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
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
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
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
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
00120 ANESTH EAR SURGERY PRXOVR DEF         NA NA NA N
00120 ANESTH EAR SURGERY ANESTH DEF         NA NA NA N
00124 ANESTH EAR EXAM PRXOVR DEF         NA NA NA N
00124 ANESTH EAR EXAM ANESTH DEF         NA NA NA N
00126 ANESTH TYMPANOTOMY PRXOVR DEF         NA NA NA N
00126 ANESTH TYMPANOTOMY ANESTH DEF         NA NA 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
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
00140 ANESTH PROCEDURES ON EYE PRXOVR DEF         NA NA NA N
00140 ANESTH PROCEDURES ON EYE ANESTH DEF         NA NA NA N
00142 ANESTH LENS SURGERY PRXOVR DEF         NA NA NA N
00142 ANESTH LENS SURGERY ANESTH DEF         NA NA NA N
00144 ANESTH CORNEAL TRANSPLANT PRXOVR DEF         NA NA NA N
00144 ANESTH CORNEAL TRANSPLANT ANESTH DEF         NA NA NA N
00145 ANESTH VITREORETINAL SURG PRXOVR DEF         NA NA NA N
00145 ANESTH VITREORETINAL SURG ANESTH DEF         NA NA NA N
00147 ANESTH IRIDECTOMY PRXOVR DEF         NA NA NA N
00147 ANESTH IRIDECTOMY ANESTH DEF         NA NA NA N
00148 ANESTH EYE EXAM PRXOVR DEF         NA NA NA N
00148 ANESTH EYE EXAM ANESTH DEF         NA NA NA N
00160 ANESTH NOSE/SINUS SURGERY PRXOVR DEF         NA NA NA N
00160 ANESTH NOSE/SINUS SURGERY ANESTH DEF         NA NA NA N
00162 ANESTH NOSE/SINUS SURGERY PRXOVR DEF         NA NA NA N
00162 ANESTH NOSE/SINUS SURGERY ANESTH DEF         NA NA NA N
00164 ANESTH BIOPSY OF NOSE PRXOVR DEF         NA NA NA N
00164 ANESTH BIOPSY OF NOSE ANESTH DEF         NA NA NA N
00170 ANESTH PROCEDURE ON MOUTH PRXOVR DEF         NA NA NA N
00170 ANESTH PROCEDURE ON MOUTH ANESTH DEF         NA NA NA N
00172 ANESTH CLEFT PALATE REPAIR PRXOVR DEF         NA NA NA N
00172 ANESTH CLEFT PALATE REPAIR ANESTH DEF         NA NA NA N
00174 ANESTH PHARYNGEAL SURGERY PRXOVR DEF         NA NA NA N
00174 ANESTH PHARYNGEAL SURGERY ANESTH DEF         NA NA NA N
00176 ANESTH PHARYNGEAL SURGERY PRXOVR DEF         NA NA NA N
00176 ANESTH PHARYNGEAL SURGERY ANESTH DEF         NA NA NA N
00190 ANESTH FACE/SKULL BONE SURG PRXOVR DEF         NA NA NA N
00190 ANESTH FACE/SKULL BONE SURG ANESTH DEF         NA NA NA N
00192 ANESTH FACIAL BONE SURGERY PRXOVR DEF         NA NA NA N
00192 ANESTH FACIAL BONE SURGERY ANESTH DEF         NA NA NA N
00210 ANESTH CRANIAL SURG NOS PRXOVR DEF         NA NA NA N
00210 ANESTH CRANIAL SURG NOS ANESTH DEF         NA NA NA N
00211 ANESTH CRAN SURG HEMOTOMA PRXOVR DEF         NA NA NA N
00211 ANESTH CRAN SURG HEMOTOMA ANESTH DEF         NA NA NA N
00212 ANESTH SKULL DRAINAGE PRXOVR DEF         NA NA NA N
00212 ANESTH SKULL DRAINAGE ANESTH DEF         NA NA NA N
00214 ANESTH SKULL DRAINAGE PRXOVR DEF         NA NA NA N
00214 ANESTH SKULL DRAINAGE ANESTH DEF         NA NA NA N
00215 ANESTH SKULL REPAIR/FRACT PRXOVR DEF         NA NA NA N
00215 ANESTH SKULL REPAIR/FRACT ANESTH DEF         NA NA NA N
00216 ANESTH HEAD VESSEL SURGERY PRXOVR DEF         NA NA NA N
00216 ANESTH HEAD VESSEL SURGERY ANESTH DEF         NA NA NA N
00218 ANESTH SPECIAL HEAD SURGERY PRXOVR DEF         NA NA NA N
00218 ANESTH SPECIAL HEAD SURGERY ANESTH DEF         NA NA NA N
00220 ANESTH INTRCRN NERVE PRXOVR DEF         NA NA NA N
00220 ANESTH INTRCRN NERVE ANESTH DEF         NA NA NA N
00222 ANESTH HEAD NERVE SURGERY PRXOVR DEF         NA NA NA N
00222 ANESTH HEAD NERVE SURGERY ANESTH DEF         NA NA NA N
00300 ANESTH HEAD/NECK/PTRUNK PRXOVR DEF         NA NA NA N
00300 ANESTH HEAD/NECK/PTRUNK ANESTH DEF         NA NA NA N
00320 ANESTH NECK ORGAN 1YR/> PRXOVR DEF         NA NA NA N
00320 ANESTH NECK ORGAN 1YR/> ANESTH DEF         NA NA NA 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
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
10004 FNA BX W/O IMG GDN EA ADDL PRXOVR DEF         NA NA NA N
10004 FNA BX W/O IMG GDN EA ADDL MAXFEE FAC         35.24 1/1/2019 12/31/2299 N
10004 FNA BX W/O IMG GDN EA ADDL MAXFEE NFF         41.59 1/1/2019 12/31/2299 N
10005 FNA BX W/US GDN 1ST LES PRXOVR DEF         NA NA NA N
10005 FNA BX W/US GDN 1ST LES MAXFEE FAC         37.55 1/1/2024 12/31/2299 N
10005 FNA BX W/US GDN 1ST LES MAXFEE NFF         71.12 1/1/2024 12/31/2299 N
10006 FNA BX W/US GDN EA ADDL PRXOVR DEF         NA NA NA N
10006 FNA BX W/US GDN EA ADDL MAXFEE FAC         28.02 1/1/2024 12/31/2299 N
10006 FNA BX W/US GDN EA ADDL MAXFEE NFF         30.80 1/1/2024 12/31/2299 N
10007 FNA BX W/FLUOR GDN 1ST LES PRXOVR DEF         NA NA NA N
10007 FNA BX W/FLUOR GDN 1ST LES MAXFEE FAC         46.20 1/1/2024 12/31/2299 N
10007 FNA BX W/FLUOR GDN 1ST LES MAXFEE NFF         156.08 1/1/2024 12/31/2299 N
10008 FNA BX W/FLUOR GDN EA ADDL PRXOVR DEF         NA NA NA N
10008 FNA BX W/FLUOR GDN EA ADDL MAXFEE FAC         18.44 1/1/2019 12/31/2299 N
10008 FNA BX W/FLUOR GDN EA ADDL MAXFEE NFF         71.70 1/1/2019 12/31/2299 N
10009 FNA BX W/CT GDN 1ST LES PRXOVR DEF         NA NA NA N
10009 FNA BX W/CT GDN 1ST LES MAXFEE FAC         61.49 1/1/2024 12/31/2299 N
10009 FNA BX W/CT GDN 1ST LES MAXFEE NFF         234.81 1/1/2024 12/31/2299 N
10010 FNA BX W/CT GDN EA ADDL PRXOVR DEF         NA NA NA N
10010 FNA BX W/CT GDN EA ADDL MAXFEE FAC         40.32 1/1/2024 12/31/2299 N
10010 FNA BX W/CT GDN EA ADDL MAXFEE NFF         137.74 1/1/2024 12/31/2299 N
10011 FNA BX W/MR GDN 1ST LES PRXOVR DEF         NA NA NA N
10011 FNA BX W/MR GDN 1ST LES MANUAL DEF         NA NA NA N
10012 FNA BX W/MR GDN EA ADDL PRXOVR DEF         NA NA NA N
10012 FNA BX W/MR GDN EA ADDL MANUAL DEF         NA NA NA N
10021 FNA BX W/O IMG GDN 1ST LES PRXOVR DEF         NA NA NA N
10021 FNA BX W/O IMG GDN 1ST LES MAXFEE FAC         49.77 1/1/2014 12/31/2299 N
10021 FNA BX W/O IMG GDN 1ST LES MAXFEE NFF         77.23 1/1/2024 12/31/2299 N
10022 FNA W/IMAGE PRXOVR DEF         NA NA NA N
10022 FNA W/IMAGE MAXFEE DEF         NA     N
10040 ACNE SURGERY PRXOVR DEF         NA NA NA N
10040 ACNE SURGERY MAXFEE FAC         48.33 1/1/2014 12/31/2299 N
10040 ACNE SURGERY MAXFEE NFF         65.24 1/1/2024 12/31/2299 N
10060 I&D ABSCESS SIMPLE/SINGLE PRXOVR DEF         NA NA NA N
10060 I&D ABSCESS SIMPLE/SINGLE MAXFEE FAC         59.75 1/1/2024 12/31/2299 N
10060 I&D ABSCESS SIMPLE/SINGLE MAXFEE NFF         76.45 1/1/2024 12/31/2299 N
10061 I&D ABSCESS COMP/MULTIPLE PRXOVR DEF         NA NA NA N
10061 I&D ABSCESS COMP/MULTIPLE MAXFEE FAC         93.44 1/1/2024 12/31/2299 N
10061 I&D ABSCESS COMP/MULTIPLE MAXFEE NFF         109.36 1/1/2024 12/31/2299 N
10120 INC&RMVL FB SUBQ TISS SMPL PRXOVR DEF         NA NA NA N
10120 INC&RMVL FB SUBQ TISS SMPL MAXFEE FAC         52.60 1/1/2024 12/31/2299 N
10120 INC&RMVL FB SUBQ TISS SMPL MAXFEE NFF         77.17 1/1/2024 12/31/2299 N
10121 INC&RMVL FB SUBQ TISS COMP PRXOVR DEF         NA NA NA N
10121 INC&RMVL FB SUBQ TISS COMP MAXFEE FAC         93.61 1/1/2024 12/31/2299 N
10121 INC&RMVL FB SUBQ TISS COMP MAXFEE NFF         136.52 1/1/2024 12/31/2299 N
10140 I&D HMTMA SEROMA/FLUID COLLJ PRXOVR DEF         NA NA NA N
10140 I&D HMTMA SEROMA/FLUID COLLJ MAXFEE FAC         60.04 1/1/2024 12/31/2299 N
10140 I&D HMTMA SEROMA/FLUID COLLJ MAXFEE NFF         88.69 1/1/2024 12/31/2299 N
10160 PNXR ASPIR ABSC HMTMA BULLA PRXOVR DEF         NA NA NA N
10160 PNXR ASPIR ABSC HMTMA BULLA MAXFEE FAC         48.28 1/1/2024 12/31/2299 N
10160 PNXR ASPIR ABSC HMTMA BULLA MAXFEE NFF         66.45 1/1/2024 12/31/2299 N
10180 I&D COMPLEX PO WOUND INFCTJ PRXOVR DEF         NA NA NA N
10180 I&D COMPLEX PO WOUND INFCTJ MAXFEE FAC         91.02 1/1/2024 12/31/2299 N
10180 I&D COMPLEX PO WOUND INFCTJ MAXFEE NFF         136.35 1/1/2024 12/31/2299 N
11000 DBRDMT ECZ/INFECTED SKIN<10% PRXOVR DEF         NA NA NA N
11000 DBRDMT ECZ/INFECTED SKIN<10% MAXFEE FAC         20.73 1/1/2024 12/31/2299 N
11000 DBRDMT ECZ/INFECTED SKIN<10% MAXFEE NFF         36.06 1/1/2024 12/31/2299 N
11001 DBRDMT ECZ/INFCT SKN EA ADDL PRXOVR DEF         NA NA NA N
11001 DBRDMT ECZ/INFCT SKN EA ADDL MAXFEE FAC         10.52 1/1/2024 12/31/2299 N
11001 DBRDMT ECZ/INFCT SKN EA ADDL MAXFEE NFF         15.77 1/1/2024 12/31/2299 N
11010 DEBRIDE SKIN AT FX SITE PRXOVR DEF         NA NA NA N
11010 DEBRIDE SKIN AT FX SITE MAXFEE FAC         140.68 1/1/2024 12/31/2299 N
11010 DEBRIDE SKIN AT FX SITE MAXFEE NFF         234.98 1/1/2024 12/31/2299 N
11011 DEBRIDE SKIN MUSC AT FX SITE PRXOVR DEF         NA NA NA N
11011 DEBRIDE SKIN MUSC AT FX SITE MAXFEE FAC         151.06 1/1/2024 12/31/2299 N
11011 DEBRIDE SKIN MUSC AT FX SITE MAXFEE NFF         269.26 1/1/2024 12/31/2299 N
11012 DEB SKIN BONE AT FX SITE PRXOVR DEF         NA NA NA N
11012 DEB SKIN BONE AT FX SITE MAXFEE FAC         211.79 1/1/2024 12/31/2299 N
11012 DEB SKIN BONE AT FX SITE MAXFEE NFF         378.03 1/1/2024 12/31/2299 N
11040 DEBRIDE SKIN; PARTIAL PRXOVR DEF         NA NA NA N
11040 DEBRIDE SKIN; PARTIAL MAXFEE DEF         NA     N
11041 DEBRIDE SKIN; FULL PRXOVR DEF         NA NA NA N
11041 DEBRIDE SKIN; FULL MAXFEE DEF         NA     N
11042 DBRDMT SUBQ TIS 1ST 20SQCM/< PRXOVR DEF         NA NA NA N
11042 DBRDMT SUBQ TIS 1ST 20SQCM/< MAXFEE FAC         30.46 1/1/2024 12/31/2299 N
11042 DBRDMT SUBQ TIS 1ST 20SQCM/< MAXFEE NFF         66.97 1/1/2024 12/31/2299 N
11043 DBRDMT MUSC&/FSCA 1ST 20/< PRXOVR DEF         NA NA NA N
11043 DBRDMT MUSC&/FSCA 1ST 20/< MAXFEE FAC         78.04 1/1/2024 12/31/2299 N
11043 DBRDMT MUSC&/FSCA 1ST 20/< MAXFEE NFF         130.94 1/1/2024 12/31/2299 N
11044 DBRDMT BONE 1ST 20 SQ CM/< PRXOVR DEF         NA NA NA N
11044 DBRDMT BONE 1ST 20 SQ CM/< MAXFEE FAC         116.20 1/1/2024 12/31/2299 N
11044 DBRDMT BONE 1ST 20 SQ CM/< MAXFEE NFF         181.37 1/1/2024 12/31/2299 N
11045 DBRDMT SUBQ TISS EACH ADDL PRXOVR DEF         NA NA NA N
11045 DBRDMT SUBQ TISS EACH ADDL MAXFEE FAC         13.33 1/1/2024 12/31/2299 N
11045 DBRDMT SUBQ TISS EACH ADDL MAXFEE NFF         20.94 1/1/2024 12/31/2299 N
11046 DBRDMT MUSC&/FSCA EA ADDL PRXOVR DEF         NA NA NA N
11046 DBRDMT MUSC&/FSCA EA ADDL MAXFEE FAC         28.21 1/1/2024 12/31/2299 N
11046 DBRDMT MUSC&/FSCA EA ADDL MAXFEE NFF         37.72 1/1/2024 12/31/2299 N
11047 DBRDMT BONE EACH ADDL PRXOVR DEF         NA NA NA N
11047 DBRDMT BONE EACH ADDL MAXFEE FAC         49.32 1/1/2024 12/31/2299 N
11047 DBRDMT BONE EACH ADDL MAXFEE NFF         61.77 1/1/2024 12/31/2299 N
11055 PARING/CUTG B9 HYPRKER LES 1 PRXOVR DEF         NA NA NA N
11055 PARING/CUTG B9 HYPRKER LES 1 MAXFEE FAC         9.82 1/1/2024 12/31/2299 N
11055 PARING/CUTG B9 HYPRKER LES 1 MAXFEE NFF         37.38 1/1/2024 12/31/2299 N
11056 PARNG/CUTG B9 HYPRKR LES 2-4 PRXOVR DEF         NA NA NA N
11056 PARNG/CUTG B9 HYPRKR LES 2-4 MAXFEE FAC         16.45 1/1/2024 12/31/2299 N
11056 PARNG/CUTG B9 HYPRKR LES 2-4 MAXFEE NFF         42.74 1/1/2024 12/31/2299 N
11057 PARNG/CUTG B9 HYPRKR LES >4 PRXOVR DEF         NA NA NA N
11057 PARNG/CUTG B9 HYPRKR LES >4 MAXFEE FAC         21.43 1/1/2024 12/31/2299 N
11057 PARNG/CUTG B9 HYPRKR LES >4 MAXFEE NFF         46.89 1/1/2024 12/31/2299 N
11100 BIOPSY SKIN LESION PRXOVR DEF         NA NA NA N
11100 BIOPSY SKIN LESION MAXFEE DEF         NA     N
11101 BIOPSY SKIN ADD-ON PRXOVR DEF         NA NA NA N
11101 BIOPSY SKIN ADD-ON MAXFEE DEF         NA     N
11102 TANGNTL BX SKIN SINGLE LES PRXOVR DEF         NA NA NA N
11102 TANGNTL BX SKIN SINGLE LES MAXFEE FAC         25.52 1/1/2024 12/31/2299 N
11102 TANGNTL BX SKIN SINGLE LES MAXFEE NFF         52.78 1/1/2024 12/31/2299 N
11103 TANGNTL BX SKIN EA SEP/ADDL PRXOVR DEF         NA NA NA N
11103 TANGNTL BX SKIN EA SEP/ADDL MAXFEE FAC         15.31 1/1/2024 12/31/2299 N
11103 TANGNTL BX SKIN EA SEP/ADDL MAXFEE NFF         29.74 1/1/2024 12/31/2299 N
11104 PUNCH BX SKIN SINGLE LESION PRXOVR DEF         NA NA NA N
11104 PUNCH BX SKIN SINGLE LESION MAXFEE FAC         31.09 1/1/2024 12/31/2299 N
11104 PUNCH BX SKIN SINGLE LESION MAXFEE NFF         65.58 1/1/2024 12/31/2299 N
11105 PUNCH BX SKIN EA SEP/ADDL PRXOVR DEF         NA NA NA N
11105 PUNCH BX SKIN EA SEP/ADDL MAXFEE FAC         12.98 1/1/2024 12/31/2299 N
11105 PUNCH BX SKIN EA SEP/ADDL MAXFEE NFF         34.07 1/1/2024 12/31/2299 N
11106 INCAL BX SKN SINGLE LES PRXOVR DEF         NA NA NA N
11106 INCAL BX SKN SINGLE LES MAXFEE FAC         38.78 1/1/2024 12/31/2299 N
11106 INCAL BX SKN SINGLE LES MAXFEE NFF         81.15 1/1/2024 12/31/2299 N
11107 INCAL BX SKN EA SEP/ADDL PRXOVR DEF         NA NA NA N
11107 INCAL BX SKN EA SEP/ADDL MAXFEE FAC         24.10 1/1/2024 12/31/2299 N
11107 INCAL BX SKN EA SEP/ADDL MAXFEE NFF         46.86 1/1/2024 12/31/2299 N
11200 RMVL SKIN TAGS UP TO&INC 15 PRXOVR DEF         NA NA NA N
11200 RMVL SKIN TAGS UP TO&INC 15 MAXFEE FAC         44.02 1/1/2024 12/31/2299 N
11200 RMVL SKIN TAGS UP TO&INC 15 MAXFEE NFF         56.78 1/1/2024 12/31/2299 N
11201 RMVL SKIN TAGS EA ADDL 10 PRXOVR DEF         NA NA NA N
11201 RMVL SKIN TAGS EA ADDL 10 MAXFEE FAC         10.46 1/1/2024 12/31/2299 N
11201 RMVL SKIN TAGS EA ADDL 10 MAXFEE NFF         13.94 1/1/2024 12/31/2299 N
11310 SHAVE SKIN LESION 0.5 CM/< PRXOVR DEF         NA NA NA N
11310 SHAVE SKIN LESION 0.5 CM/< MAXFEE FAC         37.60 1/1/2014 12/31/2299 N
11310 SHAVE SKIN LESION 0.5 CM/< MAXFEE NFF         60.39 1/1/2024 12/31/2299 N
11311 SHAVE SKIN LESION 0.6-1.0 CM PRXOVR DEF         NA NA NA N
11311 SHAVE SKIN LESION 0.6-1.0 CM MAXFEE FAC         40.59 1/1/2024 12/31/2299 N
11311 SHAVE SKIN LESION 0.6-1.0 CM MAXFEE NFF         71.12 1/1/2024 12/31/2299 N
11312 SHAVE SKIN LESION 1.1-2.0 CM PRXOVR DEF         NA NA NA N
11312 SHAVE SKIN LESION 1.1-2.0 CM MAXFEE FAC         49.48 1/1/2024 12/31/2299 N
