PRXOVR	DEF					NA	NA	NA	N
G9634	QUAL LIFE TOOL 2X SAME/IMPR	MAXFEE	DEF					NA			N
G9635	NO DOC RSN DO QUAL LIFE ASSM	PRXOVR	DEF					NA	NA	NA	N
G9635	NO DOC RSN DO QUAL LIFE ASSM	MAXFEE	DEF					NA			N
G9636	NO LIFE ASST 2X SAME/DECR	PRXOVR	DEF					NA	NA	NA	N
G9636	NO LIFE ASST 2X SAME/DECR	MAXFEE	DEF					NA			N
G9637	DOC >1 DOSE REDUC TECH	PRXOVR	DEF					NA	NA	NA	N
G9637	DOC >1 DOSE REDUC TECH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9638	NO DOC >1 DOSE REDUC TECH	PRXOVR	DEF					NA	NA	NA	N
G9638	NO DOC >1 DOSE REDUC TECH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9639	AMP NO REQD IN48H IELER PROC	PRXOVR	DEF					NA	NA	NA	N
G9639	AMP NO REQD IN48H IELER PROC	MAXFEE	DEF					NA			N
G9640	DOC PLAN HYBRID/STAGE PROC	PRXOVR	DEF					NA	NA	NA	N
G9640	DOC PLAN HYBRID/STAGE PROC	MAXFEE	DEF					NA			N
G9641	AMP REQD W/IN 48H IELER PROC	PRXOVR	DEF					NA	NA	NA	N
G9641	AMP REQD W/IN 48H IELER PROC	MAXFEE	DEF					NA			N
G9642	CURRENT SMOKER	PRXOVR	DEF					NA	NA	NA	N
G9642	CURRENT SMOKER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9643	ELECTIVE SURGERY	PRXOVR	DEF					NA	NA	NA	N
G9643	ELECTIVE SURGERY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9644	NO SMOK B/4 ANES DAY OF SURG	PRXOVR	DEF					NA	NA	NA	N
G9644	NO SMOK B/4 ANES DAY OF SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9645	HAD SMOKE B/4 ANES DAY SURG	PRXOVR	DEF					NA	NA	NA	N
G9645	HAD SMOKE B/4 ANES DAY SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9646	PT W/90D MRS 0-2	PRXOVR	DEF					NA	NA	NA	N
G9646	PT W/90D MRS 0-2	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9647	NO MRS SCORE IN 90D FOLLOWUP	PRXOVR	DEF					NA	NA	NA	N
G9647	NO MRS SCORE IN 90D FOLLOWUP	MAXFEE	DEF					NA			N
G9648	PT W/90D MRS >2	PRXOVR	DEF					NA	NA	NA	N
G9648	PT W/90D MRS >2	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9649	PSOR AS DOC SPC BM	PRXOVR	DEF					NA	NA	NA	N
G9649	PSOR AS DOC SPC BM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9651	PSOR AS DOC NO SPC BM	PRXOVR	DEF					NA	NA	NA	N
G9651	PSOR AS DOC NO SPC BM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9654	MON ANESTH CARE	PRXOVR	DEF					NA	NA	NA	N
G9654	MON ANESTH CARE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9655	TOC TOOL INCL KEY ELEM	PRXOVR	DEF					NA	NA	NA	N
G9655	TOC TOOL INCL KEY ELEM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9656	PT TRANS FROM ANEST TO PACU	PRXOVR	DEF					NA	NA	NA	N
G9656	PT TRANS FROM ANEST TO PACU	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9658	TOC TOOL INCL ELEM NOT USED	PRXOVR	DEF					NA	NA	NA	N
G9658	TOC TOOL INCL ELEM NOT USED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9659	>=86Y NO HX COLO CA/RSN SCOP	PRXOVR	DEF					NA	NA	NA	N
G9659	>=86Y NO HX COLO CA/RSN SCOP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9660	DOC MED RSN SCOPE PT >= 86Y	PRXOVR	DEF					NA	NA	NA	N
G9660	DOC MED RSN SCOPE PT >= 86Y	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9661	PT >= 86 W/ HI RISK	PRXOVR	DEF					NA	NA	NA	N
G9661	PT >= 86 W/ HI RISK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9662	PRIOR DX/ACTIVE CLIN ASCVD	PRXOVR	DEF					NA	NA	NA	N
G9662	PRIOR DX/ACTIVE CLIN ASCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9663	FAST/DIR LDL >= 190 MG/DL	PRXOVR	DEF					NA	NA	NA	N
G9663	FAST/DIR LDL >= 190 MG/DL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9664	TAKING STATIN OR REC'D ORDER	PRXOVR	DEF					NA	NA	NA	N
G9664	TAKING STATIN OR REC'D ORDER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9665	NO STATIN/NO ORDER STATIN	PRXOVR	DEF					NA	NA	NA	N
G9665	NO STATIN/NO ORDER STATIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9666	FAS/DIR LDL 70-189MG/DL MST	PRXOVR	DEF					NA	NA	NA	N
G9666	FAS/DIR LDL 70-189MG/DL MST	MAXFEE	DEF					NA			N
G9674	PT W/CLIN ASCVD DX	PRXOVR	DEF					NA	NA	NA	N
G9674	PT W/CLIN ASCVD DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9675	PT W/FAST/DIR LAB LDL-C >190	PRXOVR	DEF					NA	NA	NA	N
G9675	PT W/FAST/DIR LAB LDL-C >190	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9676	40-75Y W/TYPE 1/2 W/LDL-C RS	PRXOVR	DEF					NA	NA	NA	N
G9676	40-75Y W/TYPE 1/2 W/LDL-C RS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9687	HOSPICE ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9687	HOSPICE ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9688	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9688	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9689	INPT ELECT CAROTID INTERVENT	PRXOVR	DEF					NA	NA	NA	N
G9689	INPT ELECT CAROTID INTERVENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9690	PT IN HOS	PRXOVR	DEF					NA	NA	NA	N
G9690	PT IN HOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9691	PT HOSP DUR MSMT PERIOD	PRXOVR	DEF					NA	NA	NA	N
G9691	PT HOSP DUR MSMT PERIOD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9692	HOSP RECD BY PT DUR MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9692	HOSP RECD BY PT DUR MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9693	PT USE HOSP DURING MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9693	PT USE HOSP DURING MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9694	HOSP SRV USED PT IN MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9694	HOSP SRV USED PT IN MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9695	LONG ACT INHAL BRONCHDIL PRE	PRXOVR	DEF					NA	NA	NA	N
G9695	LONG ACT INHAL BRONCHDIL PRE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9696	MED RSN NO PRESC BRONCHDIL	PRXOVR	DEF					NA	NA	NA	N
G9696	MED RSN NO PRESC BRONCHDIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9697	PT RSN NO PRESC BRONCHDIL	PRXOVR	DEF					NA	NA	NA	N