11312 SHAVE SKIN LESION 1.1-2.0 CM MAXFEE NFF         80.46 1/1/2024 12/31/2299 N
11313 SHAVE SKIN LESION >2.0 CM PRXOVR DEF         NA NA NA N
11313 SHAVE SKIN LESION >2.0 CM MAXFEE FAC         66.49 1/1/2024 12/31/2299 N
11313 SHAVE SKIN LESION >2.0 CM MAXFEE NFF         93.96 1/1/2024 12/31/2299 N
11440 EXC FACE-MM B9+MARG 0.5 CM/< PRXOVR DEF         NA NA NA N
11440 EXC FACE-MM B9+MARG 0.5 CM/< MAXFEE FAC         55.18 1/1/2024 12/31/2299 N
11440 EXC FACE-MM B9+MARG 0.5 CM/< MAXFEE NFF         74.06 1/1/2024 12/31/2299 N
11441 EXC FACE-MM B9+MARG 0.6-1 CM PRXOVR DEF         NA NA NA N
11441 EXC FACE-MM B9+MARG 0.6-1 CM MAXFEE FAC         67.37 1/1/2024 12/31/2299 N
11441 EXC FACE-MM B9+MARG 0.6-1 CM MAXFEE NFF         89.98 1/1/2024 12/31/2299 N
11442 EXC FACE-MM B9+MARG 1.1-2 CM PRXOVR DEF         NA NA NA N
11442 EXC FACE-MM B9+MARG 1.1-2 CM MAXFEE FAC         74.23 1/1/2024 12/31/2299 N
11442 EXC FACE-MM B9+MARG 1.1-2 CM MAXFEE NFF         99.67 1/1/2024 12/31/2299 N
11443 EXC FACE-MM B9+MARG 2.1-3 CM PRXOVR DEF         NA NA NA N
11443 EXC FACE-MM B9+MARG 2.1-3 CM MAXFEE FAC         91.56 1/1/2024 12/31/2299 N
11443 EXC FACE-MM B9+MARG 2.1-3 CM MAXFEE NFF         119.04 1/1/2024 12/31/2299 N
11444 EXC FACE-MM B9+MARG 3.1-4 CM PRXOVR DEF         NA NA NA N
11444 EXC FACE-MM B9+MARG 3.1-4 CM MAXFEE FAC         114.72 1/1/2024 12/31/2299 N
11444 EXC FACE-MM B9+MARG 3.1-4 CM MAXFEE NFF         146.04 1/1/2024 12/31/2299 N
11446 EXC FACE-MM B9+MARG >4 CM PRXOVR DEF         NA NA NA N
11446 EXC FACE-MM B9+MARG >4 CM MAXFEE FAC         162.48 1/1/2024 12/31/2299 N
11446 EXC FACE-MM B9+MARG >4 CM MAXFEE NFF         198.64 1/1/2024 12/31/2299 N
11450 EXC SKN HDRDNT AX SMPL/NTRM PRXOVR DEF         NA NA NA N
11450 EXC SKN HDRDNT AX SMPL/NTRM MAXFEE FAC         134.62 1/1/2024 12/31/2299 N
11450 EXC SKN HDRDNT AX SMPL/NTRM MAXFEE NFF         227.02 1/1/2024 12/31/2299 N
11640 EXC F/E/E/N/L MAL+MRG 0.5CM< PRXOVR DEF         NA NA NA N
11640 EXC F/E/E/N/L MAL+MRG 0.5CM< MAXFEE FAC         72.29 1/1/2024 12/31/2299 N
11640 EXC F/E/E/N/L MAL+MRG 0.5CM< MAXFEE NFF         105.03 1/1/2024 12/31/2299 N
11641 EXC F/E/E/N/L MAL+MRG 0.6-1 PRXOVR DEF         NA NA NA N
11641 EXC F/E/E/N/L MAL+MRG 0.6-1 MAXFEE FAC         113.16 1/1/2024 12/31/2299 N
11641 EXC F/E/E/N/L MAL+MRG 0.6-1 MAXFEE NFF         130.02 1/1/2024 12/31/2299 N
11642 EXC F/E/E/N/L MAL+MRG 1.1-2 PRXOVR DEF         NA NA NA N
11642 EXC F/E/E/N/L MAL+MRG 1.1-2 MAXFEE FAC         115.61 1/1/2024 12/31/2299 N
11642 EXC F/E/E/N/L MAL+MRG 1.1-2 MAXFEE NFF         154.29 1/1/2024 12/31/2299 N
11643 EXC F/E/E/N/L MAL+MRG 2.1-3 PRXOVR DEF         NA NA NA N
11643 EXC F/E/E/N/L MAL+MRG 2.1-3 MAXFEE FAC         133.36 1/1/2024 12/31/2299 N
11643 EXC F/E/E/N/L MAL+MRG 2.1-3 MAXFEE NFF         182.13 1/1/2024 12/31/2299 N
11644 EXC F/E/E/N/L MAL+MRG 3.1-4 PRXOVR DEF         NA NA NA N
11644 EXC F/E/E/N/L MAL+MRG 3.1-4 MAXFEE FAC         165.23 1/1/2024 12/31/2299 N
11644 EXC F/E/E/N/L MAL+MRG 3.1-4 MAXFEE NFF         226.05 1/1/2024 12/31/2299 N
11646 EXC F/E/E/N/L MAL+MRG >4 CM PRXOVR DEF         NA NA NA N
11646 EXC F/E/E/N/L MAL+MRG >4 CM MAXFEE FAC         212.59 1/1/2024 12/31/2299 N
11646 EXC F/E/E/N/L MAL+MRG >4 CM MAXFEE NFF         294.35 1/1/2024 12/31/2299 N
11752 REMOVE NAIL BED/TIP PRXOVR DEF         NA NA NA N
11752 REMOVE NAIL BED/TIP MAXFEE DEF         NA     N
11900 INJECT SKIN LESIONS </W 7 PRXOVR DEF         NA NA NA N
11900 INJECT SKIN LESIONS </W 7 MAXFEE FAC         19.76 1/1/2024 12/31/2299 N
11900 INJECT SKIN LESIONS </W 7 MAXFEE NFF         35.95 1/1/2024 12/31/2299 N
11901 INJECT SKIN LESIONS >7 PRXOVR DEF         NA NA NA N
11901 INJECT SKIN LESIONS >7 MAXFEE FAC         33.15 1/1/2024 12/31/2299 N
11901 INJECT SKIN LESIONS >7 MAXFEE NFF         43.42 1/1/2024 12/31/2299 N
11975 INSERT CONTRACEPTIVE CAP PRXOVR DEF         NA NA NA N
11975 INSERT CONTRACEPTIVE CAP MAXFEE DEF         NA     N
11977 REMOVAL/REINSERT CONTRA CAP PRXOVR DEF         NA NA NA N
11977 REMOVAL/REINSERT CONTRA CAP MAXFEE DEF         NA     N
12001 RPR S/N/AX/GEN/TRNK 2.5CM/< PRXOVR DEF         NA NA NA N
12001 RPR S/N/AX/GEN/TRNK 2.5CM/< MAXFEE FAC         30.86 1/1/2024 12/31/2299 N
12001 RPR S/N/AX/GEN/TRNK 2.5CM/< MAXFEE NFF         70.72 1/1/2024 12/31/2299 N
12002 RPR S/N/AX/GEN/TRNK2.6-7.5CM PRXOVR DEF         NA NA NA N
12002 RPR S/N/AX/GEN/TRNK2.6-7.5CM MAXFEE FAC         39.09 1/1/2024 12/31/2299 N
12002 RPR S/N/AX/GEN/TRNK2.6-7.5CM MAXFEE NFF         81.88 1/1/2024 12/31/2299 N
12004 RPR S/N/AX/GEN/TRK7.6-12.5CM PRXOVR DEF         NA NA NA N
12004 RPR S/N/AX/GEN/TRK7.6-12.5CM MAXFEE FAC         39.32 1/1/2024 12/31/2299 N
12004 RPR S/N/AX/GEN/TRK7.6-12.5CM MAXFEE NFF         101.27 1/1/2024 12/31/2299 N
12005 RPR S/N/A/GEN/TRK12.6-20.0CM PRXOVR DEF         NA NA NA N
12005 RPR S/N/A/GEN/TRK12.6-20.0CM MAXFEE FAC         67.96 1/1/2024 12/31/2299 N
12005 RPR S/N/A/GEN/TRK12.6-20.0CM MAXFEE NFF         128.31 1/1/2024 12/31/2299 N
12006 RPR S/N/A/GEN/TRK20.1-30.0CM PRXOVR DEF         NA NA NA N
12006 RPR S/N/A/GEN/TRK20.1-30.0CM MAXFEE FAC         87.97 1/1/2024 12/31/2299 N
12006 RPR S/N/A/GEN/TRK20.1-30.0CM MAXFEE NFF         163.81 1/1/2024 12/31/2299 N
12007 RPR S/N/AX/GEN/TRNK >30.0 CM PRXOVR DEF         NA NA NA N
12007 RPR S/N/AX/GEN/TRNK >30.0 CM MAXFEE FAC         101.97 1/1/2024 12/31/2299 N
12007 RPR S/N/AX/GEN/TRNK >30.0 CM MAXFEE NFF         179.14 1/1/2024 12/31/2299 N
12011 RPR F/E/E/N/L/M 2.5 CM/< PRXOVR DEF         NA NA NA N
12011 RPR F/E/E/N/L/M 2.5 CM/< MAXFEE FAC         34.73 1/1/2024 12/31/2299 N
12011 RPR F/E/E/N/L/M 2.5 CM/< MAXFEE NFF         77.95 1/1/2024 12/31/2299 N
12013 RPR F/E/E/N/L/M 2.6-5.0 CM PRXOVR DEF         NA NA NA N
12013 RPR F/E/E/N/L/M 2.6-5.0 CM MAXFEE FAC         41.80 1/1/2024 12/31/2299 N
12013 RPR F/E/E/N/L/M 2.6-5.0 CM MAXFEE NFF         91.41 1/1/2024 12/31/2299 N
12014 RPR F/E/E/N/L/M 5.1-7.5 CM PRXOVR DEF         NA NA NA N
12014 RPR F/E/E/N/L/M 5.1-7.5 CM MAXFEE FAC         54.08 1/1/2024 12/31/2299 N
12014 RPR F/E/E/N/L/M 5.1-7.5 CM MAXFEE NFF         109.86 1/1/2024 12/31/2299 N
12015 RPR F/E/E/N/L/M 7.6-12.5 CM PRXOVR DEF         NA NA NA N
12015 RPR F/E/E/N/L/M 7.6-12.5 CM MAXFEE FAC         71.78 1/1/2024 12/31/2299 N
12015 RPR F/E/E/N/L/M 7.6-12.5 CM MAXFEE NFF         135.24 1/1/2014 12/31/2299 N
12016 RPR FE/E/EN/L/M 12.6-20.0 CM PRXOVR DEF         NA NA NA N
12016 RPR FE/E/EN/L/M 12.6-20.0 CM MAXFEE FAC         98.41 1/1/2024 12/31/2299 N
12016 RPR FE/E/EN/L/M 12.6-20.0 CM MAXFEE NFF         177.91 1/1/2024 12/31/2299 N
12017 RPR FE/E/EN/L/M 20.1-30.0 CM PRXOVR DEF         NA NA NA N
12017 RPR FE/E/EN/L/M 20.1-30.0 CM MAXFEE DEF         148.51 9/1/2013 12/31/2299 N
12018 RPR F/E/E/N/L/M >30.0 CM PRXOVR DEF         NA NA NA N
12018 RPR F/E/E/N/L/M >30.0 CM MAXFEE DEF         172.10 9/1/2013 12/31/2299 N
12020 TX SUPFC WND DEHSN SMPL CLSR PRXOVR DEF         NA NA NA N
12020 TX SUPFC WND DEHSN SMPL CLSR MAXFEE FAC         95.52 1/1/2024 12/31/2299 N
12020 TX SUPFC WND DEHSN SMPL CLSR MAXFEE NFF         155.38 1/1/2024 12/31/2299 N
12021 TX SUPFC WND DEHSN W/PACKING PRXOVR DEF         NA NA NA N
12021 TX SUPFC WND DEHSN W/PACKING MAXFEE FAC         71.81 1/1/2024 12/31/2299 N
12021 TX SUPFC WND DEHSN W/PACKING MAXFEE NFF         91.36 1/1/2024 12/31/2299 N
12031 INTMD RPR S/A/T/EXT 2.5 CM/< PRXOVR DEF         NA NA NA N
12031 INTMD RPR S/A/T/EXT 2.5 CM/< MAXFEE FAC         89.86 1/1/2024 12/31/2299 N
12031 INTMD RPR S/A/T/EXT 2.5 CM/< MAXFEE NFF         136.70 1/1/2024 12/31/2299 N
12032 INTMD RPR S/A/T/EXT 2.6-7.5 PRXOVR DEF         NA NA NA N
12032 INTMD RPR S/A/T/EXT 2.6-7.5 MAXFEE FAC         95.52 1/1/2024 12/31/2299 N
12032 INTMD RPR S/A/T/EXT 2.6-7.5 MAXFEE NFF         156.25 1/1/2024 12/31/2299 N
12034 INTMD RPR S/TR/EXT 7.6-12.5 PRXOVR DEF         NA NA NA N
12034 INTMD RPR S/TR/EXT 7.6-12.5 MAXFEE FAC         103.82 1/1/2024 12/31/2299 N
12034 INTMD RPR S/TR/EXT 7.6-12.5 MAXFEE NFF         173.03 1/1/2024 12/31/2299 N
12035 INTMD RPR S/A/T/EXT 12.6-20 PRXOVR DEF         NA NA NA N
12035 INTMD RPR S/A/T/EXT 12.6-20 MAXFEE FAC         122.68 1/1/2024 12/31/2299 N
12035 INTMD RPR S/A/T/EXT 12.6-20 MAXFEE NFF         201.58 1/1/2024 12/31/2299 N
12036 INTMD RPR S/A/T/EXT 20.1-30 PRXOVR DEF         NA NA NA N
12036 INTMD RPR S/A/T/EXT 20.1-30 MAXFEE FAC         144.66 1/1/2024 12/31/2299 N
12036 INTMD RPR S/A/T/EXT 20.1-30 MAXFEE NFF         224.77 1/1/2024 12/31/2299 N
12037 INTMD RPR S/TR/EXT >30.0 CM PRXOVR DEF         NA NA NA N
12037 INTMD RPR S/TR/EXT >30.0 CM MAXFEE FAC         167.50 1/1/2024 12/31/2299 N
12037 INTMD RPR S/TR/EXT >30.0 CM MAXFEE NFF         250.90 1/1/2024 12/31/2299 N
12051 INTMD RPR FACE/MM 2.5 CM/< PRXOVR DEF         NA NA NA N
12051 INTMD RPR FACE/MM 2.5 CM/< MAXFEE FAC         85.48 1/1/2024 12/31/2299 N
12051 INTMD RPR FACE/MM 2.5 CM/< MAXFEE NFF         147.08 1/1/2024 12/31/2299 N
12052 INTMD RPR FACE/MM 2.6-5.0 CM PRXOVR DEF         NA NA NA N
12052 INTMD RPR FACE/MM 2.6-5.0 CM MAXFEE FAC         100.53 1/1/2024 12/31/2299 N
12052 INTMD RPR FACE/MM 2.6-5.0 CM MAXFEE NFF         163.17 1/1/2024 12/31/2299 N
12053 INTMD RPR FACE/MM 5.1-7.5 CM PRXOVR DEF         NA NA NA N
12053 INTMD RPR FACE/MM 5.1-7.5 CM MAXFEE FAC         108.32 1/1/2024 12/31/2299 N
12053 INTMD RPR FACE/MM 5.1-7.5 CM MAXFEE NFF         188.61 1/1/2024 12/31/2299 N
12054 INTMD RPR FACE/MM 7.6-12.5CM PRXOVR DEF         NA NA NA N
12054 INTMD RPR FACE/MM 7.6-12.5CM MAXFEE FAC         110.92 1/1/2024 12/31/2299 N
12054 INTMD RPR FACE/MM 7.6-12.5CM MAXFEE NFF         200.03 1/1/2024 12/31/2299 N
12055 INTMD RPR FACE/MM 12.6-20 CM PRXOVR DEF         NA NA NA N
12055 INTMD RPR FACE/MM 12.6-20 CM MAXFEE FAC         151.75 1/1/2024 12/31/2299 N
12055 INTMD RPR FACE/MM 12.6-20 CM MAXFEE NFF         261.45 1/1/2024 12/31/2299 N
12056 INTMD RPR FACE/MM 20.1-30.0 PRXOVR DEF         NA NA NA N
12056 INTMD RPR FACE/MM 20.1-30.0 MAXFEE FAC         195.87 1/1/2024 12/31/2299 N
12056 INTMD RPR FACE/MM 20.1-30.0 MAXFEE NFF         300.56 1/1/2024 12/31/2299 N
12057 INTMD RPR FACE/MM >30.0 CM PRXOVR DEF         NA NA NA N
12057 INTMD RPR FACE/MM >30.0 CM MAXFEE FAC         213.52 1/1/2024 12/31/2299 N
12057 INTMD RPR FACE/MM >30.0 CM MAXFEE NFF         319.06 1/1/2024 12/31/2299 N
13120 CMPLX RPR S/A/L 1.1-2.5 CM PRXOVR DEF         NA NA NA N
13120 CMPLX RPR S/A/L 1.1-2.5 CM MAXFEE FAC         118.01 1/1/2024 12/31/2299 N
13120 CMPLX RPR S/A/L 1.1-2.5 CM MAXFEE NFF         184.11 1/1/2024 12/31/2299 N
13121 CMPLX RPR S/A/L 2.6-7.5 CM PRXOVR DEF         NA NA NA N
13121 CMPLX RPR S/A/L 2.6-7.5 CM MAXFEE FAC         129.78 1/1/2024 12/31/2299 N
13121 CMPLX RPR S/A/L 2.6-7.5 CM MAXFEE NFF         219.92 1/1/2024 12/31/2299 N
13122 CMPLX RPR S/A/L ADDL 5 CM/> PRXOVR DEF         NA NA NA N
13122 CMPLX RPR S/A/L ADDL 5 CM/> MAXFEE FAC         41.76 1/1/2024 12/31/2299 N
13122 CMPLX RPR S/A/L ADDL 5 CM/> MAXFEE NFF         68.88 1/1/2024 12/31/2299 N
13131 CMPLX RPR F/C/C/M/N/AX/G/H/F PRXOVR DEF         NA NA NA N
13131 CMPLX RPR F/C/C/M/N/AX/G/H/F MAXFEE FAC         122.16 1/1/2024 12/31/2299 N
13131 CMPLX RPR F/C/C/M/N/AX/G/H/F MAXFEE NFF         200.55 1/1/2024 12/31/2299 N
13132 CMPLX RPR F/C/C/M/N/AX/G/H/F PRXOVR DEF         NA NA NA N
13132 CMPLX RPR F/C/C/M/N/AX/G/H/F MAXFEE FAC         152.79 1/1/2024 12/31/2299 N
13132 CMPLX RPR F/C/C/M/N/AX/G/H/F MAXFEE NFF         283.98 1/1/2024 12/31/2299 N
13133 CMPLX RPR F/C/C/M/N/AX/G/H/F PRXOVR DEF         NA NA NA N
13133 CMPLX RPR F/C/C/M/N/AX/G/H/F MAXFEE FAC         66.24 1/1/2024 12/31/2299 N
13133 CMPLX RPR F/C/C/M/N/AX/G/H/F MAXFEE NFF         100.76 1/1/2024 12/31/2299 N
13150 CMPLX RPR E/N/E/L 1.0 CM/< PRXOVR DEF         NA NA NA N
13150 CMPLX RPR E/N/E/L 1.0 CM/< MAXFEE FAC         82.91 1/1/2014 12/31/2299 N
13150 CMPLX RPR E/N/E/L 1.0 CM/< MAXFEE NFF         165.11 1/1/2014 12/31/2299 N
13151 CMPLX RPR E/N/E/L 1.1-2.5 CM PRXOVR DEF         NA NA NA N
13151 CMPLX RPR E/N/E/L 1.1-2.5 CM MAXFEE FAC         140.68 1/1/2024 12/31/2299 N
13151 CMPLX RPR E/N/E/L 1.1-2.5 CM MAXFEE NFF         218.54 1/1/2024 12/31/2299 N
13152 CMPLX RPR E/N/E/L 2.6-7.5 CM PRXOVR DEF         NA NA NA N
13152 CMPLX RPR E/N/E/L 2.6-7.5 CM MAXFEE FAC         169.40 1/1/2024 12/31/2299 N
13152 CMPLX RPR E/N/E/L 2.6-7.5 CM MAXFEE NFF         327.06 1/1/2024 12/31/2299 N
13153 CMPLX RPR E/N/E/L ADDL 5CM/< PRXOVR DEF         NA NA NA N
13153 CMPLX RPR E/N/E/L ADDL 5CM/< MAXFEE FAC         71.46 1/1/2024 12/31/2299 N
13153 CMPLX RPR E/N/E/L ADDL 5CM/< MAXFEE NFF         110.58 1/1/2024 12/31/2299 N
13160 SEC CLSR SURG WND/DEHSN XTN PRXOVR DEF         NA NA NA N
13160 SEC CLSR SURG WND/DEHSN XTN MAXFEE DEF         449.01 1/1/2024 12/31/2299 N
15004 WOUND PREP F/N/HF/G PRXOVR DEF         NA NA NA N
15004 WOUND PREP F/N/HF/G MAXFEE FAC         132.72 1/1/2024 12/31/2299 N
15004 WOUND PREP F/N/HF/G MAXFEE NFF         228.28 1/1/2024 12/31/2299 N
15005 WND PREP F/N/HF/G ADDL CM PRXOVR DEF         NA NA NA N
15005 WND PREP F/N/HF/G ADDL CM MAXFEE FAC         46.37 1/1/2024 12/31/2299 N
15005 WND PREP F/N/HF/G ADDL CM MAXFEE NFF         71.17 1/1/2024 12/31/2299 N
15115 EPIDRM A-GRFT FACE/NCK/HF/G PRXOVR DEF         NA NA NA N
15115 EPIDRM A-GRFT FACE/NCK/HF/G MAXFEE FAC         414.37 1/1/2024 12/31/2299 N
15115 EPIDRM A-GRFT FACE/NCK/HF/G MAXFEE NFF         557.26 1/1/2024 12/31/2299 N
15116 EPIDRM A-GRFT F/N/HF/G ADDL PRXOVR DEF         NA NA NA N
15116 EPIDRM A-GRFT F/N/HF/G ADDL MAXFEE FAC         84.84 1/1/2024 12/31/2299 N
15116 EPIDRM A-GRFT F/N/HF/G ADDL MAXFEE NFF         122.50 1/1/2024 12/31/2299 N
15120 SKN SPLT A-GRFT FAC/NCK/HF/G PRXOVR DEF         NA NA NA N
15120 SKN SPLT A-GRFT FAC/NCK/HF/G MAXFEE FAC         351.26 1/1/2024 12/31/2299 N
15120 SKN SPLT A-GRFT FAC/NCK/HF/G MAXFEE NFF         460.44 1/1/2024 12/31/2299 N
15121 SKN SPLT A-GRFT F/N/HF/G ADD PRXOVR DEF         NA NA NA N
15121 SKN SPLT A-GRFT F/N/HF/G ADD MAXFEE FAC         82.31 1/1/2024 12/31/2299 N
15121 SKN SPLT A-GRFT F/N/HF/G ADD MAXFEE NFF         150.98 1/1/2024 12/31/2299 N
15135 DERM AUTOGRAFT FACE/NCK/HF/G PRXOVR DEF         NA NA NA N
15135 DERM AUTOGRAFT FACE/NCK/HF/G MAXFEE FAC         452.75 1/1/2024 12/31/2299 N
15135 DERM AUTOGRAFT FACE/NCK/HF/G MAXFEE NFF         596.57 1/1/2024 12/31/2299 N
15136 DERM AUTOGRAFT F/N/HF/G ADD PRXOVR DEF         NA NA NA N
15136 DERM AUTOGRAFT F/N/HF/G ADD MAXFEE FAC         67.75 1/1/2014 12/31/2299 N
15136 DERM AUTOGRAFT F/N/HF/G ADD MAXFEE NFF         68.65 1/1/2014 12/31/2299 N
15155 CULT SKIN GRAFT F/N/HF/G PRXOVR DEF         NA NA NA N
15155 CULT SKIN GRAFT F/N/HF/G MAXFEE FAC         472.16 1/1/2024 12/31/2299 N
15155 CULT SKIN GRAFT F/N/HF/G MAXFEE NFF         494 1/1/2024 12/31/2299 N
15156 CULT SKIN GRFT F/N/HFG ADD PRXOVR DEF         NA NA NA N
15156 CULT SKIN GRFT F/N/HFG ADD MAXFEE FAC         97.89 1/1/2024 12/31/2299 N
15156 CULT SKIN GRFT F/N/HFG ADD MAXFEE NFF         123.73 1/1/2014 12/31/2299 N
15157 CULT EPIDERM GRFT F/N/HFG +% PRXOVR DEF         NA NA NA N
15157 CULT EPIDERM GRFT F/N/HFG +% MAXFEE FAC         126.33 1/1/2014 12/31/2299 N
15157 CULT EPIDERM GRFT F/N/HFG +% MAXFEE NFF         136.75 1/1/2014 12/31/2299 N
15170 ACELL GRAFT TRUNK/ARMS/LEGS PRXOVR DEF         NA NA NA N
15170 ACELL GRAFT TRUNK/ARMS/LEGS MAXFEE DEF         NA     N
15171 ACELL GRAFT T/ARM/LEG ADD-ON PRXOVR DEF         NA NA NA N
15171 ACELL GRAFT T/ARM/LEG ADD-ON MAXFEE DEF         NA     N
15175 ACELLULAR GRAFT F/N/HF/G PRXOVR DEF         NA NA NA N
15175 ACELLULAR GRAFT F/N/HF/G MAXFEE DEF         NA     N
15176 ACELL GRAFT F/N/HF/G ADD-ON PRXOVR DEF         NA NA NA N
15176 ACELL GRAFT F/N/HF/G ADD-ON MAXFEE DEF         NA     N
15220 FTH GRF FR S/A/L 20 SQ CM/< PRXOVR DEF         NA NA NA N
15220 FTH GRF FR S/A/L 20 SQ CM/< MAXFEE FAC         308.52 1/1/2024 12/31/2299 N
15220 FTH GRF FR S/A/L 20 SQ CM/< MAXFEE NFF         392.96 1/1/2024 12/31/2299 N
15221 FTH GRF FR S/A/L EACH ADDL PRXOVR DEF         NA NA NA N
15221 FTH GRF FR S/A/L EACH ADDL MAXFEE FAC         49.33 1/1/2024 12/31/2299 N
15221 FTH GRF FR S/A/L EACH ADDL MAXFEE NFF         67.83 1/1/2024 12/31/2299 N
15240 FTH GR FR F/C/C/M/N/AX/G/H/F PRXOVR DEF         NA NA NA N
15240 FTH GR FR F/C/C/M/N/AX/G/H/F MAXFEE FAC         402.13 1/1/2024 12/31/2299 N
15240 FTH GR FR F/C/C/M/N/AX/G/H/F MAXFEE NFF         473.93 1/1/2024 12/31/2299 N
15241 FTH GR F/C/C/M/N/AX/G/H/F EA PRXOVR DEF         NA NA NA N
15241 FTH GR F/C/C/M/N/AX/G/H/F EA MAXFEE FAC         76.80 1/1/2024 12/31/2299 N
15241 FTH GR F/C/C/M/N/AX/G/H/F EA MAXFEE NFF         100.54 1/1/2024 12/31/2299 N
15260 FTH GRF FR N/E/E/L 20 SQCM/< PRXOVR DEF         NA NA NA N
15260 FTH GRF FR N/E/E/L 20 SQCM/< MAXFEE FAC         426.52 1/1/2024 12/31/2299 N
15260 FTH GRF FR N/E/E/L 20 SQCM/< MAXFEE NFF         507.68 1/1/2024 12/31/2299 N
15261 FTH GRF FR N/E/E/L EACH ADDL PRXOVR DEF         NA NA NA N
15261 FTH GRF FR N/E/E/L EACH ADDL MAXFEE FAC         107.31 1/1/2024 12/31/2299 N
15261 FTH GRF FR N/E/E/L EACH ADDL MAXFEE NFF         137.81 1/1/2024 12/31/2299 N
15275 SKIN SUB GRAFT FACE/NK/HF/G PRXOVR DEF         NA NA NA N
15275 SKIN SUB GRAFT FACE/NK/HF/G MAXFEE FAC         47.41 1/1/2024 12/31/2299 N
15275 SKIN SUB GRAFT FACE/NK/HF/G MAXFEE NFF         82.19 1/1/2024 12/31/2299 N
15276 SKIN SUB GRAFT F/N/HF/G ADDL PRXOVR DEF         NA NA NA N
15276 SKIN SUB GRAFT F/N/HF/G ADDL MAXFEE FAC         12.98 1/1/2024 12/31/2299 N
15276 SKIN SUB GRAFT F/N/HF/G ADDL MAXFEE NFF         16.79 1/1/2024 12/31/2299 N
15277 SKN SUB GRFT F/N/HF/G CHILD PRXOVR DEF         NA NA NA N
15277 SKN SUB GRFT F/N/HF/G CHILD MAXFEE FAC         114.72 1/1/2024 12/31/2299 N
15277 SKN SUB GRFT F/N/HF/G CHILD MAXFEE NFF         179.78 1/1/2024 12/31/2299 N
15278 SKN SUB GRFT F/N/HF/G CH ADD PRXOVR DEF         NA NA NA N
15278 SKN SUB GRFT F/N/HF/G CH ADD MAXFEE FAC         28.90 1/1/2024 12/31/2299 N
15278 SKN SUB GRFT F/N/HF/G CH ADD MAXFEE NFF         50.18 1/1/2024 12/31/2299 N
15300 APPLY SKINALLOGRFT T/ARM/LG PRXOVR DEF         NA NA NA N
15300 APPLY SKINALLOGRFT T/ARM/LG MAXFEE DEF         NA     N
15301 APPLY SKNALLOGRFT T/A/L ADDL PRXOVR DEF         NA NA NA N
15301 APPLY SKNALLOGRFT T/A/L ADDL MAXFEE DEF         NA     N
15320 APPLY SKIN ALLOGRFT F/N/HF/G PRXOVR DEF         NA NA NA N
15320 APPLY SKIN ALLOGRFT F/N/HF/G MAXFEE DEF         NA     N
15321 APLY SKNALLOGRFT F/N/HFG ADD PRXOVR DEF         NA NA NA N
15321 APLY SKNALLOGRFT F/N/HFG ADD MAXFEE DEF         NA     N
15330 APLY ACELL ALOGRFT T/ARM/LEG PRXOVR DEF         NA NA NA N
15330 APLY ACELL ALOGRFT T/ARM/LEG MAXFEE DEF         NA     N
15331 APLY ACELL GRFT T/A/L ADD-ON PRXOVR DEF         NA NA NA N
15331 APLY ACELL GRFT T/A/L ADD-ON MAXFEE DEF         NA     N
15335 APPLY ACELL GRAFT F/N/HF/G PRXOVR DEF         NA NA NA N
15335 APPLY ACELL GRAFT F/N/HF/G MAXFEE DEF         NA     N
15336 APLY ACELL GRFT F/N/HF/G ADD PRXOVR DEF         NA NA NA N
15336 APLY ACELL GRFT F/N/HF/G ADD MAXFEE DEF         NA     N
15340 APPLY CULT SKIN SUBSTITUTE PRXOVR DEF         NA NA NA N
15340 APPLY CULT SKIN SUBSTITUTE MAXFEE DEF         NA     N
15341 APPLY CULT SKIN SUB ADD-ON PRXOVR DEF         NA NA NA N
15341 APPLY CULT SKIN SUB ADD-ON MAXFEE DEF         NA     N
15342 CULTURED SKIN GRAFT; 25 CM PRXOVR DEF         NA NA NA N
15342 CULTURED SKIN GRAFT; 25 CM MAXFEE DEF         NA     N
15343 CULTURE SKN GRAFT ADDL 25 CM PRXOVR DEF         NA NA NA N
15343 CULTURE SKN GRAFT ADDL 25 CM MAXFEE DEF         NA     N
15360 APPLY CULT DERM SUB T/A/L PRXOVR DEF         NA NA NA N
15360 APPLY CULT DERM SUB T/A/L MAXFEE DEF         NA     N
15361 APLY CULT DERM SUB T/A/L ADD PRXOVR DEF         NA NA NA N
15361 APLY CULT DERM SUB T/A/L ADD MAXFEE DEF         NA     N
15365 APPLY CULT DERM SUB F/N/HF/G PRXOVR DEF         NA NA NA N
15365 APPLY CULT DERM SUB F/N/HF/G MAXFEE DEF         NA     N
15366 APPLY CULT DERM F/HF/G ADD PRXOVR DEF         NA NA NA N
15366 APPLY CULT DERM F/HF/G ADD MAXFEE DEF         NA     N
15400 APPLY SKIN XENOGRAFT T/A/L PRXOVR DEF         NA NA NA N
15400 APPLY SKIN XENOGRAFT T/A/L MAXFEE DEF         NA     N
15401 APPLY SKN XENOGRFT T/A/L ADD PRXOVR DEF         NA NA NA N
15401 APPLY SKN XENOGRFT T/A/L ADD MAXFEE DEF         NA     N
17000 DESTRUCT PREMALG LESION PRXOVR DEF         NA NA NA N
17000 DESTRUCT PREMALG LESION MAXFEE FAC         27.86 1/1/2024 12/31/2299 N
17000 DESTRUCT PREMALG LESION MAXFEE NFF         46.45 1/1/2024 12/31/2299 N
17003 DESTRUCT PREMALG LES 2-14 PRXOVR DEF         NA NA NA N
17003 DESTRUCT PREMALG LES 2-14 MAXFEE FAC         2.08 1/1/2024 12/31/2299 N
17003 DESTRUCT PREMALG LES 2-14 MAXFEE NFF         5.51 1/1/2024 12/31/2299 N
17004 DESTROY PREMAL LESIONS 15/> PRXOVR DEF         NA NA NA N
17004 DESTROY PREMAL LESIONS 15/> MAXFEE FAC         88.51 12/31/2014 12/31/2299 N
17004 DESTROY PREMAL LESIONS 15/> MAXFEE NFF         132.38 1/1/2014 12/31/2299 N
20000 INCISION OF ABSCESS PRXOVR DEF         NA NA NA N
20000 INCISION OF ABSCESS MAXFEE DEF         NA     N
20005 I&D ABSCESS SUBFASCIAL PRXOVR DEF         NA NA NA N
20005 I&D ABSCESS SUBFASCIAL MAXFEE DEF         NA     N
20100 EXPLORE WOUND NECK PRXOVR DEF         NA NA NA N
20100 EXPLORE WOUND NECK MAXFEE DEF         436.43 1/1/2024 12/31/2299 N
20101 EXPLORE WOUND CHEST PRXOVR DEF         NA NA NA N
20101 EXPLORE WOUND CHEST MAXFEE FAC         108.84 1/1/2024 12/31/2299 N
20101 EXPLORE WOUND CHEST MAXFEE NFF         312.50 1/1/2024 12/31/2299 N
20200 MUSCLE BIOPSY SUPERFICIAL PRXOVR DEF         NA NA NA N
20200 MUSCLE BIOPSY SUPERFICIAL MAXFEE FAC         61.34 1/1/2024 12/31/2299 N
20200 MUSCLE BIOPSY SUPERFICIAL MAXFEE NFF         114.90 1/1/2024 12/31/2299 N
20205 DEEP MUSCLE BIOPSY PRXOVR DEF         NA NA NA N
20205 DEEP MUSCLE BIOPSY MAXFEE FAC         82.04 1/1/2024 12/31/2299 N
20205 DEEP MUSCLE BIOPSY MAXFEE NFF         159.19 1/1/2024 12/31/2299 N
20206 BIOPSY MUSCLE PERQ NEEDLE PRXOVR DEF         NA NA NA N
20206 BIOPSY MUSCLE PERQ NEEDLE MAXFEE FAC         43.91 1/1/2024 12/31/2299 N
20206 BIOPSY MUSCLE PERQ NEEDLE MAXFEE NFF         119.39 1/1/2024 12/31/2299 N
20220 BONE BIOPSY TROCAR/NDL SUPFC PRXOVR DEF         NA NA NA N
20220 BONE BIOPSY TROCAR/NDL SUPFC MAXFEE FAC         43.95 1/1/2024 12/31/2299 N
20220 BONE BIOPSY TROCAR/NDL SUPFC MAXFEE NFF         124.24 1/1/2024 12/31/2299 N
20225 BONE BIOPSY TROCAR/NDL DEEP PRXOVR DEF         NA NA NA N
20225 BONE BIOPSY TROCAR/NDL DEEP MAXFEE FAC         84.53 1/1/2024 12/31/2299 N
20225 BONE BIOPSY TROCAR/NDL DEEP MAXFEE NFF         237.44 1/1/2024 12/31/2299 N
20240 BONE BIOPSY OPEN SUPERFICIAL PRXOVR DEF         NA NA NA N
20240 BONE BIOPSY OPEN SUPERFICIAL MAXFEE DEF         143.62 1/1/2024 12/31/2299 N
20245 BONE BIOPSY OPEN DEEP PRXOVR DEF         NA NA NA N
20245 BONE BIOPSY OPEN DEEP MAXFEE DEF         343.50 7/1/2008 12/31/2299 N
20250 BIOPSY VRT BDY OPEN THORACIC PRXOVR DEF         NA NA NA N
20250 BIOPSY VRT BDY OPEN THORACIC MAXFEE DEF         284.07 1/1/2024 12/31/2299 N
20251 BIOPSY VRT BDY OPEN LMBR/CRV PRXOVR DEF         NA NA NA N
20251 BIOPSY VRT BDY OPEN LMBR/CRV MAXFEE DEF         323.30 1/1/2024 12/31/2299 N
20500 INJECTION OF SINUS TRACT PRXOVR DEF         NA NA NA N
20500 INJECTION OF SINUS TRACT MAXFEE FAC         67.40 1/1/2014 12/31/2299 N
20500 INJECTION OF SINUS TRACT MAXFEE NFF         97.57 1/1/2024 12/31/2299 N
20501 INJECT SINUS TRACT FOR X-RAY PRXOVR DEF         NA NA NA N
20501 INJECT SINUS TRACT FOR X-RAY MAXFEE FAC         29.40 1/1/2024 12/31/2299 N
20501 INJECT SINUS TRACT FOR X-RAY MAXFEE NFF         76.48 1/1/2024 12/31/2299 N
20520 REMOVAL OF FOREIGN BODY PRXOVR DEF         NA NA NA N
20520 REMOVAL OF FOREIGN BODY MAXFEE FAC         90.29 1/1/2024 12/31/2299 N
20520 REMOVAL OF FOREIGN BODY MAXFEE NFF         120.90 1/1/2024 12/31/2299 N
20525 REMOVAL OF FOREIGN BODY PRXOVR DEF         NA NA NA N
20525 REMOVAL OF FOREIGN BODY MAXFEE FAC         126.32 1/1/2024 12/31/2299 N
20525 REMOVAL OF FOREIGN BODY MAXFEE NFF         242.42 1/1/2024 12/31/2299 N
20550 INJ TENDON SHEATH/LIGAMENT PRXOVR DEF         NA NA NA N
20550 INJ TENDON SHEATH/LIGAMENT MAXFEE FAC         32.70 1/1/2014 12/31/2299 N
20550 INJ TENDON SHEATH/LIGAMENT MAXFEE NFF         43.91 1/1/2024 12/31/2299 N
20551 INJ TENDON ORIGIN/INSERTION PRXOVR DEF         NA NA NA N
20551 INJ TENDON ORIGIN/INSERTION MAXFEE FAC         33.71 1/1/2014 12/31/2299 N
20551 INJ TENDON ORIGIN/INSERTION MAXFEE NFF         46.76 1/1/2024 12/31/2299 N
20552 INJ TRIGGER POINT 1/2 MUSCL PRXOVR DEF         NA NA NA N
20552 INJ TRIGGER POINT 1/2 MUSCL MAXFEE FAC         28.11 1/1/2024 12/31/2299 N
20552 INJ TRIGGER POINT 1/2 MUSCL MAXFEE NFF         42.08 1/1/2014 12/31/2299 N
20553 INJECT TRIGGER POINTS 3/> PRXOVR DEF         NA NA NA N
20553 INJECT TRIGGER POINTS 3/> MAXFEE FAC         33.88 1/1/2014 12/31/2299 N
20553 INJECT TRIGGER POINTS 3/> MAXFEE NFF         46.76 1/1/2024 12/31/2299 N
20555 PLACE NDL MUSC/TIS FOR RT PRXOVR DEF         NA NA NA N
20555 PLACE NDL MUSC/TIS FOR RT MAXFEE DEF         207.67 1/1/2024 12/31/2299 N
20560 NDL INSJ W/O NJX 1 OR 2 MUSC PRXOVR DEF         NA NA NA N
20560 NDL INSJ W/O NJX 1 OR 2 MUSC MAXFEE FAC         11.85 7/1/2021 12/31/2299 N
20560 NDL INSJ W/O NJX 1 OR 2 MUSC MAXFEE NFF         19.90 1/1/2024 12/31/2299 N
20561 NDL INSJ W/O NJX 3+ MUSC PRXOVR DEF         NA NA NA N
20561 NDL INSJ W/O NJX 3+ MUSC MAXFEE FAC         17.87 7/1/2021 12/31/2299 N
20561 NDL INSJ W/O NJX 3+ MUSC MAXFEE NFF         29.20 1/1/2024 12/31/2299 N
20600 DRAIN/INJ JOINT/BURSA W/O US PRXOVR DEF         NA NA NA N
20600 DRAIN/INJ JOINT/BURSA W/O US MAXFEE FAC         25.63 1/1/2024 12/31/2299 N
20600 DRAIN/INJ JOINT/BURSA W/O US MAXFEE NFF         38.61 1/1/2024 12/31/2299 N
20604 DRAIN/INJ JOINT/BURSA W/US PRXOVR DEF         NA NA NA N
20604 DRAIN/INJ JOINT/BURSA W/US MAXFEE FAC         36.16 1/1/2015 12/31/2299 N
20604 DRAIN/INJ JOINT/BURSA W/US MAXFEE NFF         58.12 1/1/2024 12/31/2299 N
20605 DRAIN/INJ JOINT/BURSA W/O US PRXOVR DEF         NA NA NA N
20605 DRAIN/INJ JOINT/BURSA W/O US MAXFEE FAC         36.82 1/1/2014 12/31/2299 N
20605 DRAIN/INJ JOINT/BURSA W/O US MAXFEE NFF         42.45 1/1/2024 12/31/2299 N
20606 DRAIN/INJ JOINT/BURSA W/US PRXOVR DEF         NA NA NA N
20606 DRAIN/INJ JOINT/BURSA W/US MAXFEE FAC         40.89 1/1/2015 12/31/2299 N
20606 DRAIN/INJ JOINT/BURSA W/US MAXFEE NFF         63.91 1/1/2024 12/31/2299 N
20610 DRAIN/INJ JOINT/BURSA W/O US PRXOVR DEF         NA NA NA N
20610 DRAIN/INJ JOINT/BURSA W/O US MAXFEE FAC         29.83 1/1/2024 12/31/2299 N
20610 DRAIN/INJ JOINT/BURSA W/O US MAXFEE NFF         51.36 1/1/2024 12/31/2299 N
20611 DRAIN/INJ JOINT/BURSA W/US PRXOVR DEF         NA NA NA N
20611 DRAIN/INJ JOINT/BURSA W/US MAXFEE FAC         48.04 1/1/2015 12/31/2299 N
20611 DRAIN/INJ JOINT/BURSA W/US MAXFEE NFF         73.36 1/1/2024 12/31/2299 N
20612 ASPIRATE/INJ GANGLION CYST PRXOVR DEF         NA NA NA N
20612 ASPIRATE/INJ GANGLION CYST MAXFEE FAC         31.48 1/1/2024 12/31/2299 N
20612 ASPIRATE/INJ GANGLION CYST MAXFEE NFF         40.32 1/1/2024 12/31/2299 N
20615 TREATMENT OF BONE CYST PRXOVR DEF         NA NA NA N
20615 TREATMENT OF BONE CYST MAXFEE FAC         81.50 1/1/2024 12/31/2299 N
20615 TREATMENT OF BONE CYST MAXFEE NFF         129.78 1/1/2024 12/31/2299 N
20650 INSERT AND REMOVE BONE PIN PRXOVR DEF         NA NA NA N
20650 INSERT AND REMOVE BONE PIN MAXFEE FAC         82.37 1/1/2024 12/31/2299 N