G9697	PT RSN NO PRESC BRONCHDIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9698	SYS RSN NO PRESC BRONCHDIL	PRXOVR	DEF					NA	NA	NA	N
G9698	SYS RSN NO PRESC BRONCHDIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9699	LONG INHAL BRONCHDIL NO PRES	PRXOVR	DEF					NA	NA	NA	N
G9699	LONG INHAL BRONCHDIL NO PRES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9700	PT IS W/HOSP DURING MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9700	PT IS W/HOSP DURING MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9701	CHILD ANBX 30 PRIOR DX ESTAB	PRXOVR	DEF					NA	NA	NA	N
G9701	CHILD ANBX 30 PRIOR DX ESTAB	MAXFEE	DEF					NA			N
G9702	PT USE HOSP DURING MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9702	PT USE HOSP DURING MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9703	ANBX 30 PRIOR TO EPISODE	PRXOVR	DEF					NA	NA	NA	N
G9703	ANBX 30 PRIOR TO EPISODE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9704	AJCC BR CA STG I: T1 MIC/T1A	PRXOVR	DEF					NA	NA	NA	N
G9704	AJCC BR CA STG I: T1 MIC/T1A	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9705	AJCC BR CA STG IB	PRXOVR	DEF					NA	NA	NA	N
G9705	AJCC BR CA STG IB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9706	LOW RECUR PROST CA	PRXOVR	DEF					NA	NA	NA	N
G9706	LOW RECUR PROST CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9707	PT HAD HOSP DUR MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9707	PT HAD HOSP DUR MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9708	BILAT MAST/HX BI /UNILAT MAS	PRXOVR	DEF					NA	NA	NA	N
G9708	BILAT MAST/HX BI /UNILAT MAS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9709	HOSP SRV USED PT IN MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9709	HOSP SRV USED PT IN MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9710	PT PROV HOSP SRV MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9710	PT PROV HOSP SRV MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9711	PT HX TOT COL OR COLON CA	PRXOVR	DEF					NA	NA	NA	N
G9711	PT HX TOT COL OR COLON CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9712	DOC MED RSN PRESC ANBX	PRXOVR	DEF					NA	NA	NA	N
G9712	DOC MED RSN PRESC ANBX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9713	PT USE HOSP DURING MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9713	PT USE HOSP DURING MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9714	PT IS W/HOSP DURING MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9714	PT IS W/HOSP DURING MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9715	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9715	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9716	BMI DOC ONL FUP NOT CMPLTD	PRXOVR	DEF					NA	NA	NA	N
G9716	BMI DOC ONL FUP NOT CMPLTD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9717	DOC PT DX DEP/BIPOL	PRXOVR	DEF					NA	NA	NA	N
G9717	DOC PT DX DEP/BIPOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9718	HOSPICE ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9718	HOSPICE ANYTIME MSMT PER	MAXFEE	DEF					NA			N
G9719	PT NOT AMBUL/IMMOB/WC	PRXOVR	DEF					NA	NA	NA	N
G9719	PT NOT AMBUL/IMMOB/WC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9720	HOSPICE ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9720	HOSPICE ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9721	PT NOT AMBUL/IMMOB/WC	PRXOVR	DEF					NA	NA	NA	N
G9721	PT NOT AMBUL/IMMOB/WC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9722	DOC HX RENAL FAIL OR CR+ >=4	PRXOVR	DEF					NA	NA	NA	N
G9722	DOC HX RENAL FAIL OR CR+ >=4	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9723	HOSP RECD BY PT DUR MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9723	HOSP RECD BY PT DUR MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9724	PT W/DOC USE ANTICOAG MST YR	PRXOVR	DEF					NA	NA	NA	N
G9724	PT W/DOC USE ANTICOAG MST YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9725	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9725	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9726	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9726	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9727	PT UNABLE CMPLT LEPF PROM	PRXOVR	DEF					NA	NA	NA	N
G9727	PT UNABLE CMPLT LEPF PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9728	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9728	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9729	PT UNBL CMPLT LEPF PROM	PRXOVR	DEF					NA	NA	NA	N
G9729	PT UNBL CMPLT LEPF PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9730	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9730	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9731	PT UNBL CMPLT LEPF PROM	PRXOVR	DEF					NA	NA	NA	N
G9731	PT UNBL CMPLT LEPF PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9732	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9732	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9733	PT UNBL CMPLT LB FS PROM	PRXOVR	DEF					NA	NA	NA	N
G9733	PT UNBL CMPLT LB FS PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9734	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9734	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9735	PT UNBL CMPLT SHLD FS PROM	PRXOVR	DEF					NA	NA	NA	N
G9735	PT UNBL CMPLT SHLD FS PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9736	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9736	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9737	PT UNBL CMPLT EWH FS PROM	PRXOVR	DEF					NA	NA	NA	N
G9737	PT UNBL CMPLT EWH FS PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9738	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9738	REFUSED TO PARTICIPATE	MAXFEE	DEF					NA			N
G9739	PT UNBL CMPLT GO FS PROM	PRXOVR	DEF					NA	NA	NA	N
G9739	PT UNBL CMPLT GO FS PROM	MAXFEE	DEF					NA			N
G9740	HOSP SRV TO PT DUR MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9740	HOSP SRV TO PT DUR MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9741	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9741	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9742	PSYCH SYMPT ASSESSED	PRXOVR	DEF					NA	NA	NA	N
G9742	PSYCH SYMPT ASSESSED	MAXFEE	DEF					NA			N
G9743	PSYCH SYMP NOT ASSESSED; RNS	PRXOVR	DEF					NA	NA	NA	N
G9743	PSYCH SYMP NOT ASSESSED; RNS	MAXFEE	DEF					NA			N
G9744	PT NOT ELI D/T ACT DIG HTN	PRXOVR	DEF					NA	NA	NA	N
G9744	PT NOT ELI D/T ACT DIG HTN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9745	DOC RSN NO HBP SCRN OR F/U	PRXOVR	DEF					NA	NA	NA	N
G9745	DOC RSN NO HBP SCRN OR F/U	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9746	MIT STEN; VALVE OR TRANS AF	PRXOVR	DEF					NA	NA	NA	N
G9746	MIT STEN; VALVE OR TRANS AF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9747	PALL DIALYSIS WITH CATHETER	PRXOVR	DEF					NA	NA	NA	N
G9747	PALL DIALYSIS WITH CATHETER	MAXFEE	DEF					NA			N
G9748	APP TRANSPL LVG KIDNEY DONOR	PRXOVR	DEF					NA	NA	NA	N
G9748	APP TRANSPL LVG KIDNEY DONOR	MAXFEE	DEF					NA			N
G9749	PALL DIALYSIS WITH CATHETER	PRXOVR	DEF					NA	NA	NA	N
G9749	PALL DIALYSIS WITH CATHETER	MAXFEE	DEF					NA			N
G9750	APP TRANSPL LVG KIDNEY DONOR	PRXOVR	DEF					NA	NA	NA	N
G9750	APP TRANSPL LVG KIDNEY DONOR	MAXFEE	DEF					NA			N
G9751	PT DIED W/IN 24 MOS RPT TIME	PRXOVR	DEF					NA	NA	NA	N
G9751	PT DIED W/IN 24 MOS RPT TIME	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9752	URGENT SURGERY	PRXOVR	DEF					NA	NA	NA	N
G9752	URGENT SURGERY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9753	DOC NO DICOM; CT OTHER FAC	PRXOVR	DEF					NA	NA	NA	N
G9753	DOC NO DICOM; CT OTHER FAC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9754	INCID PULM NODULE	PRXOVR	DEF					NA	NA	NA	N
G9754	INCID PULM NODULE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9755	DOC MED RSN NO FLLW UP	PRXOVR	DEF					NA	NA	NA	N
G9755	DOC MED RSN NO FLLW UP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9756	SURG PROC W/SILICONE OIL	PRXOVR	DEF					NA	NA	NA	N
G9756	SURG PROC W/SILICONE OIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9757	SURG PROC W/SILICONE OIL	PRXOVR	DEF					NA	NA	NA	N
G9757	SURG PROC W/SILICONE OIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9758	PT IN HOS	PRXOVR	DEF					NA	NA	NA	N
G9758	PT IN HOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9759	HX PREOP POST CAP RUP	PRXOVR	DEF					NA	NA	NA	N
G9759	HX PREOP POST CAP RUP	MAXFEE	DEF					NA			N
G9760	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9760	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9761	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9761	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9762	PT HAD >= 2-3 HPV VACCINES	PRXOVR	DEF					NA	NA	NA	N
G9762	PT HAD >= 2-3 HPV VACCINES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9763	PT NOT HAVE 2-3 HPV VACCINES	PRXOVR	DEF					NA	NA	NA	N
G9763	PT NOT HAVE 2-3 HPV VACCINES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9764	PT TREATD W/ORAL SYST OR BIO	PRXOVR	DEF					NA	NA	NA	N
G9764	PT TREATD W/ORAL SYST OR BIO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9765	DOC PAT DECLINED THERAPY	PRXOVR	DEF					NA	NA	NA	N
G9765	DOC PAT DECLINED THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9766	CVA STROKE DX TX TRANSF FAC	PRXOVR	DEF					NA	NA	NA	N
G9766	CVA STROKE DX TX TRANSF FAC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9767	HOSP NEW DX CVA CONSID EVST	PRXOVR	DEF					NA	NA	NA	N
G9767	HOSP NEW DX CVA CONSID EVST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9768	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9768	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9769	BN DEN 2YR/GOT OST MED/THER	PRXOVR	DEF					NA	NA	NA	N
G9769	BN DEN 2YR/GOT OST MED/THER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9770	PERIP NERVE BLOCK	PRXOVR	DEF					NA	NA	NA	N
G9770	PERIP NERVE BLOCK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9771	ANES END; 1 TEMP >35.5(95.9)	PRXOVR	DEF					NA	NA	NA	N
G9771	ANES END; 1 TEMP >35.5(95.9)	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9772	DOC MED RSN NO TEMP >= 35.5	PRXOVR	DEF					NA	NA	NA	N
G9772	DOC MED RSN NO TEMP >= 35.5	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9773	1 BOD TEMP >=35.5	PRXOVR	DEF					NA	NA	NA	N
G9773	1 BOD TEMP >=35.5	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9774	PT HAD HYST	PRXOVR	DEF					NA	NA	NA	N
G9774	PT HAD HYST	MAXFEE	DEF					NA			N
G9775	RECD 2 ANTI-EMET PRE/INTRAOP	PRXOVR	DEF					NA	NA	NA	N
G9775	RECD 2 ANTI-EMET PRE/INTRAOP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9776	DOC MED RSN NO PROPH ANTIEM	PRXOVR	DEF					NA	NA	NA	N
G9776	DOC MED RSN NO PROPH ANTIEM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9777	PT NO ANTIEMET PRE/INTRAOP	PRXOVR	DEF					NA	NA	NA	N
G9777	PT NO ANTIEMET PRE/INTRAOP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9778	PTS DX W/PREGN	PRXOVR	DEF					NA	NA	NA	N
G9778	PTS DX W/PREGN	MAXFEE	DEF					NA			N
G9779	PTS BREASTFEEDING	PRXOVR	DEF					NA	NA	NA	N
G9779	PTS BREASTFEEDING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9780	PTS DX W/RHABDOMYOLYSIS	PRXOVR	DEF					NA	NA	NA	N
G9780	PTS DX W/RHABDOMYOLYSIS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9781	DOC RSN NO STATIN	PRXOVR	DEF					NA	NA	NA	N
G9781	DOC RSN NO STATIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9782	HX DX FAM/PURE HYPERCHOLES	PRXOVR	DEF					NA	NA	NA	N