20650 INSERT AND REMOVE BONE PIN MAXFEE NFF         114.72 1/1/2024 12/31/2299 N
20670 REMOVAL IMPLANT SUPERFICIAL PRXOVR DEF         NA NA NA N
20670 REMOVAL IMPLANT SUPERFICIAL MAXFEE FAC         77.53 1/1/2024 12/31/2299 N
20670 REMOVAL IMPLANT SUPERFICIAL MAXFEE NFF         187.05 1/1/2024 12/31/2299 N
20680 REMOVAL OF IMPLANT DEEP PRXOVR DEF         NA NA NA N
20680 REMOVAL OF IMPLANT DEEP MAXFEE FAC         214.39 1/1/2024 12/31/2299 N
20680 REMOVAL OF IMPLANT DEEP MAXFEE NFF         311.11 1/1/2024 12/31/2299 N
20690 APPL UNIPLN UNI EXT FIXJ SYS PRXOVR DEF         NA NA NA N
20690 APPL UNIPLN UNI EXT FIXJ SYS MAXFEE DEF         305.92 1/1/2024 12/31/2299 N
20692 APPL MLTPLN UNI EXT FIXJ SYS PRXOVR DEF         NA NA NA N
20692 APPL MLTPLN UNI EXT FIXJ SYS MAXFEE DEF         573.25 1/1/2024 12/31/2299 N
20693 ADJMT/REVJ EXT FIXJ SYS ANES PRXOVR DEF         NA NA NA N
20693 ADJMT/REVJ EXT FIXJ SYS ANES MAXFEE DEF         267.08 1/1/2024 12/31/2299 N
20694 RMVL EXT FIXJ SYS UNDER ANES PRXOVR DEF         NA NA NA N
20694 RMVL EXT FIXJ SYS UNDER ANES MAXFEE FAC         174.24 1/1/2024 12/31/2299 N
20694 RMVL EXT FIXJ SYS UNDER ANES MAXFEE NFF         221.31 1/1/2024 12/31/2299 N
20700 MNL PREP&INSJ DP RX DLVR DEV PRXOVR DEF         NA NA NA N
20700 MNL PREP&INSJ DP RX DLVR DEV MAXFEE DEF         68.83 1/1/2020 12/31/2299 N
20701 RMVL DEEP RX DELIVERY DEVICE PRXOVR DEF         NA NA NA N
20701 RMVL DEEP RX DELIVERY DEVICE MAXFEE DEF         51.32 1/1/2020 12/31/2299 N
20702 MNL PREP&INSJ IMED RX DEV PRXOVR DEF         NA NA NA N
20702 MNL PREP&INSJ IMED RX DEV MAXFEE DEF         114.57 1/1/2020 12/31/2299 N
20703 RMVL IMED RX DELIVERY DEVICE PRXOVR DEF         NA NA NA N
20703 RMVL IMED RX DELIVERY DEVICE MAXFEE DEF         82.06 1/1/2020 12/31/2299 N
20704 MNL PREP&INSJ I-ARTIC RX DEV PRXOVR DEF         NA NA NA N
20704 MNL PREP&INSJ I-ARTIC RX DEV MAXFEE DEF         119.36 1/1/2020 12/31/2299 N
20705 RMVL I-ARTIC RX DELIVERY DEV PRXOVR DEF         NA NA NA N
20705 RMVL I-ARTIC RX DELIVERY DEV MAXFEE DEF         98.17 1/1/2020 12/31/2299 N
20900 REMOVAL OF BONE FOR GRAFT PRXOVR DEF         NA NA NA N
20900 REMOVAL OF BONE FOR GRAFT MAXFEE FAC         133.04 1/1/2024 12/31/2299 N
20900 REMOVAL OF BONE FOR GRAFT MAXFEE NFF         237.77 1/1/2024 12/31/2299 N
20902 REMOVAL OF BONE FOR GRAFT PRXOVR DEF         NA NA NA N
20902 REMOVAL OF BONE FOR GRAFT MAXFEE DEF         276.60 9/1/2013 12/31/2299 N
20910 REMOVE CARTILAGE FOR GRAFT PRXOVR DEF         NA NA NA N
20910 REMOVE CARTILAGE FOR GRAFT MAXFEE DEF         245.39 1/1/2024 12/31/2299 N
20912 REMOVE CARTILAGE FOR GRAFT PRXOVR DEF         NA NA NA N
20912 REMOVE CARTILAGE FOR GRAFT MAXFEE DEF         321.59 1/1/2024 12/31/2299 N
20924 REMOVAL OF TENDON FOR GRAFT PRXOVR DEF         NA NA NA N
20924 REMOVAL OF TENDON FOR GRAFT MAXFEE DEF         346.37 1/1/2024 12/31/2299 N
20926 REMOVAL OF TISSUE FOR GRAFT PRXOVR DEF         NA NA NA N
20926 REMOVAL OF TISSUE FOR GRAFT MAXFEE DEF         NA     N
20974 ELECTRICAL BONE STIMULATION PRXOVR DEF         NA NA NA N
20974 ELECTRICAL BONE STIMULATION MAXFEE FAC         35.56 1/1/2024 12/31/2299 N
20974 ELECTRICAL BONE STIMULATION MAXFEE NFF         41.53 1/1/2024 12/31/2299 N
20975 ELECTRICAL BONE STIMULATION PRXOVR DEF         NA NA NA N
20975 ELECTRICAL BONE STIMULATION MAXFEE DEF         144.52 12/15/2005 12/31/2299 N
20986 CPTR-ASST DIR MS PX IO IMG PRXOVR DEF         NA NA NA N
20986 CPTR-ASST DIR MS PX IO IMG MANUAL DEF         NA NA NA N
20987 CPTR-ASST DIR MS PX PRE IMG PRXOVR DEF         NA NA NA N
20987 CPTR-ASST DIR MS PX PRE IMG MANUAL DEF         NA NA NA N
20999 UNLISTED PX MUSCSKEL GENERAL PRXOVR DEF         NA NA NA N
20999 UNLISTED PX MUSCSKEL GENERAL MANUAL DEF         NA NA NA N
21010 INCISION OF JAW JOINT PRXOVR DEF         NA NA NA N
21010 INCISION OF JAW JOINT MAXFEE DEF         532.99 1/1/2000 12/31/2299 N
21011 EXC FACE LES SC <2 CM PRXOVR DEF         NA NA NA N
21011 EXC FACE LES SC <2 CM MAXFEE FAC         132.54 1/1/2024 12/31/2299 N
21011 EXC FACE LES SC <2 CM MAXFEE NFF         193.45 1/1/2024 12/31/2299 N
21012 EXC FACE LES SBQ 2 CM/> PRXOVR DEF         NA NA NA N
21012 EXC FACE LES SBQ 2 CM/> MAXFEE DEF         192.48 1/1/2024 12/31/2299 N
21013 EXC FACE TUM DEEP < 2 CM PRXOVR DEF         NA NA NA N
21013 EXC FACE TUM DEEP < 2 CM MAXFEE FAC         205.74 1/1/2024 12/31/2299 N
21013 EXC FACE TUM DEEP < 2 CM MAXFEE NFF         277.20 1/1/2024 12/31/2299 N
21014 EXC FACE TUM DEEP 2 CM/> PRXOVR DEF         NA NA NA N
21014 EXC FACE TUM DEEP 2 CM/> MAXFEE DEF         297.76 1/1/2024 12/31/2299 N
21015 RESECT FACE/SCALP TUM < 2 CM PRXOVR DEF         NA NA NA N
21015 RESECT FACE/SCALP TUM < 2 CM MAXFEE DEF         358.18 1/1/2024 12/31/2299 N
21016 RESECT FACE/SCALP TUM 2 CM/> PRXOVR DEF         NA NA NA N
21016 RESECT FACE/SCALP TUM 2 CM/> MAXFEE DEF         602.81 1/1/2024 12/31/2299 N
21025 EXCISION OF BONE LOWER JAW PRXOVR DEF         NA NA NA N
21025 EXCISION OF BONE LOWER JAW MAXFEE FAC         415.56 1/1/2024 12/31/2299 N
21025 EXCISION OF BONE LOWER JAW MAXFEE NFF         542.79 1/1/2024 12/31/2299 N
21026 EXCISION OF FACIAL BONE(S) PRXOVR DEF         NA NA NA N
21026 EXCISION OF FACIAL BONE(S) MAXFEE FAC         217.85 1/1/2024 12/31/2299 N
21026 EXCISION OF FACIAL BONE(S) MAXFEE NFF         274.08 1/1/2024 12/31/2299 N
21029 CONTOUR OF FACE BONE LESION PRXOVR DEF         NA NA NA N
21029 CONTOUR OF FACE BONE LESION MAXFEE FAC         335.86 1/1/2024 12/31/2299 N
21029 CONTOUR OF FACE BONE LESION MAXFEE NFF         448.58 1/1/2024 12/31/2299 N
21030 EXCISE MAX/ZYGOMA B9 TUMOR PRXOVR DEF         NA NA NA N
21030 EXCISE MAX/ZYGOMA B9 TUMOR MAXFEE FAC         209.87 1/1/2024 12/31/2299 N
21030 EXCISE MAX/ZYGOMA B9 TUMOR MAXFEE NFF         285.95 1/1/2024 12/31/2299 N
21031 REMOVE EXOSTOSIS MANDIBLE PRXOVR DEF         NA NA NA N
21031 REMOVE EXOSTOSIS MANDIBLE MAXFEE FAC         139.97 1/1/2024 12/31/2299 N
21031 REMOVE EXOSTOSIS MANDIBLE MAXFEE NFF         200.71 1/1/2024 12/31/2299 N
21032 REMOVE EXOSTOSIS MAXILLA PRXOVR DEF         NA NA NA N
21032 REMOVE EXOSTOSIS MAXILLA MAXFEE FAC         141.88 1/1/2024 12/31/2299 N
21032 REMOVE EXOSTOSIS MAXILLA MAXFEE NFF         204.30 1/1/2024 12/31/2299 N
21034 EXCISE MAX/ZYGOMA MAL TUMOR PRXOVR DEF         NA NA NA N
21034 EXCISE MAX/ZYGOMA MAL TUMOR MAXFEE FAC         576.89 1/1/2024 12/31/2299 N
21034 EXCISE MAX/ZYGOMA MAL TUMOR MAXFEE NFF         673.65 1/1/2024 12/31/2299 N
21040 EXCISE MANDIBLE LESION PRXOVR DEF         NA NA NA N
21040 EXCISE MANDIBLE LESION MAXFEE FAC         186.01 1/1/2024 12/31/2299 N
21040 EXCISE MANDIBLE LESION MAXFEE NFF         240.86 1/1/2024 12/31/2299 N
21044 REMOVAL OF JAW BONE LESION PRXOVR DEF         NA NA NA N
21044 REMOVAL OF JAW BONE LESION MAXFEE DEF         598.07 1/1/2024 12/31/2299 N
21045 EXTENSIVE JAW SURGERY PRXOVR DEF         NA NA NA N
21045 EXTENSIVE JAW SURGERY MAXFEE DEF         831.25 1/1/2024 12/31/2299 N
21046 REMOVE MANDIBLE CYST COMPLEX PRXOVR DEF         NA NA NA N
21046 REMOVE MANDIBLE CYST COMPLEX MAXFEE DEF         644.26 1/1/2024 12/31/2299 N
21047 EXCISE LWR JAW CYST W/REPAIR PRXOVR DEF         NA NA NA N
21047 EXCISE LWR JAW CYST W/REPAIR MAXFEE DEF         798.44 1/1/2024 12/31/2299 N
21048 REMOVE MAXILLA CYST COMPLEX PRXOVR DEF         NA NA NA N
21048 REMOVE MAXILLA CYST COMPLEX MAXFEE DEF         663.05 1/1/2024 12/31/2299 N
21049 EXCIS UPPR JAW CYST W/REPAIR PRXOVR DEF         NA NA NA N
21049 EXCIS UPPR JAW CYST W/REPAIR MAXFEE DEF         756.48 1/1/2024 12/31/2299 N
21050 REMOVAL OF JAW JOINT PRXOVR DEF         NA NA NA N
21050 REMOVAL OF JAW JOINT MAXFEE DEF         638.42 1/1/2024 12/31/2299 N
21060 REMOVE JAW JOINT CARTILAGE PRXOVR DEF         NA NA NA N
21060 REMOVE JAW JOINT CARTILAGE MAXFEE DEF         568.62 1/1/2000 12/31/2299 N
21070 REMOVE CORONOID PROCESS PRXOVR DEF         NA NA NA N
21070 REMOVE CORONOID PROCESS MAXFEE DEF         423.24 1/1/2024 12/31/2299 N
21073 MNPJ OF TMJ W/ANESTH PRXOVR DEF         NA NA NA N
21073 MNPJ OF TMJ W/ANESTH MAXFEE FAC         137.83 1/1/2024 12/31/2299 N
21073 MNPJ OF TMJ W/ANESTH MAXFEE NFF         227.92 1/1/2024 12/31/2299 N
21076 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21076 PREPARE FACE/ORAL PROSTHESIS MAXFEE FAC         558.46 1/1/2014 12/31/2299 N
21076 PREPARE FACE/ORAL PROSTHESIS MAXFEE NFF         726.79 1/1/2014 12/31/2299 N
21077 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21077 PREPARE FACE/ORAL PROSTHESIS MAXFEE FAC         1411.97 1/1/2014 12/31/2299 N
21077 PREPARE FACE/ORAL PROSTHESIS MAXFEE NFF         1827.48 1/1/2014 12/31/2299 N
21079 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21079 PREPARE FACE/ORAL PROSTHESIS MAXFEE FAC         781.77 1/1/2024 12/31/2299 N
21079 PREPARE FACE/ORAL PROSTHESIS MAXFEE NFF         1076.85 1/1/2024 12/31/2299 N
21080 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21080 PREPARE FACE/ORAL PROSTHESIS MAXFEE FAC         901.74 1/1/2024 12/31/2299 N
21080 PREPARE FACE/ORAL PROSTHESIS MAXFEE NFF         1229.94 1/1/2024 12/31/2299 N
21081 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21081 PREPARE FACE/ORAL PROSTHESIS MAXFEE FAC         812.81 1/1/2024 12/31/2299 N
21081 PREPARE FACE/ORAL PROSTHESIS MAXFEE NFF         1108.99 1/1/2024 12/31/2299 N
21082 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21082 PREPARE FACE/ORAL PROSTHESIS MAXFEE FAC         695.66 1/1/2024 12/31/2299 N
21082 PREPARE FACE/ORAL PROSTHESIS MAXFEE NFF         979.60 1/1/2024 12/31/2299 N
21083 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21083 PREPARE FACE/ORAL PROSTHESIS MAXFEE FAC         671.50 1/1/2024 12/31/2299 N
21083 PREPARE FACE/ORAL PROSTHESIS MAXFEE NFF         945.55 1/1/2024 12/31/2299 N
21084 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21084 PREPARE FACE/ORAL PROSTHESIS MAXFEE FAC         740.64 1/1/2014 12/31/2299 N
21084 PREPARE FACE/ORAL PROSTHESIS MAXFEE NFF         1032.57 1/1/2014 12/31/2299 N
21085 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21085 PREPARE FACE/ORAL PROSTHESIS MAXFEE FAC         322.49 1/1/2024 12/31/2299 N
21085 PREPARE FACE/ORAL PROSTHESIS MAXFEE NFF         423.06 1/1/2024 12/31/2299 N
21086 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21086 PREPARE FACE/ORAL PROSTHESIS MAXFEE FAC         884.47 1/1/2024 12/31/2299 N
21086 PREPARE FACE/ORAL PROSTHESIS MAXFEE NFF         1203.52 1/1/2024 12/31/2299 N
21087 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21087 PREPARE FACE/ORAL PROSTHESIS MAXFEE FAC         867.89 1/1/2024 12/31/2299 N
21087 PREPARE FACE/ORAL PROSTHESIS MAXFEE NFF         1182 1/1/2024 12/31/2299 N
21088 PREPARE FACE/ORAL PROSTHESIS PRXOVR DEF         NA NA NA N
21088 PREPARE FACE/ORAL PROSTHESIS MANUAL DEF         NA NA NA N
21089 UNLISTED MAXLFCL PROSTH PX PRXOVR DEF         NA NA NA N
21089 UNLISTED MAXLFCL PROSTH PX MANUAL DEF         NA NA NA N
21100 MAXILLOFACIAL FIXATION PRXOVR DEF         NA NA NA N
21100 MAXILLOFACIAL FIXATION MAXFEE FAC         213.39 1/1/2024 12/31/2299 N
21100 MAXILLOFACIAL FIXATION MAXFEE NFF         321.67 1/1/2024 12/31/2299 N
21110 INTERDENTAL FIXATION PRXOVR DEF         NA NA NA N
21110 INTERDENTAL FIXATION MAXFEE DEF         546.15 1/1/2024 12/31/2299 N
21116 INJECTION JAW JOINT X-RAY PRXOVR DEF         NA NA NA N
21116 INJECTION JAW JOINT X-RAY MAXFEE FAC         31.08 1/1/2024 12/31/2299 N
21116 INJECTION JAW JOINT X-RAY MAXFEE NFF         115.07 1/1/2024 12/31/2299 N
21120 RECONSTRUCTION OF CHIN PRXOVR DEF         NA NA NA N
21120 RECONSTRUCTION OF CHIN MAXFEE FAC         194.75 1/1/2014 12/31/2299 N
21120 RECONSTRUCTION OF CHIN MAXFEE NFF         271.51 1/1/2014 12/31/2299 N
21121 RECONSTRUCTION OF CHIN PRXOVR DEF         NA NA NA N
21121 RECONSTRUCTION OF CHIN MAXFEE FAC         283.20 1/1/2024 12/31/2299 N
21121 RECONSTRUCTION OF CHIN MAXFEE NFF         385.49 1/1/2024 12/31/2299 N
21122 RECONSTRUCTION OF CHIN PRXOVR DEF         NA NA NA N
21122 RECONSTRUCTION OF CHIN MAXFEE DEF         410.55 1/1/2004 12/31/2299 N
21123 RECONSTRUCTION OF CHIN PRXOVR DEF         NA NA NA N
21123 RECONSTRUCTION OF CHIN MAXFEE DEF         546.15 1/1/2024 12/31/2299 N
21125 AUGMENTATION LOWER JAW BONE PRXOVR DEF         NA NA NA N
21125 AUGMENTATION LOWER JAW BONE MAXFEE FAC         406.30 1/1/2014 12/31/2299 N
21125 AUGMENTATION LOWER JAW BONE MAXFEE NFF         1016.42 1/1/2014 12/31/2299 N
21127 AUGMENTATION LOWER JAW BONE PRXOVR DEF         NA NA NA N
21127 AUGMENTATION LOWER JAW BONE MAXFEE FAC         517.63 1/1/2014 12/31/2299 N
21127 AUGMENTATION LOWER JAW BONE MAXFEE NFF         1147.21 1/1/2014 12/31/2299 N
21141 LEFORT I-1 PIECE W/O GRAFT PRXOVR DEF         NA NA NA N
21141 LEFORT I-1 PIECE W/O GRAFT MAXFEE DEF         898.35 1/1/2024 12/31/2299 N
21142 LEFORT I-2 PIECE W/O GRAFT PRXOVR DEF         NA NA NA N
21142 LEFORT I-2 PIECE W/O GRAFT MAXFEE DEF         934.01 1/1/2024 12/31/2299 N
21143 LEFORT I-3/> PIECE W/O GRAFT PRXOVR DEF         NA NA NA N
21143 LEFORT I-3/> PIECE W/O GRAFT MAXFEE DEF         970.36 1/1/2024 12/31/2299 N
21145 LEFORT I-1 PIECE W/ GRAFT PRXOVR DEF         NA NA NA N
21145 LEFORT I-1 PIECE W/ GRAFT MAXFEE DEF         957.67 1/1/2024 12/31/2299 N
21146 LEFORT I-2 PIECE W/ GRAFT PRXOVR DEF         NA NA NA N
21146 LEFORT I-2 PIECE W/ GRAFT MAXFEE DEF         993.67 1/1/2024 12/31/2299 N
21147 LEFORT I-3/> PIECE W/ GRAFT PRXOVR DEF         NA NA NA N
21147 LEFORT I-3/> PIECE W/ GRAFT MAXFEE DEF         990.35 1/1/2000 12/31/2299 N
21150 LEFORT II ANTERIOR INTRUSION PRXOVR DEF         NA NA NA N
21150 LEFORT II ANTERIOR INTRUSION MAXFEE DEF         1177.19 4/1/2008 12/31/2299 N
21151 LEFORT II W/BONE GRAFTS PRXOVR DEF         NA NA NA N