G9782	HX DX FAM/PURE HYPERCHOLES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9783	DOC DX DM; FAST <70; NO STAT	PRXOVR	DEF					NA	NA	NA	N
G9783	DOC DX DM; FAST <70; NO STAT	MAXFEE	DEF					NA			N
G9784	PATH/DERM PROV 2ND BIOP OPIN	PRXOVR	DEF					NA	NA	NA	N
G9784	PATH/DERM PROV 2ND BIOP OPIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9785	PATH REPORT SENT	PRXOVR	DEF					NA	NA	NA	N
G9785	PATH REPORT SENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9786	PATH REPORT NOT SENT	PRXOVR	DEF					NA	NA	NA	N
G9786	PATH REPORT NOT SENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9787	PT ALIVE	PRXOVR	DEF					NA	NA	NA	N
G9787	PT ALIVE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9788	MOST RCT BP </= 140/90	PRXOVR	DEF					NA	NA	NA	N
G9788	MOST RCT BP </= 140/90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9789	RECORD BP IP; ER; URG/SELF	PRXOVR	DEF					NA	NA	NA	N
G9789	RECORD BP IP; ER; URG/SELF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9790	MOST RCT BP >/= 140/90	PRXOVR	DEF					NA	NA	NA	N
G9790	MOST RCT BP >/= 140/90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9791	MOST RCT TOB STAT FREE	PRXOVR	DEF					NA	NA	NA	N
G9791	MOST RCT TOB STAT FREE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9792	MOST RCT TOB STAT NOT FREE	PRXOVR	DEF					NA	NA	NA	N
G9792	MOST RCT TOB STAT NOT FREE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9793	PT ON DAILY ASA/ANTIPLAT	PRXOVR	DEF					NA	NA	NA	N
G9793	PT ON DAILY ASA/ANTIPLAT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9794	DOC MED RSN NO DAILY ASPIRIN	PRXOVR	DEF					NA	NA	NA	N
G9794	DOC MED RSN NO DAILY ASPIRIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9795	PT NO DAILY ASA/ANTIPLAT	PRXOVR	DEF					NA	NA	NA	N
G9795	PT NO DAILY ASA/ANTIPLAT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9796	PT NOT CURRENTLY ON STATIN	PRXOVR	DEF					NA	NA	NA	N
G9796	PT NOT CURRENTLY ON STATIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9797	PT CURRENTLY ON STATIN	PRXOVR	DEF					NA	NA	NA	N
G9797	PT CURRENTLY ON STATIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9798	D/C AMI BTW 7/1-6/30 MEAS PD	PRXOVR	DEF					NA	NA	NA	N
G9798	D/C AMI BTW 7/1-6/30 MEAS PD	MAXFEE	DEF					NA			N
G9799	MED DISP EVT INDIC HX ASTH	PRXOVR	DEF					NA	NA	NA	N
G9799	MED DISP EVT INDIC HX ASTH	MAXFEE	DEF					NA			N
G9800	PT ID INTOL/ALLEG BETA-BLOCK	PRXOVR	DEF					NA	NA	NA	N
G9800	PT ID INTOL/ALLEG BETA-BLOCK	MAXFEE	DEF					NA			N
G9801	NONACUT TRANSF FROM INPT	PRXOVR	DEF					NA	NA	NA	N
G9801	NONACUT TRANSF FROM INPT	MAXFEE	DEF					NA			N
G9802	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9802	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					NA			N
G9803	PT PRESC 135 DAY TRMT	PRXOVR	DEF					NA	NA	NA	N
G9803	PT PRESC 135 DAY TRMT	MAXFEE	DEF					NA			N
G9804	PT NOT PRESC 135 DAY TRMT	PRXOVR	DEF					NA	NA	NA	N
G9804	PT NOT PRESC 135 DAY TRMT	MAXFEE	DEF					NA			N
G9805	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9805	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9806	PT RECD CERV CYTO/HPV	PRXOVR	DEF					NA	NA	NA	N
G9806	PT RECD CERV CYTO/HPV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9807	PT NO RECD CERV CYTO/HPV	PRXOVR	DEF					NA	NA	NA	N
G9807	PT NO RECD CERV CYTO/HPV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9808	PT NO ASTHM CONT MED MST PER	PRXOVR	DEF					NA	NA	NA	N
G9808	PT NO ASTHM CONT MED MST PER	MAXFEE	DEF					NA			N
G9809	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9809	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					NA			N
G9810	PDC 75% W/ASTH CONT MED	PRXOVR	DEF					NA	NA	NA	N
G9810	PDC 75% W/ASTH CONT MED	MAXFEE	DEF					NA			N
G9811	NO PDC 75% W/ASTH CONT MED	PRXOVR	DEF					NA	NA	NA	N
G9811	NO PDC 75% W/ASTH CONT MED	MAXFEE	DEF					NA			N
G9812	PT DIED DURING INPT/30D AFT	PRXOVR	DEF					NA	NA	NA	N
G9812	PT DIED DURING INPT/30D AFT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9813	PT NOT DIED W/IN 30D OF PROC	PRXOVR	DEF					NA	NA	NA	N
G9813	PT NOT DIED W/IN 30D OF PROC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9814	DEATH DURING INDEX HOSP	PRXOVR	DEF					NA	NA	NA	N
G9814	DEATH DURING INDEX HOSP	MAXFEE	DEF					NA			N
G9815	DEATH NOT DURING INDEX HOSP	PRXOVR	DEF					NA	NA	NA	N
G9815	DEATH NOT DURING INDEX HOSP	MAXFEE	DEF					NA			N
G9816	DEATH <30 DAY POST DISCHARGE	PRXOVR	DEF					NA	NA	NA	N
G9816	DEATH <30 DAY POST DISCHARGE	MAXFEE	DEF					NA			N
G9817	NO DEATH 30-DAYS POST-DISCH	PRXOVR	DEF					NA	NA	NA	N
G9817	NO DEATH 30-DAYS POST-DISCH	MAXFEE	DEF					NA			N
G9818	DOC SEX ACTIVITY	PRXOVR	DEF					NA	NA	NA	N
G9818	DOC SEX ACTIVITY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9819	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9819	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9820	DOC CHLAM SCR TEST W/FOLLOW	PRXOVR	DEF					NA	NA	NA	N
G9820	DOC CHLAM SCR TEST W/FOLLOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9821	NO DOC CHLAM SCR TS W/FOLLOW	PRXOVR	DEF					NA	NA	NA	N
G9821	NO DOC CHLAM SCR TS W/FOLLOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9822	ENDO ABL PROC YR PREV IND DT	PRXOVR	DEF					NA	NA	NA	N
G9822	ENDO ABL PROC YR PREV IND DT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9823	ENDO SMPL/HYST BX RES DOC	PRXOVR	DEF					NA	NA	NA	N
G9823	ENDO SMPL/HYST BX RES DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9824	ENDO SMPL/HYST BX RES NO DOC	PRXOVR	DEF					NA	NA	NA	N
G9824	ENDO SMPL/HYST BX RES NO DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9825	HER-2 NEG;UNDOC/UNKN	PRXOVR	DEF					NA	NA	NA	N
G9825	HER-2 NEG;UNDOC/UNKN	MAXFEE	DEF					NA			N
G9826	TRANSF PRACT AFT INIT CHEMO	PRXOVR	DEF					NA	NA	NA	N
G9826	TRANSF PRACT AFT INIT CHEMO	MAXFEE	DEF					NA			N
G9827	HER-2 TARG THER NO INIT TX	PRXOVR	DEF					NA	NA	NA	N
G9827	HER-2 TARG THER NO INIT TX	MAXFEE	DEF					NA			N
G9828	HER-2 TARG THER DUR INIT TX	PRXOVR	DEF					NA	NA	NA	N
G9828	HER-2 TARG THER DUR INIT TX	MAXFEE	DEF					NA			N
G9829	BREAST ADJ CHEMO ADMIN	PRXOVR	DEF					NA	NA	NA	N
G9829	BREAST ADJ CHEMO ADMIN	MAXFEE	DEF					NA			N
G9830	HER-2 POS	PRXOVR	DEF					NA	NA	NA	N
G9830	HER-2 POS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9831	AJCC STG BRT CA DX II OR III	PRXOVR	DEF					NA	NA	NA	N
G9831	AJCC STG BRT CA DX II OR III	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9832	BRT CA DX I; NO T1/T1A/T1B	PRXOVR	DEF					NA	NA	NA	N
G9832	BRT CA DX I; NO T1/T1A/T1B	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9833	TRANSF PRACT AFT INIT CHEMO	PRXOVR	DEF					NA	NA	NA	N
G9833	TRANSF PRACT AFT INIT CHEMO	MAXFEE	DEF					NA			N
G9834	PT MET DIS AT DX	PRXOVR	DEF					NA	NA	NA	N
G9834	PT MET DIS AT DX	MAXFEE	DEF					NA			N
G9835	TRASTUZ GIVEN W/IN 12 MOS DX	PRXOVR	DEF					NA	NA	NA	N
G9835	TRASTUZ GIVEN W/IN 12 MOS DX	MAXFEE	DEF					NA			N
G9836	RSN NO TRAST GIVEN DOC	PRXOVR	DEF					NA	NA	NA	N
G9836	RSN NO TRAST GIVEN DOC	MAXFEE	DEF					NA			N
G9837	TRASTUZ NOT IN 12 MOS DX	PRXOVR	DEF					NA	NA	NA	N
G9837	TRASTUZ NOT IN 12 MOS DX	MAXFEE	DEF					NA			N
G9838	PT MET DIS AT DX	PRXOVR	DEF					NA	NA	NA	N
G9838	PT MET DIS AT DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9839	ANTI-EGFR MON ANTI THER	PRXOVR	DEF					NA	NA	NA	N
G9839	ANTI-EGFR MON ANTI THER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9840	GENE TESTING PERFORMED	PRXOVR	DEF					NA	NA	NA	N
G9840	GENE TESTING PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9841	GENE TESTING NOT PERFORMED	PRXOVR	DEF					NA	NA	NA	N
G9841	GENE TESTING NOT PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9842	PT MET DIS AT DX	PRXOVR	DEF					NA	NA	NA	N
G9842	PT MET DIS AT DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9843	KRAS OR NRAS GENE MUTATION	PRXOVR	DEF					NA	NA	NA	N
G9843	KRAS OR NRAS GENE MUTATION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9844	PT NO RECD ANTI-EGFR THER	PRXOVR	DEF					NA	NA	NA	N
G9844	PT NO RECD ANTI-EGFR THER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9845	PT RECD ANTI-EGFR THER	PRXOVR	DEF					NA	NA	NA	N
G9845	PT RECD ANTI-EGFR THER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9846	PT DIED FROM CANCER	PRXOVR	DEF					NA	NA	NA	N
G9846	PT DIED FROM CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9847	PT RECD CHEMO LAST 14D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9847	PT RECD CHEMO LAST 14D LIFE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9848	PT NO CHEMO LAST 14D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9848	PT NO CHEMO LAST 14D LIFE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9849	PT DIED FROM CANCER	PRXOVR	DEF					NA	NA	NA	N
G9849	PT DIED FROM CANCER	MAXFEE	DEF					NA			N
G9850	1/MORE ED LAST 30D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9850	1/MORE ED LAST 30D LIFE	MAXFEE	DEF					NA			N
G9851	1/NO ED VISIT LAST 30D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9851	1/NO ED VISIT LAST 30D LIFE	MAXFEE	DEF					NA			N
G9852	PT DIED FROM CANCER	PRXOVR	DEF					NA	NA	NA	N
G9852	PT DIED FROM CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9853	ICU STAY LAST 30D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9853	ICU STAY LAST 30D LIFE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9854	NO ICU STAY LAST 30D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9854	NO ICU STAY LAST 30D LIFE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9855	PT DIED FROM CANCER	PRXOVR	DEF					NA	NA	NA	N
G9855	PT DIED FROM CANCER	MAXFEE	DEF					NA			N
G9856	PT NO HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9856	PT NO HOSPICE	MAXFEE	DEF					NA			N
G9857	PT ADMIT HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9857	PT ADMIT HOSPICE	MAXFEE	DEF					NA			N
G9858	PT ENROLL HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9858	PT ENROLL HOSPICE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9859	PT DIED FROM CANCER	PRXOVR	DEF					NA	NA	NA	N
G9859	PT DIED FROM CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9860	PT LESS 3D HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9860	PT LESS 3D HOSPICE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9861	PT MORE THAN 3D HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9861	PT MORE THAN 3D HOSPICE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9862	DOC RSN NO 10 YR FOLLOW	PRXOVR	DEF					NA	NA	NA	N
G9862	DOC RSN NO 10 YR FOLLOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9890	EM BRIDGE PAYMENT	PRXOVR	DEF					NA	NA	NA	N
G9890	EM BRIDGE PAYMENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9891	EM SESSION REPORTING	PRXOVR	DEF					NA	NA	NA	N
G9891	EM SESSION REPORTING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9892	DOC PT RSN NO DIL MAC EXAM	PRXOVR	DEF					NA	NA	NA	N
G9892	DOC PT RSN NO DIL MAC EXAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9893	NO MAC EXAM	PRXOVR	DEF					NA	NA	NA	N
G9893	NO MAC EXAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9894	ADR DEP THRPY PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
G9894	ADR DEP THRPY PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9895	DOC MED RSN NO ADR DEP THRPY	PRXOVR	DEF					NA	NA	NA	N
G9895	DOC MED RSN NO ADR DEP THRPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9896	DOC PT RSN NO ADR DEP THRPY	PRXOVR	DEF					NA	NA	NA	N
G9896	DOC PT RSN NO ADR DEP THRPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9897	PT NT PRSC ADR DEP THRPY RNG	PRXOVR	DEF					NA	NA	NA	N