21151 LEFORT II W/BONE GRAFTS MAXFEE DEF         1300.61 1/1/2000 12/31/2299 N
21154 LEFORT III W/O LEFORT I PRXOVR DEF         NA NA NA N
21154 LEFORT III W/O LEFORT I MAXFEE DEF         1485.98 1/1/2024 12/31/2299 N
21155 LEFORT III W/ LEFORT I PRXOVR DEF         NA NA NA N
21155 LEFORT III W/ LEFORT I MAXFEE DEF         1578.36 1/1/2000 12/31/2299 N
21159 LEFORT III W/FHDW/O LEFORT I PRXOVR DEF         NA NA NA N
21159 LEFORT III W/FHDW/O LEFORT I MAXFEE DEF         1956.16 1/1/2000 12/31/2299 N
21160 LEFORT III W/FHD W/ LEFORT I PRXOVR DEF         NA NA NA N
21160 LEFORT III W/FHD W/ LEFORT I MAXFEE DEF         2109.20 1/1/2000 12/31/2299 N
21172 RECONSTRUCT ORBIT/FOREHEAD PRXOVR DEF         NA NA NA N
21172 RECONSTRUCT ORBIT/FOREHEAD MAXFEE DEF         1346.63 1/1/2024 12/31/2299 N
21175 RECONSTRUCT ORBIT/FOREHEAD PRXOVR DEF         NA NA NA N
21175 RECONSTRUCT ORBIT/FOREHEAD MAXFEE DEF         1626.28 1/1/2024 12/31/2299 N
21179 RECONSTRUCT ENTIRE FOREHEAD PRXOVR DEF         NA NA NA N
21179 RECONSTRUCT ENTIRE FOREHEAD MAXFEE DEF         1103.91 1/1/2024 12/31/2299 N
21180 RECONSTRUCT ENTIRE FOREHEAD PRXOVR DEF         NA NA NA N
21180 RECONSTRUCT ENTIRE FOREHEAD MAXFEE DEF         1235.27 1/1/2024 12/31/2299 N
21181 CONTOUR CRANIAL BONE LESION PRXOVR DEF         NA NA NA N
21181 CONTOUR CRANIAL BONE LESION MAXFEE DEF         485.44 1/1/2024 12/31/2299 N
21182 RECONSTRUCT CRANIAL BONE PRXOVR DEF         NA NA NA N
21182 RECONSTRUCT CRANIAL BONE MAXFEE DEF         1599.78 1/1/2024 12/31/2299 N
21183 RECONSTRUCT CRANIAL BONE PRXOVR DEF         NA NA NA N
21183 RECONSTRUCT CRANIAL BONE MAXFEE DEF         1735.98 1/1/2024 12/31/2299 N
21184 RECONSTRUCT CRANIAL BONE PRXOVR DEF         NA NA NA N
21184 RECONSTRUCT CRANIAL BONE MAXFEE DEF         1781.43 1/1/2000 12/31/2299 N
21188 RECONSTRUCTION OF MIDFACE PRXOVR DEF         NA NA NA N
21188 RECONSTRUCTION OF MIDFACE MAXFEE DEF         1101.70 1/1/2024 12/31/2299 N
21193 RECONST LWR JAW W/O GRAFT PRXOVR DEF         NA NA NA N
21193 RECONST LWR JAW W/O GRAFT MAXFEE DEF         827.40 1/1/2024 12/31/2299 N
21194 RECONST LWR JAW W/GRAFT PRXOVR DEF         NA NA NA N
21194 RECONST LWR JAW W/GRAFT MAXFEE DEF         968.01 1/1/2024 12/31/2299 N
21195 RECONST LWR JAW W/O FIXATION PRXOVR DEF         NA NA NA N
21195 RECONST LWR JAW W/O FIXATION MAXFEE DEF         840.30 1/1/2024 12/31/2299 N
21196 RECONST LWR JAW W/FIXATION PRXOVR DEF         NA NA NA N
21196 RECONST LWR JAW W/FIXATION MAXFEE DEF         922.72 1/1/2024 12/31/2299 N
21198 RECONSTR LWR JAW SEGMENT PRXOVR DEF         NA NA NA N
21198 RECONSTR LWR JAW SEGMENT MAXFEE DEF         807.32 1/1/2024 12/31/2299 N
21199 RECONSTR LWR JAW W/ADVANCE PRXOVR DEF         NA NA NA N
21199 RECONSTR LWR JAW W/ADVANCE MAXFEE DEF         805.93 1/1/2024 12/31/2299 N
21206 RECONSTRUCT UPPER JAW BONE PRXOVR DEF         NA NA NA N
21206 RECONSTRUCT UPPER JAW BONE MAXFEE DEF         690.40 1/1/2024 12/31/2299 N
21208 AUGMENTATION OF FACIAL BONES PRXOVR DEF         NA NA NA N
21208 AUGMENTATION OF FACIAL BONES MAXFEE FAC         589.20 1/1/2024 12/31/2299 N
21208 AUGMENTATION OF FACIAL BONES MAXFEE NFF         863.77 1/1/2024 12/31/2299 N
21209 REDUCTION OF FACIAL BONES PRXOVR DEF         NA NA NA N
21209 REDUCTION OF FACIAL BONES MAXFEE FAC         316.48 1/1/2024 12/31/2299 N
21209 REDUCTION OF FACIAL BONES MAXFEE NFF         421.68 1/1/2024 12/31/2299 N
21210 FACE BONE GRAFT PRXOVR DEF         NA NA NA N
21210 FACE BONE GRAFT MAXFEE FAC         594.12 1/1/2024 12/31/2299 N
21210 FACE BONE GRAFT MAXFEE NFF         925.37 1/1/2024 12/31/2299 N
21215 LOWER JAW BONE GRAFT PRXOVR DEF         NA NA NA N
21215 LOWER JAW BONE GRAFT MAXFEE FAC         624.27 1/1/2024 12/31/2299 N
21215 LOWER JAW BONE GRAFT MAXFEE NFF         2181.75 1/1/2024 12/31/2299 N
21230 RIB CARTILAGE GRAFT PRXOVR DEF         NA NA NA N
21230 RIB CARTILAGE GRAFT MAXFEE DEF         583.54 1/1/2000 12/31/2299 N
21235 EAR CARTILAGE GRAFT PRXOVR DEF         NA NA NA N
21235 EAR CARTILAGE GRAFT MAXFEE FAC         300.07 1/1/2024 12/31/2299 N
21235 EAR CARTILAGE GRAFT MAXFEE NFF         427.54 1/1/2024 12/31/2299 N
21240 RECONSTRUCTION OF JAW JOINT PRXOVR DEF         NA NA NA N
21240 RECONSTRUCTION OF JAW JOINT MAXFEE DEF         821.88 1/1/2024 12/31/2299 N
21242 RECONSTRUCTION OF JAW JOINT PRXOVR DEF         NA NA NA N
21242 RECONSTRUCTION OF JAW JOINT MAXFEE DEF         730.34 1/1/2000 12/31/2299 N
21243 RECONSTRUCTION OF JAW JOINT PRXOVR DEF         NA NA NA N
21243 RECONSTRUCTION OF JAW JOINT MAXFEE DEF         940.96 1/1/2000 12/31/2299 N
21244 RECONSTRUCTION OF LOWER JAW PRXOVR DEF         NA NA NA N
21244 RECONSTRUCTION OF LOWER JAW MAXFEE DEF         704.18 1/1/2024 12/31/2299 N
21245 RECONSTRUCTION OF JAW PRXOVR DEF         NA NA NA N
21245 RECONSTRUCTION OF JAW MAXFEE FAC         469.78 1/1/2024 12/31/2299 N
21245 RECONSTRUCTION OF JAW MAXFEE NFF         660.32 1/1/2024 12/31/2299 N
21246 RECONSTRUCTION OF JAW PRXOVR DEF         NA NA NA N
21246 RECONSTRUCTION OF JAW MAXFEE DEF         604.86 1/1/2024 12/31/2299 N
21247 RECONSTRUCT LOWER JAW BONE PRXOVR DEF         NA NA NA N
21247 RECONSTRUCT LOWER JAW BONE MAXFEE DEF         1219.56 1/1/2000 12/31/2299 N
21248 RECONSTRUCTION OF JAW PRXOVR DEF         NA NA NA N
21248 RECONSTRUCTION OF JAW MAXFEE FAC         478.71 1/1/2024 12/31/2299 N
21248 RECONSTRUCTION OF JAW MAXFEE NFF         668.85 1/1/2024 12/31/2299 N
21249 RECONSTRUCTION OF JAW PRXOVR DEF         NA NA NA N
21249 RECONSTRUCTION OF JAW MAXFEE FAC         760.22 1/1/2024 12/31/2299 N
21249 RECONSTRUCTION OF JAW MAXFEE NFF         1021.81 1/1/2024 12/31/2299 N
21255 RECONSTRUCT LOWER JAW BONE PRXOVR DEF         NA NA NA N
21255 RECONSTRUCT LOWER JAW BONE MAXFEE DEF         965.25 1/1/2024 12/31/2299 N
21256 RECONSTRUCTION OF ORBIT PRXOVR DEF         NA NA NA N
21256 RECONSTRUCTION OF ORBIT MAXFEE DEF         911.51 1/1/2000 12/31/2299 N
21260 REVISE EYE SOCKETS PRXOVR DEF         NA NA NA N
21260 REVISE EYE SOCKETS MAXFEE DEF         956.66 1/1/2024 12/31/2299 N
21261 REVISE EYE SOCKETS PRXOVR DEF         NA NA NA N
21261 REVISE EYE SOCKETS MAXFEE DEF         1318.39 1/1/2000 12/31/2299 N
21263 REVISE EYE SOCKETS PRXOVR DEF         NA NA NA N
21263 REVISE EYE SOCKETS MAXFEE DEF         1517.61 1/1/2000 12/31/2299 N
21267 REVISE EYE SOCKETS PRXOVR DEF         NA NA NA N
21267 REVISE EYE SOCKETS MAXFEE DEF         1006.99 1/1/2024 12/31/2299 N
21268 REVISE EYE SOCKETS PRXOVR DEF         NA NA NA N
21268 REVISE EYE SOCKETS MAXFEE DEF         1188.58 1/1/2024 12/31/2299 N
21270 AUGMENTATION CHEEK BONE PRXOVR DEF         NA NA NA N
21270 AUGMENTATION CHEEK BONE MAXFEE FAC         391.94 1/1/2014 12/31/2299 N
21270 AUGMENTATION CHEEK BONE MAXFEE FAC         411.54 1/1/2024 12/31/2299 N
21270 AUGMENTATION CHEEK BONE MAXFEE NFF         539.79 1/1/2014 12/31/2299 N
21270 AUGMENTATION CHEEK BONE MAXFEE NFF         566.78 1/1/2024 12/31/2299 N
21275 REVISION ORBITOFACIAL BONES PRXOVR DEF         NA NA NA N
21275 REVISION ORBITOFACIAL BONES MAXFEE DEF         611.19 1/1/2024 12/31/2299 N
21295 REVISION OF JAW MUSCLE/BONE PRXOVR DEF         NA NA NA N
21295 REVISION OF JAW MUSCLE/BONE MAXFEE DEF         94.94 7/1/2008 12/31/2299 N
21296 REVISION OF JAW MUSCLE/BONE PRXOVR DEF         NA NA NA N
21296 REVISION OF JAW MUSCLE/BONE MAXFEE DEF         217.39 1/1/2004 12/31/2299 N
21299 UNLISTED CRANFCL&MAXLFCL PX PRXOVR DEF         NA NA NA N
21299 UNLISTED CRANFCL&MAXLFCL PX MANUAL DEF         NA NA NA N
21300 TREATMENT OF SKULL FRACTURE PRXOVR DEF         NA NA NA N
21300 TREATMENT OF SKULL FRACTURE MAXFEE DEF         NA     N
21310 CLOSED TX NOSE FX W/O MANJ PRXOVR DEF         NA NA NA N
21310 CLOSED TX NOSE FX W/O MANJ MAXFEE DEF         NA     N
21315 CLSD TX NSL FX MNPJ WO STBLJ PRXOVR DEF         NA NA NA N
21315 CLSD TX NSL FX MNPJ WO STBLJ MAXFEE FAC         60.21 1/1/2024 12/31/2299 N
21315 CLSD TX NSL FX MNPJ WO STBLJ MAXFEE NFF         123.68 1/1/2014 12/31/2299 N
21320 CLSD TX NSL FX W/MNPJ&STABLJ PRXOVR DEF         NA NA NA N
21320 CLSD TX NSL FX W/MNPJ&STABLJ MAXFEE FAC         55.52 1/1/2024 12/31/2299 N
21320 CLSD TX NSL FX W/MNPJ&STABLJ MAXFEE NFF         116.45 1/1/2024 12/31/2299 N
21325 OPEN TX NOSE FX UNCOMPLICATD PRXOVR DEF         NA NA NA N
21325 OPEN TX NOSE FX UNCOMPLICATD MAXFEE DEF         276.45 1/1/2024 12/31/2299 N
21330 OPEN TX NOSE FX W/SKELE FIXJ PRXOVR DEF         NA NA NA N
21330 OPEN TX NOSE FX W/SKELE FIXJ MAXFEE DEF         339.11 1/1/2024 12/31/2299 N
21335 OPEN TX NOSE & SEPTAL FX PRXOVR DEF         NA NA NA N
21335 OPEN TX NOSE & SEPTAL FX MAXFEE DEF         525.93 1/1/2024 12/31/2299 N
21336 OPEN TX SEPTAL FX W/WO STABJ PRXOVR DEF         NA NA NA N
21336 OPEN TX SEPTAL FX W/WO STABJ MAXFEE DEF         360.19 1/1/2024 12/31/2299 N
21337 CLOSED TX SEPTAL&NOSE FX PRXOVR DEF         NA NA NA N
21337 CLOSED TX SEPTAL&NOSE FX MAXFEE FAC         153.65 1/1/2024 12/31/2299 N
21337 CLOSED TX SEPTAL&NOSE FX MAXFEE NFF         216.98 1/1/2024 12/31/2299 N
21338 OPEN NASOETHMOID FX W/O FIXJ PRXOVR DEF         NA NA NA N
21338 OPEN NASOETHMOID FX W/O FIXJ MAXFEE DEF         452.74 1/1/2024 12/31/2299 N
21339 OPEN NASOETHMOID FX W/ FIXJ PRXOVR DEF         NA NA NA N
21339 OPEN NASOETHMOID FX W/ FIXJ MAXFEE DEF         495.06 1/1/2024 12/31/2299 N
21340 PERQ TX NASOETHMOID FX PRXOVR DEF         NA NA NA N
21340 PERQ TX NASOETHMOID FX MAXFEE DEF         541.69 1/1/2000 12/31/2299 N
21343 OPEN TX DPRSD FRONT SINUS FX PRXOVR DEF         NA NA NA N
21343 OPEN TX DPRSD FRONT SINUS FX MAXFEE DEF         666.04 1/1/2024 12/31/2299 N
21344 OPEN TX COMPL FRONT SINUS FX PRXOVR DEF         NA NA NA N
21344 OPEN TX COMPL FRONT SINUS FX MAXFEE DEF         865.13 1/1/2024 12/31/2299 N
21345 CLOSED TX NOSE/JAW FX PRXOVR DEF         NA NA NA N
21345 CLOSED TX NOSE/JAW FX MAXFEE FAC         333.35 1/1/2014 12/31/2299 N
21345 CLOSED TX NOSE/JAW FX MAXFEE FAC         350.02 1/1/2024 12/31/2299 N
21345 CLOSED TX NOSE/JAW FX MAXFEE NFF         447.76 1/1/2014 12/31/2299 N
21345 CLOSED TX NOSE/JAW FX MAXFEE NFF         470.15 1/1/2024 12/31/2299 N
21346 OPN TX NASOMAX FX W/FIXJ PRXOVR DEF         NA NA NA N
21346 OPN TX NASOMAX FX W/FIXJ MAXFEE DEF         575.17 1/1/2024 12/31/2299 N
21347 OPN TX NASOMAX FX MULTPLE PRXOVR DEF         NA NA NA N
21347 OPN TX NASOMAX FX MULTPLE MAXFEE DEF         660.47 1/1/2024 12/31/2299 N
21348 OPN TX NASOMAX FX W/GRAFT PRXOVR DEF         NA NA NA N
21348 OPN TX NASOMAX FX W/GRAFT MAXFEE DEF         780.24 1/1/2000 12/31/2299 N
21355 PERQ TX MALAR FRACTURE PRXOVR DEF         NA NA NA N
21355 PERQ TX MALAR FRACTURE MAXFEE FAC         167.84 1/1/2024 12/31/2299 N
21355 PERQ TX MALAR FRACTURE MAXFEE NFF         229.79 1/1/2024 12/31/2299 N
21356 OPN TX DPRSD ZYGOMATIC ARCH PRXOVR DEF         NA NA NA N
21356 OPN TX DPRSD ZYGOMATIC ARCH MAXFEE FAC         207.29 1/1/2024 12/31/2299 N
21356 OPN TX DPRSD ZYGOMATIC ARCH MAXFEE NFF         280.83 1/1/2024 12/31/2299 N
21360 OPN TX DPRSD MALAR FRACTURE PRXOVR DEF         NA NA NA N
21360 OPN TX DPRSD MALAR FRACTURE MAXFEE DEF         394.33 1/1/2024 12/31/2299 N
21365 OPN TX COMPLX MALAR FX PRXOVR DEF         NA NA NA N
21365 OPN TX COMPLX MALAR FX MAXFEE DEF         780.78 1/1/2024 12/31/2299 N
21366 OPN TX COMPLX MALAR W/GRFT PRXOVR DEF         NA NA NA N
21366 OPN TX COMPLX MALAR W/GRFT MAXFEE DEF         860.53 1/1/2024 12/31/2299 N
21385 OPN TX ORBIT FX TRANSANTRAL PRXOVR DEF         NA NA NA N
21385 OPN TX ORBIT FX TRANSANTRAL MAXFEE DEF         528.14 1/1/2024 12/31/2299 N
21386 OPN TX ORBIT FX PERIORBITAL PRXOVR DEF         NA NA NA N
21386 OPN TX ORBIT FX PERIORBITAL MAXFEE DEF         528.26 1/1/2024 12/31/2299 N
21387 OPN TX ORBIT FX COMBINED PRXOVR DEF         NA NA NA N
21387 OPN TX ORBIT FX COMBINED MAXFEE DEF         505.17 1/1/2024 12/31/2299 N
21390 OPN TX ORBIT PERIORBTL IMPLT PRXOVR DEF         NA NA NA N
21390 OPN TX ORBIT PERIORBTL IMPLT MAXFEE DEF         611.23 1/1/2024 12/31/2299 N
21395 OPN TX ORBIT PERIORBT W/GRFT PRXOVR DEF         NA NA NA N
21395 OPN TX ORBIT PERIORBT W/GRFT MAXFEE DEF         653.81 1/1/2024 12/31/2299 N
21400 CLOSED TX ORBIT W/O MANIPULJ PRXOVR DEF         NA NA NA N
21400 CLOSED TX ORBIT W/O MANIPULJ MAXFEE FAC         84.44 1/1/2024 12/31/2299 N
21400 CLOSED TX ORBIT W/O MANIPULJ MAXFEE NFF         108.49 1/1/2024 12/31/2299 N
21401 CLOSED TX ORBIT W/MANIPULJ PRXOVR DEF         NA NA NA N
21401 CLOSED TX ORBIT W/MANIPULJ MAXFEE FAC         167.67 1/1/2024 12/31/2299 N
21401 CLOSED TX ORBIT W/MANIPULJ MAXFEE NFF         263.36 1/1/2024 12/31/2299 N
21406 OPN TX ORBIT FX W/O IMPLANT PRXOVR DEF         NA NA NA N
21406 OPN TX ORBIT FX W/O IMPLANT MAXFEE DEF         366.35 1/1/2024 12/31/2299 N
21407 OPN TX ORBIT FX W/IMPLANT PRXOVR DEF         NA NA NA N
21407 OPN TX ORBIT FX W/IMPLANT MAXFEE DEF         459.15 1/1/2024 12/31/2299 N
21408 OPN TX ORBIT FX W/BONE GRFT PRXOVR DEF         NA NA NA N
21408 OPN TX ORBIT FX W/BONE GRFT MAXFEE DEF         603.88 1/1/2024 12/31/2299 N
21421 TREAT MOUTH ROOF FRACTURE PRXOVR DEF         NA NA NA N
21421 TREAT MOUTH ROOF FRACTURE MAXFEE FAC         280.49 1/1/2024 12/31/2299 N
21421 TREAT MOUTH ROOF FRACTURE MAXFEE NFF         333.09 1/1/2024 12/31/2299 N
21422 TREAT MOUTH ROOF FRACTURE PRXOVR DEF         NA NA NA N
21422 TREAT MOUTH ROOF FRACTURE MAXFEE DEF         496.59 1/1/2024 12/31/2299 N
21423 TREAT MOUTH ROOF FRACTURE PRXOVR DEF         NA NA NA N
21423 TREAT MOUTH ROOF FRACTURE MAXFEE DEF         569.86 1/1/2024 12/31/2299 N
21431 TREAT CRANIOFACIAL FRACTURE PRXOVR DEF         NA NA NA N
21431 TREAT CRANIOFACIAL FRACTURE MAXFEE DEF         393.83 1/1/2024 12/31/2299 N
21432 TREAT CRANIOFACIAL FRACTURE PRXOVR DEF         NA NA NA N
21432 TREAT CRANIOFACIAL FRACTURE MAXFEE DEF         435.38 1/1/2024 12/31/2299 N
21433 TREAT CRANIOFACIAL FRACTURE PRXOVR DEF         NA NA NA N
21433 TREAT CRANIOFACIAL FRACTURE MAXFEE DEF         1232.77 1/1/2024 12/31/2299 N
21435 TREAT CRANIOFACIAL FRACTURE PRXOVR DEF         NA NA NA N
21435 TREAT CRANIOFACIAL FRACTURE MAXFEE DEF         874.97 1/1/2024 12/31/2299 N
21436 TREAT CRANIOFACIAL FRACTURE PRXOVR DEF         NA NA NA N
21436 TREAT CRANIOFACIAL FRACTURE MAXFEE DEF         1227.69 1/1/2024 12/31/2299 N
21440 TREAT DENTAL RIDGE FRACTURE PRXOVR DEF         NA NA NA N
21440 TREAT DENTAL RIDGE FRACTURE MAXFEE FAC         288.27 1/1/2024 12/31/2299 N
21440 TREAT DENTAL RIDGE FRACTURE MAXFEE NFF         359.39 1/1/2024 12/31/2299 N
21445 TREAT DENTAL RIDGE FRACTURE PRXOVR DEF         NA NA NA N
21445 TREAT DENTAL RIDGE FRACTURE MAXFEE FAC         336.55 1/1/2024 12/31/2299 N
21445 TREAT DENTAL RIDGE FRACTURE MAXFEE NFF         418.05 1/1/2024 12/31/2299 N
21450 TREAT LOWER JAW FRACTURE PRXOVR DEF         NA NA NA N
21450 TREAT LOWER JAW FRACTURE MAXFEE FAC         250.90 1/1/2024 12/31/2299 N
21450 TREAT LOWER JAW FRACTURE MAXFEE NFF         309.55 1/1/2024 12/31/2299 N
21451 TREAT LOWER JAW FRACTURE PRXOVR DEF         NA NA NA N
21451 TREAT LOWER JAW FRACTURE MAXFEE FAC         334.64 1/1/2024 12/31/2299 N
21451 TREAT LOWER JAW FRACTURE MAXFEE NFF         401.43 1/1/2024 12/31/2299 N
21452 TREAT LOWER JAW FRACTURE PRXOVR DEF         NA NA NA N
21452 TREAT LOWER JAW FRACTURE MAXFEE FAC         243.11 1/1/2024 12/31/2299 N
21452 TREAT LOWER JAW FRACTURE MAXFEE NFF         394.34 1/1/2024 12/31/2299 N
21453 TREAT LOWER JAW FRACTURE PRXOVR DEF         NA NA NA N
21453 TREAT LOWER JAW FRACTURE MAXFEE FAC         486.39 1/1/2024 12/31/2299 N
21453 TREAT LOWER JAW FRACTURE MAXFEE NFF         571.87 1/1/2024 12/31/2299 N
21454 TREAT LOWER JAW FRACTURE PRXOVR DEF         NA NA NA N
21454 TREAT LOWER JAW FRACTURE MAXFEE DEF         378.10 1/1/2000 12/31/2299 N
21461 TREAT LOWER JAW FRACTURE PRXOVR DEF         NA NA NA N
21461 TREAT LOWER JAW FRACTURE MAXFEE FAC         548.34 1/1/2024 12/31/2299 N
21461 TREAT LOWER JAW FRACTURE MAXFEE NFF         984.08 1/1/2024 12/31/2299 N
21462 TREAT LOWER JAW FRACTURE PRXOVR DEF         NA NA NA N
21462 TREAT LOWER JAW FRACTURE MAXFEE FAC         611.15 1/1/2024 12/31/2299 N
21462 TREAT LOWER JAW FRACTURE MAXFEE NFF         1050.65 1/1/2024 12/31/2299 N
21465 TREAT LOWER JAW FRACTURE PRXOVR DEF         NA NA NA N
21465 TREAT LOWER JAW FRACTURE MAXFEE DEF         576.70 1/1/2024 12/31/2299 N
21470 TREAT LOWER JAW FRACTURE PRXOVR DEF         NA NA NA N
21470 TREAT LOWER JAW FRACTURE MAXFEE DEF         876.96 1/1/2024 12/31/2299 N
21480 RESET DISLOCATED JAW PRXOVR DEF         NA NA NA N
21480 RESET DISLOCATED JAW MAXFEE FAC         20.50 1/1/2024 12/31/2299 N
21480 RESET DISLOCATED JAW MAXFEE NFF         73.02 1/1/2024 12/31/2299 N
21485 RESET DISLOCATED JAW PRXOVR DEF         NA NA NA N
21485 RESET DISLOCATED JAW MAXFEE FAC         415.97 1/1/2024 12/31/2299 N
21485 RESET DISLOCATED JAW MAXFEE NFF         509.92 1/1/2024 12/31/2299 N
21490 REPAIR DISLOCATED JAW PRXOVR DEF         NA NA NA N
21490 REPAIR DISLOCATED JAW MAXFEE DEF         524.55 1/1/2024 12/31/2299 N
21493 TREAT HYOID BONE FRACTURE PRXOVR DEF         NA NA NA N
21493 TREAT HYOID BONE FRACTURE MAXFEE DEF         NA     N
21494 TREAT HYOID BONE FRACTURE PRXOVR DEF         NA NA NA N
21494 TREAT HYOID BONE FRACTURE MAXFEE DEF         NA     N
21495 TREAT HYOID BONE FRACTURE PRXOVR DEF         NA NA NA N
21495 TREAT HYOID BONE FRACTURE MAXFEE DEF         NA     N
21497 INTERDENTAL WIRING PRXOVR DEF         NA NA NA N
21497 INTERDENTAL WIRING MAXFEE FAC         477.12 10/1/2014 12/31/2299 N
21497 INTERDENTAL WIRING MAXFEE NFF         500.98 1/1/2024 12/31/2299 N
21499 UNLISTED MUSCSKEL PX HEAD PRXOVR DEF         NA NA NA N
21499 UNLISTED MUSCSKEL PX HEAD MANUAL DEF         NA NA NA N
30400 RECONSTRUCTION OF NOSE PRXOVR DEF         NA NA NA N
30400 RECONSTRUCTION OF NOSE MAXFEE DEF         644.02 1/1/2024 12/31/2299 N
30410 RECONSTRUCTION OF NOSE PRXOVR DEF         NA NA NA N
30410 RECONSTRUCTION OF NOSE MAXFEE DEF         739.54 1/1/2024 12/31/2299 N
30420 RECONSTRUCTION OF NOSE PRXOVR DEF         NA NA NA N
30420 RECONSTRUCTION OF NOSE MAXFEE DEF         773.38 1/1/2024 12/31/2299 N
30430 REVISION OF NOSE PRXOVR DEF         NA NA NA N
30430 REVISION OF NOSE MAXFEE DEF         564.08 1/1/2024 12/31/2299 N
30435 REVISION OF NOSE PRXOVR DEF         NA NA NA N
30435 REVISION OF NOSE MAXFEE DEF         701.89 1/1/2024 12/31/2299 N
30450 REVISION OF NOSE PRXOVR DEF         NA NA NA N
30450 REVISION OF NOSE MAXFEE DEF         918.67 1/1/2024 12/31/2299 N
30460 REVISION OF NOSE PRXOVR DEF         NA NA NA N
30460 REVISION OF NOSE MAXFEE DEF         524.98 1/1/2024 12/31/2299 N
30462 REVISION OF NOSE PRXOVR DEF         NA NA NA N
30462 REVISION OF NOSE MAXFEE DEF         1017.49 1/1/2024 12/31/2299 N
30465 REPAIR NASAL STENOSIS PRXOVR DEF         NA NA NA N
30465 REPAIR NASAL STENOSIS MAXFEE DEF         630.59 1/1/2024 12/31/2299 N
30469 RPR NSL VLV COLLAPSE W/RMDLG PRXOVR DEF         NA NA NA N
30469 RPR NSL VLV COLLAPSE W/RMDLG MAXFEE FAC         115.14 1/1/2023 12/31/2299 N
30469 RPR NSL VLV COLLAPSE W/RMDLG MAXFEE NFF         1829.18 1/1/2023 12/31/2299 N
30520 REPAIR OF NASAL SEPTUM PRXOVR DEF         NA NA NA N
30520 REPAIR OF NASAL SEPTUM MAXFEE DEF         351.43 1/1/2024 12/31/2299 N
30540 RPR CHOANAL ATRESIA NTRANASL PRXOVR DEF         NA NA NA N
30540 RPR CHOANAL ATRESIA NTRANASL MAXFEE DEF         406.23 1/1/2024 12/31/2299 N
30545 RPR CHOANAL ATRESIA TRSNPLTN PRXOVR DEF         NA NA NA N
30545 RPR CHOANAL ATRESIA TRSNPLTN MAXFEE DEF         613.89 1/1/2024 12/31/2299 N
30560 LYSIS INTRANASAL SYNECHIA PRXOVR DEF         NA NA NA N
30560 LYSIS INTRANASAL SYNECHIA MAXFEE FAC         78.21 1/1/2024 12/31/2299 N
30560 LYSIS INTRANASAL SYNECHIA MAXFEE NFF         170.96 1/1/2024 12/31/2299 N
30580 REPAIR UPPER JAW FISTULA PRXOVR DEF         NA NA NA N
30580 REPAIR UPPER JAW FISTULA MAXFEE FAC         235.15 1/1/2024 12/31/2299 N
30580 REPAIR UPPER JAW FISTULA MAXFEE NFF         351.80 1/1/2024 12/31/2299 N
30600 REPAIR MOUTH/NOSE FISTULA PRXOVR DEF         NA NA NA N
30600 REPAIR MOUTH/NOSE FISTULA MAXFEE FAC         195.18 1/1/2024 12/31/2299 N
30600 REPAIR MOUTH/NOSE FISTULA MAXFEE NFF         276.08 1/1/2024 12/31/2299 N
30620 INTRANASAL RECONSTRUCTION PRXOVR DEF         NA NA NA N
30620 INTRANASAL RECONSTRUCTION MAXFEE DEF         363.93 1/1/2024 12/31/2299 N
30630 REPAIR NASAL SEPTUM DEFECT PRXOVR DEF         NA NA NA N
30630 REPAIR NASAL SEPTUM DEFECT MAXFEE DEF         383.57 1/1/2024 12/31/2299 N
40490 BIOPSY OF LIP PRXOVR DEF         NA NA NA N
40490 BIOPSY OF LIP MAXFEE FAC         63.27 1/1/2016 12/31/2299 N
40490 BIOPSY OF LIP MAXFEE NFF         66.43 1/1/2024 12/31/2299 N
40500 PARTIAL EXCISION OF LIP PRXOVR DEF         NA NA NA N
40500 PARTIAL EXCISION OF LIP MAXFEE FAC         263.93 1/1/2024 12/31/2299 N
40500 PARTIAL EXCISION OF LIP MAXFEE NFF         271.32 1/1/2024 12/31/2299 N
40510 PARTIAL EXCISION OF LIP PRXOVR DEF         NA NA NA N
40510 PARTIAL EXCISION OF LIP MAXFEE FAC         273.73 1/1/2016 12/31/2299 N
40510 PARTIAL EXCISION OF LIP MAXFEE NFF         287.42 1/1/2024 12/31/2299 N
40520 PARTIAL EXCISION OF LIP PRXOVR DEF         NA NA NA N
40520 PARTIAL EXCISION OF LIP MAXFEE FAC         272.73 1/1/2024 12/31/2299 N
40520 PARTIAL EXCISION OF LIP MAXFEE NFF         272.23 1/1/2024 12/31/2299 N
40525 RECONSTRUCT LIP WITH FLAP PRXOVR DEF         NA NA NA N
40525 RECONSTRUCT LIP WITH FLAP MAXFEE DEF         438.59 1/1/2000 12/31/2299 N
40527 RECONSTRUCT LIP WITH FLAP PRXOVR DEF         NA NA NA N
40527 RECONSTRUCT LIP WITH FLAP MAXFEE DEF         524.88 1/1/2000 12/31/2299 N
40530 PARTIAL REMOVAL OF LIP PRXOVR DEF         NA NA NA N
40530 PARTIAL REMOVAL OF LIP MAXFEE FAC         300.41 1/1/2024 12/31/2299 N
40530 PARTIAL REMOVAL OF LIP MAXFEE NFF         300.41 1/1/2024 12/31/2299 N
40650 RPR LIP FTH VERMILION ONLY PRXOVR DEF         NA NA NA N
40650 RPR LIP FTH VERMILION ONLY MAXFEE FAC         222.05 1/1/2024 12/31/2299 N
40650 RPR LIP FTH VERMILION ONLY MAXFEE NFF         249.34 1/1/2024 12/31/2299 N
40652 RPR LIP FTH<HALF VER HEIGHT PRXOVR DEF         NA NA NA N
40652 RPR LIP FTH<HALF VER HEIGHT MAXFEE FAC         263.97 1/1/2024 12/31/2299 N
40652 RPR LIP FTH<HALF VER HEIGHT MAXFEE NFF         267.16 1/1/2024 12/31/2299 N
40654 RPR LIP FTH>1HALF VER HT/CPX PRXOVR DEF         NA NA NA N
40654 RPR LIP FTH>1HALF VER HT/CPX MAXFEE FAC         325.09 1/1/2024 12/31/2299 N
40654 RPR LIP FTH>1HALF VER HT/CPX MAXFEE NFF         325.09 1/1/2024 12/31/2299 N
40700 REPAIR CLEFT LIP/NASAL PRXOVR DEF         NA NA NA N
40700 REPAIR CLEFT LIP/NASAL MAXFEE DEF         614.93 1/1/2024 12/31/2299 N
40701 REPAIR CLEFT LIP/NASAL PRXOVR DEF         NA NA NA N
40701 REPAIR CLEFT LIP/NASAL MAXFEE DEF         936.99 1/1/2024 12/31/2299 N
40702 REPAIR CLEFT LIP/NASAL PRXOVR DEF         NA NA NA N
40702 REPAIR CLEFT LIP/NASAL MAXFEE DEF         633.19 1/1/2024 12/31/2299 N
40720 REPAIR CLEFT LIP/NASAL PRXOVR DEF         NA NA NA N
40720 REPAIR CLEFT LIP/NASAL MAXFEE DEF         676.99 1/1/2024 12/31/2299 N
40761 REPAIR CLEFT LIP/NASAL PRXOVR DEF         NA NA NA N
40761 REPAIR CLEFT LIP/NASAL MAXFEE DEF         709.15 1/1/2004 12/31/2299 N
40799 UNLISTED PROCEDURE LIPS PRXOVR DEF         NA NA NA N
40799 UNLISTED PROCEDURE LIPS MANUAL DEF         NA NA NA N
40800 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
40800 DRAINAGE OF MOUTH LESION MAXFEE FAC         85.75 1/1/2024 12/31/2299 N
40800 DRAINAGE OF MOUTH LESION MAXFEE NFF         111.89 1/1/2024 12/31/2299 N
40801 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
40801 DRAINAGE OF MOUTH LESION MAXFEE FAC         156.59 1/1/2024 12/31/2299 N
40801 DRAINAGE OF MOUTH LESION MAXFEE NFF         166.11 1/1/2024 12/31/2299 N
40804 REMOVAL FOREIGN BODY MOUTH PRXOVR DEF         NA NA NA N
40804 REMOVAL FOREIGN BODY MOUTH MAXFEE FAC         96.34 1/1/2024 12/31/2299 N
40804 REMOVAL FOREIGN BODY MOUTH MAXFEE NFF         114.52 1/1/2024 12/31/2299 N
40805 REMOVAL FOREIGN BODY MOUTH PRXOVR DEF         NA NA NA N
40805 REMOVAL FOREIGN BODY MOUTH MAXFEE FAC         148.37 1/1/2024 12/31/2299 N
40805 REMOVAL FOREIGN BODY MOUTH MAXFEE NFF         208.10 1/1/2024 12/31/2299 N
40806 INCISION OF LIP FOLD PRXOVR DEF         NA NA NA N
40806 INCISION OF LIP FOLD MAXFEE FAC         21.12 1/1/2024 12/31/2299 N
40806 INCISION OF LIP FOLD MAXFEE NFF         74.01 1/1/2024 12/31/2299 N
40808 BIOPSY OF MOUTH LESION PRXOVR DEF         NA NA NA N
40808 BIOPSY OF MOUTH LESION MAXFEE FAC         83.15 1/1/2024 12/31/2299 N
40808 BIOPSY OF MOUTH LESION MAXFEE NFF         98.85 1/1/2024 12/31/2299 N
40810 EXCISION OF MOUTH LESION PRXOVR DEF         NA NA NA N
40810 EXCISION OF MOUTH LESION MAXFEE FAC         76.45 1/1/2024 12/31/2299 N
40810 EXCISION OF MOUTH LESION MAXFEE NFF         112.47 1/1/2024 12/31/2299 N
40812 EXCISE/REPAIR MOUTH LESION PRXOVR DEF         NA NA NA N
40812 EXCISE/REPAIR MOUTH LESION MAXFEE FAC         112.46 1/1/2024 12/31/2299 N
40812 EXCISE/REPAIR MOUTH LESION MAXFEE NFF         151.86 1/1/2024 12/31/2299 N
40814 EXCISE/REPAIR MOUTH LESION PRXOVR DEF         NA NA NA N
40814 EXCISE/REPAIR MOUTH LESION MAXFEE FAC         188.87 1/1/2024 12/31/2299 N
40814 EXCISE/REPAIR MOUTH LESION MAXFEE NFF         203.32 1/1/2024 12/31/2299 N
40816 EXCISION OF MOUTH LESION PRXOVR DEF         NA NA NA N
40816 EXCISION OF MOUTH LESION MAXFEE FAC         207.53 1/1/2024 12/31/2299 N
40816 EXCISION OF MOUTH LESION MAXFEE NFF         207.53 1/1/2024 12/31/2299 N
40818 EXCISE ORAL MUCOSA FOR GRAFT PRXOVR DEF         NA NA NA N
40818 EXCISE ORAL MUCOSA FOR GRAFT MAXFEE FAC         150.50 1/1/2024 12/31/2299 N
40818 EXCISE ORAL MUCOSA FOR GRAFT MAXFEE NFF         189.99 1/1/2024 12/31/2299 N
40819 EXCISE LIP OR CHEEK FOLD PRXOVR DEF         NA NA NA N
40819 EXCISE LIP OR CHEEK FOLD MAXFEE FAC         128.08 1/1/2024 12/31/2299 N
40819 EXCISE LIP OR CHEEK FOLD MAXFEE NFF         163.41 1/1/2024 12/31/2299 N
40820 TREATMENT OF MOUTH LESION PRXOVR DEF         NA NA NA N
40820 TREATMENT OF MOUTH LESION MAXFEE FAC         87.10 1/1/2024 12/31/2299 N
40820 TREATMENT OF MOUTH LESION MAXFEE NFF         141.51 1/1/2024 12/31/2299 N
40830 REPAIR MOUTH LACERATION PRXOVR DEF         NA NA NA N
40830 REPAIR MOUTH LACERATION MAXFEE FAC         88.71 1/1/2024 12/31/2299 N
40830 REPAIR MOUTH LACERATION MAXFEE NFF         141.87 1/1/2024 12/31/2299 N
40831 REPAIR MOUTH LACERATION PRXOVR DEF         NA NA NA N
40831 REPAIR MOUTH LACERATION MAXFEE FAC         127.05 1/1/2024 12/31/2299 N
40831 REPAIR MOUTH LACERATION MAXFEE NFF         180.05 1/1/2024 12/31/2299 N
40840 RECONSTRUCTION OF MOUTH PRXOVR DEF         NA NA NA N
40840 RECONSTRUCTION OF MOUTH MAXFEE FAC         419.81 1/1/2024 12/31/2299 N
40840 RECONSTRUCTION OF MOUTH MAXFEE NFF         447.29 1/1/2024 12/31/2299 N
40842 RECONSTRUCTION OF MOUTH PRXOVR DEF         NA NA NA N
40842 RECONSTRUCTION OF MOUTH MAXFEE FAC         419.75 1/1/2024 12/31/2299 N
40842 RECONSTRUCTION OF MOUTH MAXFEE NFF         480.86 1/1/2024 12/31/2299 N
40843 RECONSTRUCTION OF MOUTH PRXOVR DEF         NA NA NA N
40843 RECONSTRUCTION OF MOUTH MAXFEE FAC         577.50 1/1/2024 12/31/2299 N
40843 RECONSTRUCTION OF MOUTH MAXFEE NFF         619.11 1/1/2024 12/31/2299 N
40844 RECONSTRUCTION OF MOUTH PRXOVR DEF         NA NA NA N
40844 RECONSTRUCTION OF MOUTH MAXFEE FAC         759.68 1/1/2024 12/31/2299 N
40844 RECONSTRUCTION OF MOUTH MAXFEE NFF         775.01 1/1/2024 12/31/2299 N