G9897	PT NT PRSC ADR DEP THRPY RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9898	PT 66+ SNP OR LTC POS > 90D	PRXOVR	DEF					NA	NA	NA	N
G9898	PT 66+ SNP OR LTC POS > 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9899	SCRN MAM PERF RSLTS DOC	PRXOVR	DEF					NA	NA	NA	N
G9899	SCRN MAM PERF RSLTS DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9900	SCRN MAM PERF RSLTS NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G9900	SCRN MAM PERF RSLTS NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9901	PT 66+ SNP OR LTC POS > 90D	PRXOVR	DEF					NA	NA	NA	N
G9901	PT 66+ SNP OR LTC POS > 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9902	PT SCRN TBCO AND ID AS USER	PRXOVR	DEF					NA	NA	NA	N
G9902	PT SCRN TBCO AND ID AS USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9903	PT SCRN TBCO ID AS NON USER	PRXOVR	DEF					NA	NA	NA	N
G9903	PT SCRN TBCO ID AS NON USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9904	DOC MED RSN NO TBCO SCRN	PRXOVR	DEF					NA	NA	NA	N
G9904	DOC MED RSN NO TBCO SCRN	MAXFEE	DEF					NA			N
G9905	NO PT TBCO SCRN RNG	PRXOVR	DEF					NA	NA	NA	N
G9905	NO PT TBCO SCRN RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9906	PT RECV TBCO CESS INTERV	PRXOVR	DEF					NA	NA	NA	N
G9906	PT RECV TBCO CESS INTERV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9907	DOC MED RSN NO TBCO INTERV	PRXOVR	DEF					NA	NA	NA	N
G9907	DOC MED RSN NO TBCO INTERV	MAXFEE	DEF					NA			N
G9908	NO PT TBCO CESS INTERV RNG	PRXOVR	DEF					NA	NA	NA	N
G9908	NO PT TBCO CESS INTERV RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9909	DOC MED RSN NO TBCO INTERV	PRXOVR	DEF					NA	NA	NA	N
G9909	DOC MED RSN NO TBCO INTERV	MAXFEE	DEF					NA			N
G9910	PT 66+ SNP OR LTC POS > 90D	PRXOVR	DEF					NA	NA	NA	N
G9910	PT 66+ SNP OR LTC POS > 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9911	NODE NEG PRE/POST SYST THER	PRXOVR	DEF					NA	NA	NA	N
G9911	NODE NEG PRE/POST SYST THER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9912	HBV STATUS ASSESED AND INT	PRXOVR	DEF					NA	NA	NA	N
G9912	HBV STATUS ASSESED AND INT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9913	NO HBV STATUS ASSESD AND INT	PRXOVR	DEF					NA	NA	NA	N
G9913	NO HBV STATUS ASSESD AND INT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9914	PT RECEIVING ANTI-TNF AGENT	PRXOVR	DEF					NA	NA	NA	N
G9914	PT RECEIVING ANTI-TNF AGENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9915	NO DOCUMNTD HBV RESULTS RCD	PRXOVR	DEF					NA	NA	NA	N
G9915	NO DOCUMNTD HBV RESULTS RCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9916	FUNCT STATUS PAST 12 MONTHS	PRXOVR	DEF					NA	NA	NA	N
G9916	FUNCT STATUS PAST 12 MONTHS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9917	ADV DEM CRGVR LIMITED	PRXOVR	DEF					NA	NA	NA	N
G9917	ADV DEM CRGVR LIMITED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9918	NO FUNCT STAT PERF; RSN NOS	PRXOVR	DEF					NA	NA	NA	N
G9918	NO FUNCT STAT PERF; RSN NOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9919	SCRN ND POS ND PROV OF REC	PRXOVR	DEF					NA	NA	NA	N
G9919	SCRN ND POS ND PROV OF REC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9920	SCRNING PERF AND NEGATIVE	PRXOVR	DEF					NA	NA	NA	N
G9920	SCRNING PERF AND NEGATIVE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9921	NO OR PART SCRN ND RNG OR OS	PRXOVR	DEF					NA	NA	NA	N
G9921	NO OR PART SCRN ND RNG OR OS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9922	SFTY CNCRNS SCRN ND MIT RECS	PRXOVR	DEF					NA	NA	NA	N
G9922	SFTY CNCRNS SCRN ND MIT RECS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9923	SAFTY CNCRNS SCRN AND NEG	PRXOVR	DEF					NA	NA	NA	N
G9923	SAFTY CNCRNS SCRN AND NEG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9924	DOC MED RSN NO SCRN OR RECS	PRXOVR	DEF					NA	NA	NA	N
G9924	DOC MED RSN NO SCRN OR RECS	MAXFEE	DEF					NA			N
G9925	NO SCRN PROV RSN NOS	PRXOVR	DEF					NA	NA	NA	N
G9925	NO SCRN PROV RSN NOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9926	SFTY CNCRNS SCRN BUT NO RECS	PRXOVR	DEF					NA	NA	NA	N
G9926	SFTY CNCRNS SCRN BUT NO RECS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9927	DOC NO WARF /FDA PT TRIAL	PRXOVR	DEF					NA	NA	NA	N
G9927	DOC NO WARF /FDA PT TRIAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9928	NO WARF OR FDA DRUG PRESC	PRXOVR	DEF					NA	NA	NA	N
G9928	NO WARF OR FDA DRUG PRESC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9929	TRS/REV AF	PRXOVR	DEF					NA	NA	NA	N
G9929	TRS/REV AF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9930	COM CARE	PRXOVR	DEF					NA	NA	NA	N
G9930	COM CARE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9931	NO CHAD OR CHAD SCR 0 OR 1	PRXOVR	DEF					NA	NA	NA	N
G9931	NO CHAD OR CHAD SCR 0 OR 1	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9932	DOC PT RSN NO TB SCRN RECRDS	PRXOVR	DEF					NA	NA	NA	N
G9932	DOC PT RSN NO TB SCRN RECRDS	MAXFEE	DEF					NA			N
G9933	CANC DETECTD DURING COL SCRN	PRXOVR	DEF					NA	NA	NA	N
G9933	CANC DETECTD DURING COL SCRN	MAXFEE	DEF					NA			N
G9934	DOC RSN NOT DETECTING CANCER	PRXOVR	DEF					NA	NA	NA	N
G9934	DOC RSN NOT DETECTING CANCER	MAXFEE	DEF					NA			N
G9935	CANC NOT DETECTD DURING SRCN	PRXOVR	DEF					NA	NA	NA	N
G9935	CANC NOT DETECTD DURING SRCN	MAXFEE	DEF					NA			N
G9936	PMH PLYP/NEO CO/RECT/JUN/ANS	PRXOVR	DEF					NA	NA	NA	N
G9936	PMH PLYP/NEO CO/RECT/JUN/ANS	MAXFEE	DEF					NA			N
G9937	DIG OR SURV COLSCO	PRXOVR	DEF					NA	NA	NA	N
G9937	DIG OR SURV COLSCO	MAXFEE	DEF					NA			N
G9938	PT 66+ SNP OR LTC POS > 90D	PRXOVR	DEF					NA	NA	NA	N
G9938	PT 66+ SNP OR LTC POS > 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9939	SAME PATH/DERM PERF BIOPSY	PRXOVR	DEF					NA	NA	NA	N