40845 RECONSTRUCTION OF MOUTH PRXOVR DEF         NA NA NA N
40845 RECONSTRUCTION OF MOUTH MAXFEE FAC         988.38 1/1/2024 12/31/2299 N
40845 RECONSTRUCTION OF MOUTH MAXFEE NFF         1037.80 1/1/2024 12/31/2299 N
40899 UNLISTED PX VESTIBULE MOUTH PRXOVR DEF         NA NA NA N
40899 UNLISTED PX VESTIBULE MOUTH MANUAL DEF         NA NA NA N
41000 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
41000 DRAINAGE OF MOUTH LESION MAXFEE FAC         98.66 1/1/2024 12/31/2299 N
41000 DRAINAGE OF MOUTH LESION MAXFEE NFF         103.59 1/1/2024 12/31/2299 N
41005 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
41005 DRAINAGE OF MOUTH LESION MAXFEE FAC         95.58 1/1/2024 12/31/2299 N
41005 DRAINAGE OF MOUTH LESION MAXFEE NFF         122.15 1/1/2024 12/31/2299 N
41006 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
41006 DRAINAGE OF MOUTH LESION MAXFEE FAC         146.92 1/1/2024 12/31/2299 N
41006 DRAINAGE OF MOUTH LESION MAXFEE NFF         190.33 1/1/2024 12/31/2299 N
41007 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
41007 DRAINAGE OF MOUTH LESION MAXFEE FAC         170.12 1/1/2024 12/31/2299 N
41007 DRAINAGE OF MOUTH LESION MAXFEE NFF         187.61 1/1/2024 12/31/2299 N
41008 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
41008 DRAINAGE OF MOUTH LESION MAXFEE FAC         191.29 1/1/2024 12/31/2299 N
41008 DRAINAGE OF MOUTH LESION MAXFEE NFF         201.24 1/1/2024 12/31/2299 N
41009 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
41009 DRAINAGE OF MOUTH LESION MAXFEE FAC         193.48 1/1/2024 12/31/2299 N
41009 DRAINAGE OF MOUTH LESION MAXFEE NFF         217.68 1/1/2024 12/31/2299 N
41010 INCISION OF TONGUE FOLD PRXOVR DEF         NA NA NA N
41010 INCISION OF TONGUE FOLD MAXFEE FAC         59.10 1/1/2024 12/31/2299 N
41010 INCISION OF TONGUE FOLD MAXFEE NFF         114.03 1/1/2024 12/31/2299 N
41015 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
41015 DRAINAGE OF MOUTH LESION MAXFEE FAC         187.70 1/1/2024 12/31/2299 N
41015 DRAINAGE OF MOUTH LESION MAXFEE NFF         235.24 1/1/2024 12/31/2299 N
41016 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
41016 DRAINAGE OF MOUTH LESION MAXFEE FAC         228.71 1/1/2024 12/31/2299 N
41016 DRAINAGE OF MOUTH LESION MAXFEE NFF         243.98 1/1/2024 12/31/2299 N
41017 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
41017 DRAINAGE OF MOUTH LESION MAXFEE FAC         195.26 1/1/2024 12/31/2299 N
41017 DRAINAGE OF MOUTH LESION MAXFEE NFF         240.52 1/1/2024 12/31/2299 N
41018 DRAINAGE OF MOUTH LESION PRXOVR DEF         NA NA NA N
41018 DRAINAGE OF MOUTH LESION MAXFEE FAC         253.30 1/1/2024 12/31/2299 N
41018 DRAINAGE OF MOUTH LESION MAXFEE NFF         269.86 1/1/2024 12/31/2299 N
41019 PLACE NEEDLES H&N FOR RT PRXOVR DEF         NA NA NA N
41019 PLACE NEEDLES H&N FOR RT MAXFEE DEF         306.38 1/1/2024 12/31/2299 N
41100 BIOPSY OF TONGUE PRXOVR DEF         NA NA NA N
41100 BIOPSY OF TONGUE MAXFEE FAC         76.21 1/1/2024 12/31/2299 N
41100 BIOPSY OF TONGUE MAXFEE NFF         97.42 1/1/2024 12/31/2299 N
41105 BIOPSY OF TONGUE PRXOVR DEF         NA NA NA N
41105 BIOPSY OF TONGUE MAXFEE FAC         75.25 1/1/2024 12/31/2299 N
41105 BIOPSY OF TONGUE MAXFEE NFF         97.25 1/1/2024 12/31/2299 N
41108 BIOPSY OF FLOOR OF MOUTH PRXOVR DEF         NA NA NA N
41108 BIOPSY OF FLOOR OF MOUTH MAXFEE FAC         59.83 1/1/2024 12/31/2299 N
41108 BIOPSY OF FLOOR OF MOUTH MAXFEE NFF         87.04 1/1/2024 12/31/2299 N
41110 EXCISION OF TONGUE LESION PRXOVR DEF         NA NA NA N
41110 EXCISION OF TONGUE LESION MAXFEE FAC         100.06 1/1/2016 12/31/2299 N
41110 EXCISION OF TONGUE LESION MAXFEE NFF         119.57 1/1/2024 12/31/2299 N
41112 EXCISION OF TONGUE LESION PRXOVR DEF         NA NA NA N
41112 EXCISION OF TONGUE LESION MAXFEE FAC         147.53 1/1/2024 12/31/2299 N
41112 EXCISION OF TONGUE LESION MAXFEE NFF         176.97 1/1/2024 12/31/2299 N
41113 EXCISION OF TONGUE LESION PRXOVR DEF         NA NA NA N
41113 EXCISION OF TONGUE LESION MAXFEE FAC         184.72 1/1/2024 12/31/2299 N
41113 EXCISION OF TONGUE LESION MAXFEE NFF         188.78 1/1/2024 12/31/2299 N
41114 EXCISION OF TONGUE LESION PRXOVR DEF         NA NA NA N
41114 EXCISION OF TONGUE LESION MAXFEE DEF         419.83 1/1/2024 12/31/2299 N
41115 EXCISION OF TONGUE FOLD PRXOVR DEF         NA NA NA N
41115 EXCISION OF TONGUE FOLD MAXFEE FAC         102.24 1/1/2024 12/31/2299 N
41115 EXCISION OF TONGUE FOLD MAXFEE NFF         141.19 1/1/2024 12/31/2299 N
41116 EXCISION OF MOUTH LESION PRXOVR DEF         NA NA NA N
41116 EXCISION OF MOUTH LESION MAXFEE FAC         141.65 1/1/2024 12/31/2299 N
41116 EXCISION OF MOUTH LESION MAXFEE NFF         186.47 1/1/2024 12/31/2299 N
41120 PARTIAL REMOVAL OF TONGUE PRXOVR DEF         NA NA NA N
41120 PARTIAL REMOVAL OF TONGUE MAXFEE DEF         582.58 1/1/2024 12/31/2299 N
41130 PARTIAL REMOVAL OF TONGUE PRXOVR DEF         NA NA NA N
41130 PARTIAL REMOVAL OF TONGUE MAXFEE DEF         706.93 1/1/2024 12/31/2299 N
41135 TONGUE AND NECK SURGERY PRXOVR DEF         NA NA NA N
41135 TONGUE AND NECK SURGERY MAXFEE DEF         1184.53 1/1/2024 12/31/2299 N
41140 REMOVAL OF TONGUE PRXOVR DEF         NA NA NA N
41140 REMOVAL OF TONGUE MAXFEE DEF         1258.87 1/1/2024 12/31/2299 N
41145 TONGUE REMOVAL NECK SURGERY PRXOVR DEF         NA NA NA N
41145 TONGUE REMOVAL NECK SURGERY MAXFEE DEF         1524.85 1/1/2024 12/31/2299 N
41150 TONGUE MOUTH JAW SURGERY PRXOVR DEF         NA NA NA N
41150 TONGUE MOUTH JAW SURGERY MAXFEE DEF         1210.88 1/1/2024 12/31/2299 N
41153 TONGUE MOUTH NECK SURGERY PRXOVR DEF         NA NA NA N
41153 TONGUE MOUTH NECK SURGERY MAXFEE DEF         1351.08 1/1/2024 12/31/2299 N
41155 TONGUE JAW & NECK SURGERY PRXOVR DEF         NA NA NA N
41155 TONGUE JAW & NECK SURGERY MAXFEE DEF         1594.55 1/1/2024 12/31/2299 N
41250 REPAIR TONGUE LACERATION PRXOVR DEF         NA NA NA N
41250 REPAIR TONGUE LACERATION MAXFEE FAC         90.45 1/1/2024 12/31/2299 N
41250 REPAIR TONGUE LACERATION MAXFEE NFF         147.60 1/1/2024 12/31/2299 N
41251 REPAIR TONGUE LACERATION PRXOVR DEF         NA NA NA N
41251 REPAIR TONGUE LACERATION MAXFEE FAC         126.48 1/1/2024 12/31/2299 N
41251 REPAIR TONGUE LACERATION MAXFEE NFF         162.48 1/1/2024 12/31/2299 N
41252 REPAIR TONGUE LACERATION PRXOVR DEF         NA NA NA N
41252 REPAIR TONGUE LACERATION MAXFEE FAC         153.84 1/1/2024 12/31/2299 N
41252 REPAIR TONGUE LACERATION MAXFEE NFF         170.61 1/1/2024 12/31/2299 N
41500 FIXATION OF TONGUE PRXOVR DEF         NA NA NA N
41500 FIXATION OF TONGUE MAXFEE DEF         NA     N
41510 TONGUE TO LIP SURGERY PRXOVR DEF         NA NA NA N
41510 TONGUE TO LIP SURGERY MAXFEE DEF         250.53 1/1/2024 12/31/2299 N
41512 TONGUE SUSPENSION PRXOVR DEF         NA NA NA N
41512 TONGUE SUSPENSION MAXFEE DEF         447.42 1/1/2024 12/31/2299 N
41520 RECONSTRUCTION TONGUE FOLD PRXOVR DEF         NA NA NA N
41520 RECONSTRUCTION TONGUE FOLD MAXFEE FAC         155.96 1/1/2024 12/31/2299 N
41520 RECONSTRUCTION TONGUE FOLD MAXFEE NFF         189.99 1/1/2024 12/31/2299 N
41530 TONGUE BASE VOL REDUCTION PRXOVR DEF         NA NA NA N
41530 TONGUE BASE VOL REDUCTION MAXFEE FAC         394.86 1/1/2024 12/31/2299 N
41530 TONGUE BASE VOL REDUCTION MAXFEE NFF         981.43 1/1/2024 12/31/2299 N
41599 UNLISTED PX TONGUE FLR MOUTH PRXOVR DEF         NA NA NA N
41599 UNLISTED PX TONGUE FLR MOUTH MANUAL DEF         NA NA NA N
41800 DRAINAGE OF GUM LESION PRXOVR DEF         NA NA NA N
41800 DRAINAGE OF GUM LESION MAXFEE FAC         78.56 1/1/2024 12/31/2299 N
41800 DRAINAGE OF GUM LESION MAXFEE NFF         159.82 1/1/2024 12/31/2299 N
41805 REMOVAL FOREIGN BODY GUM PRXOVR DEF         NA NA NA N
41805 REMOVAL FOREIGN BODY GUM MAXFEE FAC         102.09 1/1/2024 12/31/2299 N
41805 REMOVAL FOREIGN BODY GUM MAXFEE NFF         163.34 1/1/2024 12/31/2299 N
41806 REMOVAL FOREIGN BODY JAWBONE PRXOVR DEF         NA NA NA N
41806 REMOVAL FOREIGN BODY JAWBONE MAXFEE FAC         143.96 1/1/2024 12/31/2299 N
41806 REMOVAL FOREIGN BODY JAWBONE MAXFEE NFF         214.73 1/1/2024 12/31/2299 N
41821 EXCISION OF GUM FLAP PRXOVR DEF         NA NA NA N
41821 EXCISION OF GUM FLAP MANUAL DEF         NA NA NA N
41822 EXCISION OF GUM LESION PRXOVR DEF         NA NA NA N
41822 EXCISION OF GUM LESION MAXFEE FAC         141.40 1/1/2016 12/31/2299 N
41822 EXCISION OF GUM LESION MAXFEE NFF         141.40 1/1/2014 12/31/2299 N
41823 EXCISION OF GUM LESION PRXOVR DEF         NA NA NA N
41823 EXCISION OF GUM LESION MAXFEE FAC         217.94 1/1/2024 12/31/2299 N
41823 EXCISION OF GUM LESION MAXFEE NFF         273.22 1/1/2024 12/31/2299 N
41825 EXCISION OF GUM LESION PRXOVR DEF         NA NA NA N
41825 EXCISION OF GUM LESION MAXFEE FAC         82.05 1/1/2024 12/31/2299 N
41825 EXCISION OF GUM LESION MAXFEE NFF         114.03 1/1/2024 12/31/2299 N
41826 EXCISION OF GUM LESION PRXOVR DEF         NA NA NA N
41826 EXCISION OF GUM LESION MAXFEE FAC         124.13 1/1/2024 12/31/2299 N
41826 EXCISION OF GUM LESION MAXFEE NFF         165.32 1/1/2024 12/31/2299 N
41827 EXCISION OF GUM LESION PRXOVR DEF         NA NA NA N
41827 EXCISION OF GUM LESION MAXFEE FAC         198.94 1/1/2024 12/31/2299 N
41827 EXCISION OF GUM LESION MAXFEE NFF         231.93 1/1/2024 12/31/2299 N
41850 TREATMENT OF GUM LESION PRXOVR DEF         NA NA NA N
41850 TREATMENT OF GUM LESION MANUAL DEF         NA NA NA N
41899 UNLISTED PX DENTALVLR STRUX PRXOVR DEF         NA NA NA N
41899 UNLISTED PX DENTALVLR STRUX MANUAL DEF         NA NA NA N
42000 DRAINAGE MOUTH ROOF LESION PRXOVR DEF         NA NA NA N
42000 DRAINAGE MOUTH ROOF LESION MAXFEE FAC         57.73 1/1/2024 12/31/2299 N
42000 DRAINAGE MOUTH ROOF LESION MAXFEE NFF         106.22 1/1/2024 12/31/2299 N
42100 BIOPSY ROOF OF MOUTH PRXOVR DEF         NA NA NA N
42100 BIOPSY ROOF OF MOUTH MAXFEE FAC         65.99 1/1/2024 12/31/2299 N
42100 BIOPSY ROOF OF MOUTH MAXFEE NFF         87.57 1/1/2024 12/31/2299 N
42104 EXCISION LESION MOUTH ROOF PRXOVR DEF         NA NA NA N
42104 EXCISION LESION MOUTH ROOF MAXFEE FAC         94.97 1/1/2024 12/31/2299 N
42104 EXCISION LESION MOUTH ROOF MAXFEE NFF         126.24 1/1/2024 12/31/2299 N
42106 EXCISION LESION MOUTH ROOF PRXOVR DEF         NA NA NA N
42106 EXCISION LESION MOUTH ROOF MAXFEE FAC         121.85 1/1/2024 12/31/2299 N
42106 EXCISION LESION MOUTH ROOF MAXFEE NFF         158.78 1/1/2024 12/31/2299 N
42107 EXCISION LESION MOUTH ROOF PRXOVR DEF         NA NA NA N
42107 EXCISION LESION MOUTH ROOF MAXFEE FAC         255.92 1/1/2024 12/31/2299 N
42107 EXCISION LESION MOUTH ROOF MAXFEE NFF         255.92 1/1/2024 12/31/2299 N
42120 REMOVE PALATE/LESION PRXOVR DEF         NA NA NA N
42120 REMOVE PALATE/LESION MAXFEE DEF         524.21 1/1/2024 12/31/2299 N
42140 EXCISION OF UVULA PRXOVR DEF         NA NA NA N
42140 EXCISION OF UVULA MAXFEE FAC         93.90 1/1/2024 12/31/2299 N
42140 EXCISION OF UVULA MAXFEE NFF         162.48 1/1/2024 12/31/2299 N
42145 REPAIR PALATE PHARYNX/UVULA PRXOVR DEF         NA NA NA N
42145 REPAIR PALATE PHARYNX/UVULA MAXFEE DEF         483.79 1/1/2024 12/31/2299 N
42160 TREATMENT MOUTH ROOF LESION PRXOVR DEF         NA NA NA N
42160 TREATMENT MOUTH ROOF LESION MAXFEE FAC         99.05 1/1/2024 12/31/2299 N
42160 TREATMENT MOUTH ROOF LESION MAXFEE NFF         123.30 1/1/2024 12/31/2299 N
42180 REPAIR LAC PALATE<2 CM PRXOVR DEF         NA NA NA N
42180 REPAIR LAC PALATE<2 CM MAXFEE FAC         136.36 1/1/2024 12/31/2299 N
42180 REPAIR LAC PALATE<2 CM MAXFEE NFF         136.36 1/1/2024 12/31/2299 N
42182 REPAIR PALATE PRXOVR DEF         NA NA NA N
42182 REPAIR PALATE MAXFEE FAC         202.08 1/1/2024 12/31/2299 N
42182 REPAIR PALATE MAXFEE NFF         202.08 1/1/2024 12/31/2299 N
42200 RECONSTRUCT CLEFT PALATE PRXOVR DEF         NA NA NA N
42200 RECONSTRUCT CLEFT PALATE MAXFEE DEF         542.09 1/1/2024 12/31/2299 N
42205 RECONSTRUCT CLEFT PALATE PRXOVR DEF         NA NA NA N
42205 RECONSTRUCT CLEFT PALATE MAXFEE DEF         539.78 1/1/2024 12/31/2299 N
42210 RECONSTRUCT CLEFT PALATE PRXOVR DEF         NA NA NA N
42210 RECONSTRUCT CLEFT PALATE MAXFEE DEF         721.49 1/1/2024 12/31/2299 N
42215 RECONSTRUCT CLEFT PALATE PRXOVR DEF         NA NA NA N
42215 RECONSTRUCT CLEFT PALATE MAXFEE DEF         471.09 1/1/2024 12/31/2299 N
42220 RECONSTRUCT CLEFT PALATE PRXOVR DEF         NA NA NA N
42220 RECONSTRUCT CLEFT PALATE MAXFEE DEF         359.79 1/1/2024 12/31/2299 N
42225 RECONSTRUCT CLEFT PALATE PRXOVR DEF         NA NA NA N
42225 RECONSTRUCT CLEFT PALATE MAXFEE DEF         580.19 1/1/2024 12/31/2299 N
42226 LENGTHENING OF PALATE PRXOVR DEF         NA NA NA N
42226 LENGTHENING OF PALATE MAXFEE DEF         552.78 1/1/2024 12/31/2299 N
42227 LENGTHENING OF PALATE PRXOVR DEF         NA NA NA N
42227 LENGTHENING OF PALATE MAXFEE DEF         547.47 1/1/2024 12/31/2299 N
42235 REPAIR PALATE PRXOVR DEF         NA NA NA N
42235 REPAIR PALATE MAXFEE DEF         442.49 1/1/2024 12/31/2299 N
42260 REPAIR NOSE TO LIP FISTULA PRXOVR DEF         NA NA NA N
42260 REPAIR NOSE TO LIP FISTULA MAXFEE FAC         396.86 1/1/2024 12/31/2299 N
42260 REPAIR NOSE TO LIP FISTULA MAXFEE NFF         444.71 1/1/2024 12/31/2299 N
42280 PREPARATION PALATE MOLD PRXOVR DEF         NA NA NA N
42280 PREPARATION PALATE MOLD MAXFEE FAC         90.25 1/1/2016 12/31/2299 N
42280 PREPARATION PALATE MOLD MAXFEE NFF         90.25 1/1/2014 12/31/2299 N
42281 INSERTION PALATE PROSTHESIS PRXOVR DEF         NA NA NA N
42281 INSERTION PALATE PROSTHESIS MAXFEE FAC         105.44 1/1/2024 12/31/2299 N
42281 INSERTION PALATE PROSTHESIS MAXFEE NFF         116.80 1/1/2024 12/31/2299 N
42299 UNLISTED PX PALATE UVULA PRXOVR DEF         NA NA NA N