G9939	SAME PATH/DERM PERF BIOPSY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9940	DOC REAS NO STATIN THERAPY	PRXOVR	DEF					NA	NA	NA	N
G9940	DOC REAS NO STATIN THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9941	PRE AND POST VAS WTHN 3 MOS	PRXOVR	DEF					NA	NA	NA	N
G9941	PRE AND POST VAS WTHN 3 MOS	MAXFEE	DEF					NA			N
G9942	ADTL SPINE PROC ON SAME DATE	PRXOVR	DEF					NA	NA	NA	N
G9942	ADTL SPINE PROC ON SAME DATE	MAXFEE	DEF					NA			N
G9943	BK PN NT MSR VAS SCL PRE/PST	PRXOVR	DEF					NA	NA	NA	N
G9943	BK PN NT MSR VAS SCL PRE/PST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9944	VAS 3 MON PRE AND 1 YR POST	PRXOVR	DEF					NA	NA	NA	N
G9944	VAS 3 MON PRE AND 1 YR POST	MAXFEE	DEF					NA			N
G9945	PT W/CANCER SCOLIOSIS	PRXOVR	DEF					NA	NA	NA	N
G9945	PT W/CANCER SCOLIOSIS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9946	BK PAIN NO VAS	PRXOVR	DEF					NA	NA	NA	N
G9946	BK PAIN NO VAS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9947	PRE AND POST VAS WTHN 3 MOS	PRXOVR	DEF					NA	NA	NA	N
G9947	PRE AND POST VAS WTHN 3 MOS	MAXFEE	DEF					NA			N
G9948	ADTL SPINE PROC ON SAME DATE	PRXOVR	DEF					NA	NA	NA	N
G9948	ADTL SPINE PROC ON SAME DATE	MAXFEE	DEF					NA			N
G9949	LEG PAIN NO VAS	PRXOVR	DEF					NA	NA	NA	N
G9949	LEG PAIN NO VAS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9954	PT >2 RSK FAC POST-OP VOMIT	PRXOVR	DEF					NA	NA	NA	N
G9954	PT >2 RSK FAC POST-OP VOMIT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9955	INHLNT ANESTH ONLY FOR INDUC	PRXOVR	DEF					NA	NA	NA	N
G9955	INHLNT ANESTH ONLY FOR INDUC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9956	COMBO THRPY OF >= 2 PROPHLY	PRXOVR	DEF					NA	NA	NA	N
G9956	COMBO THRPY OF >= 2 PROPHLY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9957	DOC MED RSN NO COMBO THRPY	PRXOVR	DEF					NA	NA	NA	N
G9957	DOC MED RSN NO COMBO THRPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9958	NO COMBO PROHPYL THRP FOR PT	PRXOVR	DEF					NA	NA	NA	N
G9958	NO COMBO PROHPYL THRP FOR PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9959	SYSTEMIC ANTIMICRO NOT PRESC	PRXOVR	DEF					NA	NA	NA	N
G9959	SYSTEMIC ANTIMICRO NOT PRESC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9960	MED RSN SYS ANTIMI NT RX	PRXOVR	DEF					NA	NA	NA	N
G9960	MED RSN SYS ANTIMI NT RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9961	SYSTEMIC ANTIMICRO PRESC	PRXOVR	DEF					NA	NA	NA	N
G9961	SYSTEMIC ANTIMICRO PRESC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9962	EMBOLIZATION DOC SEPARATLY	PRXOVR	DEF					NA	NA	NA	N
G9962	EMBOLIZATION DOC SEPARATLY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9963	EMBOLIZATION NOT DOC SEPARAT	PRXOVR	DEF					NA	NA	NA	N
G9963	EMBOLIZATION NOT DOC SEPARAT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9964	PT RECV >=1 WELL-CHLD VISIT	PRXOVR	DEF					NA	NA	NA	N
G9964	PT RECV >=1 WELL-CHLD VISIT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9965	NO WELL-CHLD VIST RECV BY PT	PRXOVR	DEF					NA	NA	NA	N
G9965	NO WELL-CHLD VIST RECV BY PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9966	SCRN; INTER; REPORT CHILD	PRXOVR	DEF					NA	NA	NA	N
G9966	SCRN; INTER; REPORT CHILD	MAXFEE	DEF					NA			N
G9967	NO SCRN; INTER; REPRT CHILD	PRXOVR	DEF					NA	NA	NA	N
G9967	NO SCRN; INTER; REPRT CHILD	MAXFEE	DEF					NA			N
G9968	PT REFRD 2 PVDR/SPCLST IN PP	PRXOVR	DEF					NA	NA	NA	N
G9968	PT REFRD 2 PVDR/SPCLST IN PP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9969	PVDR RFRD PT RPRT RCVD	PRXOVR	DEF					NA	NA	NA	N
G9969	PVDR RFRD PT RPRT RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9970	PVDR RFRD PT NO RPRT RCVD	PRXOVR	DEF					NA	NA	NA	N
G9970	PVDR RFRD PT NO RPRT RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9974	MAC EXAM PERF	PRXOVR	DEF					NA	NA	NA	N
G9974	MAC EXAM PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9975	DOC MED RSN NO DIL MAC EXAM	PRXOVR	DEF					NA	NA	NA	N
G9975	DOC MED RSN NO DIL MAC EXAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9976	DOC PAT RSN NO MAC EXM PERF	PRXOVR	DEF					NA	NA	NA	N
G9976	DOC PAT RSN NO MAC EXM PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9977	DIL MAC EXAM NO PERF RSN NOS	PRXOVR	DEF					NA	NA	NA	N
G9977	DIL MAC EXAM NO PERF RSN NOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
H0001	ALCOHOL AND/OR DRUG ASSESS	MAXFEE	AOD					77.22	1/1/2018	12/31/2299	R
H0004	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	AOD					19.31	1/1/2018	12/31/2299	R N
H0005	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	HK1					9.37	8/1/2019	12/31/2299	R
H0005	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	AOD					8.37	8/1/2019	12/31/2299	R
H0005	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	AF1					11.02	8/1/2019	12/31/2299	R
H0006	ALCOHOL AND/OR DRUG SERVICES	TIERED	AOD					NA	NA	NA	R
H0010	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	AOD					256.33	1/1/2018	12/31/2299	R
H0010	ALCOHOL AND/OR DRUG SERVICES	PRXOVR	AOD					NA	NA	NA	R
H0011	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	AOD					392.86	1/1/2018	12/31/2299	R
H0011	ALCOHOL AND/OR DRUG SERVICES	PRXOVR	AOD					NA	NA	NA	R
H0012	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	AOD					360.36	1/1/2018	12/31/2299	R
H0012	ALCOHOL AND/OR DRUG SERVICES	PRXOVR	AOD					NA	NA	NA	R
H0014	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	NLU					90.16	1/1/2018	12/31/2299	R
H0014	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	LAT					238.92	1/1/2018	12/31/2299	R
H0014	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	RAT					338.35	1/1/2018	12/31/2299	R
H0014	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	NRU					127.68	1/1/2018	12/31/2299	R
H0015	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	TG1					224.82	1/1/2018	12/31/2299	R
H0015	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	HK1					149.88	1/1/2018	12/31/2299	R
H0015	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	AOD					103.04	1/1/2018	12/31/2299	R
H0015	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	TG2					154.56	1/1/2018	12/31/2299	R
H0020	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	OTP					16.38	1/1/2017	12/31/2299	N
H0020	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	TS1					343.98	1/1/2017	12/31/2299	N
H0020	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	TV1					114.66	1/1/2017	12/31/2299	N
H0020	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	HG1					458.64	1/1/2017	12/31/2299	N
H0020	ALCOHOL AND/OR DRUG SERVICES	MAXFEE	UB1					229.32	1/1/2017	12/31/2299	N
H0020	ALCOHOL AND/OR DRUG SERVICES	PRXOVR	OTP					NA	NA	NA	N
H0038	SELF-HELP/PEER SVC PER 15MIN	MAXFEE	HQ1					2.59	1/1/2018	12/31/2299	R
H0038	SELF-HELP/PEER SVC PER 15MIN	MAXFEE	AOD					15.51	1/1/2018	12/31/2299	R
H0048	SPEC COLL NON-BLOOD:A/D TEST	MAXFEE	AOD					14.48	1/1/2018	12/31/2299	R
H0048	SPEC COLL NON-BLOOD:A/D TEST	PRXOVR	AOD					NA	NA	NA	R
H2000	COMP MULTIDISIPLN EVALUATION	MAXFEE	A03					170.43	1/1/2023	12/31/2299	N
H2000	COMP MULTIDISIPLN EVALUATION	MAXFEE	A01					527.25	1/1/2023	12/31/2299	N
H2000	COMP MULTIDISIPLN EVALUATION	MAXFEE	A04					165	1/1/2023	12/31/2299	N
H2000	COMP MULTIDISIPLN EVALUATION	MAXFEE	A05					147.72	1/1/2023	12/31/2299	N
H2000	COMP MULTIDISIPLN EVALUATION	MAXFEE	A02					324.67	1/1/2023	12/31/2299	N
H2034	A/D HALFWAY HOUSE; PER DIEM	MAXFEE	AOD					152.57	1/1/2018	12/31/2299	R
H2034	A/D HALFWAY HOUSE; PER DIEM	PRXOVR	AOD					NA	NA	NA	R
H2036	A/D TX PROGRAM; PER DIEM	MAXFEE	TG1					303.49	1/1/2018	12/31/2299	R
H2036	A/D TX PROGRAM; PER DIEM	MAXFEE	AOD					213.70	1/1/2018	12/31/2299	R
J0571	BUPRENORPHINE ORAL 1MG	PRXOVR	DEF					NA	NA	NA	N
J0571	BUPRENORPHINE ORAL 1MG	MAXFEE	DEF					2.85	1/1/2022	12/31/2299	N
J0572	BUPREN/NAL UP TO 3MG BUPRENO	PRXOVR	DEF					NA	NA	NA	N
J0572	BUPREN/NAL UP TO 3MG BUPRENO	MAXFEE	DEF					10.10	4/1/2022	12/31/2299	N
J0573	BUPREN/NAL 3.1 TO 6MG BUPREN	PRXOVR	DEF					NA	NA	NA	N
J0573	BUPREN/NAL 3.1 TO 6MG BUPREN	MAXFEE	DEF					9.89	1/1/2022	12/31/2299	N
J0574	BUPREN/NAL 6.1 TO 10MG BUPRE	PRXOVR	DEF					NA	NA	NA	N
J0574	BUPREN/NAL 6.1 TO 10MG BUPRE	MAXFEE	DEF					15.15	4/1/2022	12/31/2299	N
J0575	BUPREN/NAL OVER 10MG BUPRENO	PRXOVR	DEF					NA	NA	NA	N
J0575	BUPREN/NAL OVER 10MG BUPRENO	MAXFEE	DEF					19.77	1/1/2022	12/31/2299	N
J2310	INJ NALOXONE HYDROCHLORIDE	PRXOVR	DEF					NA	NA	NA	N
J2310	INJ NALOXONE HYDROCHLORIDE	MAXFEE	DEF					9.45	7/1/2023	12/31/2299	N
J2315	NALTREXONE; DEPOT FORM	PRXOVR	DEF					NA	NA	NA	N
J2315	NALTREXONE; DEPOT FORM	MAXFEE	DEF					3.94	7/1/2023	12/31/2299	N
J3490	DRUGS UNCLASSIFIED INJECTION	PRXOVR	DEF					NA	NA	NA	N
J3490	DRUGS UNCLASSIFIED INJECTION	MANUAL	DEF					NA	NA	NA	N
J8499	ORAL PRESCRIP DRUG NON CHEMO	MAXFEE	OTP					1.20	1/1/2017	12/31/2299	N
J8499	ORAL PRESCRIP DRUG NON CHEMO	PRXOVR	DEF					NA	NA	NA	N
K1034	COVID TEST SELF-ADMN/COLLECT	PRXOVR	DEF					NA	NA	NA	N
K1034	COVID TEST SELF-ADMN/COLLECT	MAXFEE	DEF					12	4/4/2022	12/31/2299	N
Q9991	BUPRENORPH XR 100 MG OR LESS	PRXOVR	DEF					NA	NA	NA	N
Q9991	BUPRENORPH XR 100 MG OR LESS	MAXFEE	DEF					1886.37	7/1/2023	12/31/2299	N
Q9992	BUPRENORPHINE XR OVER 100 MG	PRXOVR	DEF					NA	NA	NA	N
Q9992	BUPRENORPHINE XR OVER 100 MG	MAXFEE	DEF					1886.37	7/1/2023	12/31/2299	N
S5000	PRESCRIPTION DRUG; GENERIC	MAXFEE	OTP					1.20	1/1/2017	12/31/2299	N
S5000	PRESCRIPTION DRUG; GENERIC	MAXFEE	AOD					0.55	1/1/2017	12/31/2299	N
S5001	PRESCRIPTION DRUG;BRAND NAME	MAXFEE	OTP					2.30	1/1/2022	12/31/2299	N
S9482	FAMILY STABILIZATION 15 MIN	MAXFEE	A03					30.92	7/1/2022	12/31/2299	S
S9482	FAMILY STABILIZATION 15 MIN	MAXFEE	A01					34.95	7/1/2022	12/31/2299	S
S9482	FAMILY STABILIZATION 15 MIN	MAXFEE	A04					24.77	7/1/2022	12/31/2299	S
S9482	FAMILY STABILIZATION 15 MIN	MAXFEE	A02					34.01	7/1/2022	12/31/2299	S
S9484	CRISIS INTERVENTION PER HOUR	MAXFEE	A03					125.25	7/1/2022	12/31/2299	N
S9484	CRISIS INTERVENTION PER HOUR	MAXFEE	A01					139.32	7/1/2022	12/31/2299	N
S9484	CRISIS INTERVENTION PER HOUR	MAXFEE	A04					102.89	7/1/2022	12/31/2299	N
S9484	CRISIS INTERVENTION PER HOUR	MAXFEE	A02					136.49	7/1/2022	12/31/2299	N
S9485	CRISIS INTERVENTION MENTAL H	MAXFEE	A03					432.63	7/1/2022	12/31/2299	N
S9485	CRISIS INTERVENTION MENTAL H	MAXFEE	A01					476.64	7/1/2022	12/31/2299	N
S9485	CRISIS INTERVENTION MENTAL H	MAXFEE	A04					365.55	7/1/2022	12/31/2299	N
S9485	CRISIS INTERVENTION MENTAL H	MAXFEE	A02					466.34	7/1/2022	12/31/2299	N
T1002	RN SERVICES UP TO 15 MINUTES	MAXFEE	OF1					31.92	1/1/2018	12/31/2299	R N
T1002	RN SERVICES UP TO 15 MINUTES	MAXFEE	HQ1					13.83	8/1/2019	12/31/2299	R N
T1002	RN SERVICES UP TO 15 MINUTES	MAXFEE	HC1					41	1/1/2018	12/31/2299	R N
T1003	LPN/LVN SERVICES UP TO 15MIN	MAXFEE	OF1					22.54	1/1/2018	12/31/2299	R
T1003	LPN/LVN SERVICES UP TO 15MIN	MAXFEE	HC1					29.13	1/1/2018	12/31/2299	R
T1023	PROGRAM INTAKE ASSESSMENT	PRXOVR	DEF					NA	NA	NA	S
T1023	PROGRAM INTAKE ASSESSMENT	MAXFEE	DEF					30	7/1/2021	12/31/2299	S
T1502	MEDICATION ADMIN VISIT	MAXFEE	OTP					16.38	1/1/2017	12/31/2299	N
T1502	MEDICATION ADMIN VISIT	MAXFEE	TS1					343.98	1/1/2017	12/31/2299	N
T1502	MEDICATION ADMIN VISIT	MAXFEE	TV1					114.66	1/1/2017	12/31/2299	N
T1502	MEDICATION ADMIN VISIT	MAXFEE	HG1					458.64	1/1/2017	12/31/2299	N
T1502	MEDICATION ADMIN VISIT	MAXFEE	UB1					229.32	1/1/2017	12/31/2299	N
T1502	MEDICATION ADMIN VISIT	PRXOVR	OTP					NA	NA	NA	N