42299 UNLISTED PX PALATE UVULA MANUAL DEF         NA NA NA N
42300 DRAINAGE OF SALIVARY GLAND PRXOVR DEF         NA NA NA N
42300 DRAINAGE OF SALIVARY GLAND MAXFEE FAC         122.65 1/1/2016 12/31/2299 N
42300 DRAINAGE OF SALIVARY GLAND MAXFEE NFF         128.78 1/1/2024 12/31/2299 N
42305 DRAINAGE OF SALIVARY GLAND PRXOVR DEF         NA NA NA N
42305 DRAINAGE OF SALIVARY GLAND MAXFEE DEF         250.36 1/1/2024 12/31/2299 N
42310 DRAINAGE OF SALIVARY GLAND PRXOVR DEF         NA NA NA N
42310 DRAINAGE OF SALIVARY GLAND MAXFEE FAC         105.85 1/1/2016 12/31/2299 N
42310 DRAINAGE OF SALIVARY GLAND MAXFEE NFF         111.14 1/1/2024 12/31/2299 N
42320 DRAINAGE OF SALIVARY GLAND PRXOVR DEF         NA NA NA N
42320 DRAINAGE OF SALIVARY GLAND MAXFEE FAC         140.89 1/1/2016 12/31/2299 N
42320 DRAINAGE OF SALIVARY GLAND MAXFEE NFF         147.93 1/1/2024 12/31/2299 N
42325 CREATE SALIVARY CYST DRAIN PRXOVR DEF         NA NA NA N
42325 CREATE SALIVARY CYST DRAIN MAXFEE DEF         NA     N
42326 CREATE SALIVARY CYST DRAIN PRXOVR DEF         NA NA NA N
42326 CREATE SALIVARY CYST DRAIN MAXFEE DEF         NA     N
42330 REMOVAL OF SALIVARY STONE PRXOVR DEF         NA NA NA N
42330 REMOVAL OF SALIVARY STONE MAXFEE FAC         100.17 1/1/2024 12/31/2299 N
42330 REMOVAL OF SALIVARY STONE MAXFEE NFF         123.68 1/1/2024 12/31/2299 N
42335 REMOVAL OF SALIVARY STONE PRXOVR DEF         NA NA NA N
42335 REMOVAL OF SALIVARY STONE MAXFEE FAC         167.07 1/1/2024 12/31/2299 N
42335 REMOVAL OF SALIVARY STONE MAXFEE NFF         224.77 1/1/2024 12/31/2299 N
42340 REMOVAL OF SALIVARY STONE PRXOVR DEF         NA NA NA N
42340 REMOVAL OF SALIVARY STONE MAXFEE FAC         248.81 1/1/2024 12/31/2299 N
42340 REMOVAL OF SALIVARY STONE MAXFEE NFF         276.85 1/1/2024 12/31/2299 N
42400 BIOPSY OF SALIVARY GLAND PRXOVR DEF         NA NA NA N
42400 BIOPSY OF SALIVARY GLAND MAXFEE FAC         47.88 1/1/2016 12/31/2299 N
42400 BIOPSY OF SALIVARY GLAND MAXFEE NFF         61.53 1/1/2024 12/31/2299 N
42405 BIOPSY OF SALIVARY GLAND PRXOVR DEF         NA NA NA N
42405 BIOPSY OF SALIVARY GLAND MAXFEE FAC         144.22 1/1/2024 12/31/2299 N
42405 BIOPSY OF SALIVARY GLAND MAXFEE NFF         173.49 1/1/2024 12/31/2299 N
42408 EXCISION OF SALIVARY CYST PRXOVR DEF         NA NA NA N
42408 EXCISION OF SALIVARY CYST MAXFEE FAC         223.88 1/1/2024 12/31/2299 N
42408 EXCISION OF SALIVARY CYST MAXFEE NFF         282.91 1/1/2024 12/31/2299 N
42409 DRAINAGE OF SALIVARY CYST PRXOVR DEF         NA NA NA N
42409 DRAINAGE OF SALIVARY CYST MAXFEE FAC         159.19 1/1/2024 12/31/2299 N
42409 DRAINAGE OF SALIVARY CYST MAXFEE NFF         206.08 1/1/2024 12/31/2299 N
42410 EXCISE PAROTID GLAND/LESION PRXOVR DEF         NA NA NA N
42410 EXCISE PAROTID GLAND/LESION MAXFEE DEF         450.56 1/1/2024 12/31/2299 N
42415 EXCISE PAROTID GLAND/LESION PRXOVR DEF         NA NA NA N
42415 EXCISE PAROTID GLAND/LESION MAXFEE DEF         844.85 1/1/2024 12/31/2299 N
42420 EXCISE PAROTID GLAND/LESION PRXOVR DEF         NA NA NA N
42420 EXCISE PAROTID GLAND/LESION MAXFEE DEF         931.76 1/1/2000 12/31/2299 N
42425 EXCISE PAROTID GLAND/LESION PRXOVR DEF         NA NA NA N
42425 EXCISE PAROTID GLAND/LESION MAXFEE DEF         654.68 1/1/2000 12/31/2299 N
42426 EXCISE PAROTID GLAND/LESION PRXOVR DEF         NA NA NA N
42426 EXCISE PAROTID GLAND/LESION MAXFEE DEF         1181.05 1/1/2000 12/31/2299 N
42440 EXCISE SUBMAXILLARY GLAND PRXOVR DEF         NA NA NA N
42440 EXCISE SUBMAXILLARY GLAND MAXFEE DEF         385.44 1/1/2010 12/31/2299 N
42450 EXCISE SUBLINGUAL GLAND PRXOVR DEF         NA NA NA N
42450 EXCISE SUBLINGUAL GLAND MAXFEE FAC         230.11 1/1/2024 12/31/2299 N
42450 EXCISE SUBLINGUAL GLAND MAXFEE NFF         244.32 1/1/2024 12/31/2299 N
42500 REPAIR SALIVARY DUCT PRXOVR DEF         NA NA NA N
42500 REPAIR SALIVARY DUCT MAXFEE FAC         250.02 1/1/2024 12/31/2299 N
42500 REPAIR SALIVARY DUCT MAXFEE NFF         250.02 1/1/2024 12/31/2299 N
42505 REPAIR SALIVARY DUCT PRXOVR DEF         NA NA NA N
42505 REPAIR SALIVARY DUCT MAXFEE FAC         359.87 1/1/2024 12/31/2299 N
42505 REPAIR SALIVARY DUCT MAXFEE NFF         359.87 1/1/2024 12/31/2299 N
42507 PAROTID DUCT DIVERSION PRXOVR DEF         NA NA NA N
42507 PAROTID DUCT DIVERSION MAXFEE DEF         318.38 1/1/2024 12/31/2299 N
42508 PAROTID DUCT DIVERSION PRXOVR DEF         NA NA NA N
42508 PAROTID DUCT DIVERSION MAXFEE DEF         NA     N
42509 PAROTID DUCT DIVERSION PRXOVR DEF         NA NA NA N
42509 PAROTID DUCT DIVERSION MAXFEE DEF         553.97 1/1/2024 12/31/2299 N
42510 PAROTID DUCT DIVERSION PRXOVR DEF         NA NA NA N
42510 PAROTID DUCT DIVERSION MAXFEE DEF         434.62 1/1/2024 12/31/2299 N
42550 INJECTION FOR SALIVARY X-RAY PRXOVR DEF         NA NA NA N
42550 INJECTION FOR SALIVARY X-RAY MAXFEE FAC         51.33 1/1/2016 12/31/2299 N
42550 INJECTION FOR SALIVARY X-RAY MAXFEE NFF         82.54 1/1/2024 12/31/2299 N
42600 CLOSURE OF SALIVARY FISTULA PRXOVR DEF         NA NA NA N
42600 CLOSURE OF SALIVARY FISTULA MAXFEE FAC         254.29 1/1/2024 12/31/2299 N
42600 CLOSURE OF SALIVARY FISTULA MAXFEE NFF         283.43 1/1/2024 12/31/2299 N
42650 DILATION OF SALIVARY DUCT PRXOVR DEF         NA NA NA N
42650 DILATION OF SALIVARY DUCT MAXFEE FAC         50.96 1/1/2016 12/31/2299 N
42650 DILATION OF SALIVARY DUCT MAXFEE NFF         53.51 1/1/2024 12/31/2299 N
42660 DILATION OF SALIVARY DUCT PRXOVR DEF         NA NA NA N
42660 DILATION OF SALIVARY DUCT MAXFEE FAC         66.55 1/1/2024 12/31/2299 N
42660 DILATION OF SALIVARY DUCT MAXFEE NFF         66.55 1/1/2024 12/31/2299 N
42665 LIGATION OF SALIVARY DUCT PRXOVR DEF         NA NA NA N
42665 LIGATION OF SALIVARY DUCT MAXFEE FAC         136.34 1/1/2024 12/31/2299 N
42665 LIGATION OF SALIVARY DUCT MAXFEE NFF         196.05 1/1/2024 12/31/2299 N
42699 UNLISTED PX SALIVRY GLND/DUX PRXOVR DEF         NA NA NA N
42699 UNLISTED PX SALIVRY GLND/DUX MANUAL DEF         NA NA NA N
70140 X-RAY EXAM OF FACIAL BONES PRXOVR DEF         NA NA NA N
70140 X-RAY EXAM OF FACIAL BONES MAXFEE DEF         25.34 1/1/2024 12/31/2299 N
70140 X-RAY EXAM OF FACIAL BONES MAXFEE DEF TC       16.47 1/1/2024 12/31/2299 N
70140 X-RAY EXAM OF FACIAL BONES MAXFEE DEF 26       8.87 1/1/2024 12/31/2299 N
70150 X-RAY EXAM OF FACIAL BONES PRXOVR DEF         NA NA NA N
70150 X-RAY EXAM OF FACIAL BONES MAXFEE DEF         33.06 1/1/2024 12/31/2299 N
70150 X-RAY EXAM OF FACIAL BONES MAXFEE DEF TC       21.49 1/1/2024 12/31/2299 N
70150 X-RAY EXAM OF FACIAL BONES MAXFEE DEF 26       11.57 1/1/2024 12/31/2299 N
70160 X-RAY EXAM OF NASAL BONES PRXOVR DEF         NA NA NA N
70160 X-RAY EXAM OF NASAL BONES MAXFEE DEF         21.70 1/1/2024 12/31/2299 N
70160 X-RAY EXAM OF NASAL BONES MAXFEE DEF TC       14.10 1/1/2024 12/31/2299 N
70160 X-RAY EXAM OF NASAL BONES MAXFEE DEF 26       7.60 1/1/2024 12/31/2299 N
70170 X-RAY EXAM OF TEAR DUCT PRXOVR DEF         NA NA NA N
70170 X-RAY EXAM OF TEAR DUCT MAXFEE DEF         137.51 1/1/2018 12/31/2299 N
70170 X-RAY EXAM OF TEAR DUCT MAXFEE DEF 26       13.75 1/1/2018 12/31/2299 N
70170 X-RAY EXAM OF TEAR DUCT MAXFEE DEF TC       123.76 1/1/2018 12/31/2299 N
70190 X-RAY EXAM OF EYE SOCKETS PRXOVR DEF         NA NA NA N
70190 X-RAY EXAM OF EYE SOCKETS MAXFEE DEF         26.08 1/1/2024 12/31/2299 N
70190 X-RAY EXAM OF EYE SOCKETS MAXFEE DEF TC       16.95 1/1/2024 12/31/2299 N
70190 X-RAY EXAM OF EYE SOCKETS MAXFEE DEF 26       9.13 1/1/2024 12/31/2299 N
70200 X-RAY EXAM OF EYE SOCKETS PRXOVR DEF         NA NA NA N
70200 X-RAY EXAM OF EYE SOCKETS MAXFEE DEF         32.79 1/1/2024 12/31/2299 N
70200 X-RAY EXAM OF EYE SOCKETS MAXFEE DEF TC       21.31 1/1/2024 12/31/2299 N
70200 X-RAY EXAM OF EYE SOCKETS MAXFEE DEF 26       11.48 1/1/2024 12/31/2299 N
70210 X-RAY EXAM OF SINUSES PRXOVR DEF         NA NA NA N
70210 X-RAY EXAM OF SINUSES MAXFEE DEF         24.53 1/1/2024 12/31/2299 N
70210 X-RAY EXAM OF SINUSES MAXFEE DEF TC       17.17 1/1/2024 12/31/2299 N
70210 X-RAY EXAM OF SINUSES MAXFEE DEF 26       7.36 1/1/2024 12/31/2299 N
70220 X-RAY EXAM OF SINUSES PRXOVR DEF         NA NA NA N
70220 X-RAY EXAM OF SINUSES MAXFEE DEF         30.23 1/1/2018 12/31/2299 N
70220 X-RAY EXAM OF SINUSES MAXFEE DEF 26       10.58 1/1/2018 12/31/2299 N
70220 X-RAY EXAM OF SINUSES MAXFEE DEF TC       19.65 1/1/2018 12/31/2299 N
70240 X-RAY EXAM PITUITARY SADDLE PRXOVR DEF         NA NA NA N
70240 X-RAY EXAM PITUITARY SADDLE MAXFEE DEF         19.64 1/1/2024 12/31/2299 N
70240 X-RAY EXAM PITUITARY SADDLE MAXFEE DEF TC       11.78 1/1/2024 12/31/2299 N
70240 X-RAY EXAM PITUITARY SADDLE MAXFEE DEF 26       7.86 1/1/2024 12/31/2299 N
70250 X-RAY EXAM OF SKULL PRXOVR DEF         NA NA NA N
70250 X-RAY EXAM OF SKULL MAXFEE DEF         27.46 1/1/2024 12/31/2299 N
70250 X-RAY EXAM OF SKULL MAXFEE DEF TC       19.22 1/1/2024 12/31/2299 N
70250 X-RAY EXAM OF SKULL MAXFEE DEF 26       8.24 1/1/2024 12/31/2299 N
70260 X-RAY EXAM OF SKULL PRXOVR DEF         NA NA NA N
70260 X-RAY EXAM OF SKULL MAXFEE DEF         37.45 1/1/2018 12/31/2299 N
70260 X-RAY EXAM OF SKULL MAXFEE DEF 26       11.24 1/1/2018 12/31/2299 N
70260 X-RAY EXAM OF SKULL MAXFEE DEF TC       26.22 1/1/2018 12/31/2299 N
70300 X-RAY EXAM OF TEETH PRXOVR DEF         NA NA NA N
70300 X-RAY EXAM OF TEETH MAXFEE DEF         11.27 1/1/2018 12/31/2299 N
70300 X-RAY EXAM OF TEETH MAXFEE DEF 26       4.51 1/1/2018 12/31/2299 N
70300 X-RAY EXAM OF TEETH MAXFEE DEF TC       6.76 1/1/2018 12/31/2299 N
70310 X-RAY EXAM OF TEETH PRXOVR DEF         NA NA NA N
70310 X-RAY EXAM OF TEETH MAXFEE DEF         19.73 1/1/2024 12/31/2299 N
70310 X-RAY EXAM OF TEETH MAXFEE DEF TC       13.81 1/1/2024 12/31/2299 N
70310 X-RAY EXAM OF TEETH MAXFEE DEF 26       5.92 1/1/2024 12/31/2299 N
70320 FULL MOUTH X-RAY OF TEETH PRXOVR DEF         NA NA NA N
70320 FULL MOUTH X-RAY OF TEETH MAXFEE DEF         31.50 1/1/2024 12/31/2299 N
70320 FULL MOUTH X-RAY OF TEETH MAXFEE DEF TC       22.05 1/1/2024 12/31/2299 N
70320 FULL MOUTH X-RAY OF TEETH MAXFEE DEF 26       9.45 1/1/2024 12/31/2299 N
70328 X-RAY EXAM OF JAW JOINT PRXOVR DEF         NA NA NA N
70328 X-RAY EXAM OF JAW JOINT MAXFEE DEF         21.39 1/1/2024 12/31/2299 N
70328 X-RAY EXAM OF JAW JOINT MAXFEE DEF TC       14.97 1/1/2024 12/31/2299 N
70328 X-RAY EXAM OF JAW JOINT MAXFEE DEF 26       6.42 1/1/2024 12/31/2299 N
70330 X-RAY EXAM OF JAW JOINTS PRXOVR DEF         NA NA NA N
70330 X-RAY EXAM OF JAW JOINTS MAXFEE DEF         33.75 1/1/2024 12/31/2299 N
70330 X-RAY EXAM OF JAW JOINTS MAXFEE DEF TC       23.62 1/1/2024 12/31/2299 N
70330 X-RAY EXAM OF JAW JOINTS MAXFEE DEF 26       10.13 1/1/2024 12/31/2299 N
70332 X-RAY EXAM OF JAW JOINT PRXOVR DEF         NA NA NA N
70332 X-RAY EXAM OF JAW JOINT MAXFEE DEF         62.17 1/1/2024 12/31/2299 N
70332 X-RAY EXAM OF JAW JOINT MAXFEE DEF TC       40.41 1/1/2024 12/31/2299 N
70332 X-RAY EXAM OF JAW JOINT MAXFEE DEF 26       21.76 1/1/2024 12/31/2299 N
70336 MAGNETIC IMAGE JAW JOINT PRXOVR DEF         NA NA NA N
70336 MAGNETIC IMAGE JAW JOINT MAXFEE DEF         262.42 1/1/2018 12/31/2299 N
70336 MAGNETIC IMAGE JAW JOINT MAXFEE DEF 26       52.48 1/1/2018 12/31/2299 N
70336 MAGNETIC IMAGE JAW JOINT MAXFEE DEF TC       209.94 1/1/2018 12/31/2299 N
70350 X-RAY HEAD FOR ORTHODONTIA PRXOVR DEF         NA NA NA N
70350 X-RAY HEAD FOR ORTHODONTIA MAXFEE DEF         15.75 1/1/2024 12/31/2299 N
70350 X-RAY HEAD FOR ORTHODONTIA MAXFEE DEF TC       9.45 1/1/2024 12/31/2299 N
70350 X-RAY HEAD FOR ORTHODONTIA MAXFEE DEF 26       6.30 1/1/2024 12/31/2299 N
70355 PANORAMIC X-RAY OF JAWS PRXOVR DEF         NA NA NA N
70355 PANORAMIC X-RAY OF JAWS MAXFEE DEF         17.49 1/1/2018 12/31/2299 N
70355 PANORAMIC X-RAY OF JAWS MAXFEE DEF 26       6.12 1/1/2018 12/31/2299 N
70355 PANORAMIC X-RAY OF JAWS MAXFEE DEF TC       11.37 1/1/2018 12/31/2299 N
70360 X-RAY EXAM OF NECK PRXOVR DEF         NA NA NA N
70360 X-RAY EXAM OF NECK MAXFEE DEF         17.94 1/1/2018 12/31/2299 N
70360 X-RAY EXAM OF NECK MAXFEE DEF 26       5.38 1/1/2018 12/31/2299 N
70360 X-RAY EXAM OF NECK MAXFEE DEF TC       12.56 1/1/2018 12/31/2299 N
70370 THROAT X-RAY & FLUOROSCOPY PRXOVR DEF         NA NA NA N
70370 THROAT X-RAY & FLUOROSCOPY MAXFEE DEF         53.47 1/1/2024 12/31/2299 N
70370 THROAT X-RAY & FLUOROSCOPY MAXFEE DEF TC       37.43 1/1/2024 12/31/2299 N
70370 THROAT X-RAY & FLUOROSCOPY MAXFEE DEF 26       16.04 1/1/2024 12/31/2299 N
70373 CONTRAST X-RAY OF LARYNX PRXOVR DEF         NA NA NA N
70373 CONTRAST X-RAY OF LARYNX MAXFEE DEF         NA     N
70380 X-RAY EXAM OF SALIVARY GLAND PRXOVR DEF         NA NA NA N
70380 X-RAY EXAM OF SALIVARY GLAND MAXFEE DEF         25.90 1/1/2024 12/31/2299 N
70380 X-RAY EXAM OF SALIVARY GLAND MAXFEE DEF TC       18.13 1/1/2024 12/31/2299 N
70380 X-RAY EXAM OF SALIVARY GLAND MAXFEE DEF 26       7.77 1/1/2024 12/31/2299 N
70390 X-RAY EXAM OF SALIVARY DUCT PRXOVR DEF         NA NA NA N
70390 X-RAY EXAM OF SALIVARY DUCT MAXFEE DEF         65.82 1/1/2024 12/31/2299 N
70390 X-RAY EXAM OF SALIVARY DUCT MAXFEE DEF TC       49.36 1/1/2024 12/31/2299 N
70390 X-RAY EXAM OF SALIVARY DUCT MAXFEE DEF 26       16.46 1/1/2024 12/31/2299 N
70450 CT HEAD/BRAIN W/O DYE PRXOVR DEF         NA NA NA N
70450 CT HEAD/BRAIN W/O DYE MAXFEE DEF         100.97 1/1/2018 12/31/2299 N
70450 CT HEAD/BRAIN W/O DYE MAXFEE DEF 26       35.34 1/1/2018 12/31/2299 N
70450 CT HEAD/BRAIN W/O DYE MAXFEE DEF TC       65.63 1/1/2018 12/31/2299 N
70460 CT HEAD/BRAIN W/DYE PRXOVR DEF         NA NA NA N
70460 CT HEAD/BRAIN W/DYE MAXFEE DEF         137.87 1/1/2018 12/31/2299 N
70460 CT HEAD/BRAIN W/DYE MAXFEE DEF 26       48.25 1/1/2018 12/31/2299 N
70460 CT HEAD/BRAIN W/DYE MAXFEE DEF TC       89.62 1/1/2018 12/31/2299 N
70470 CT HEAD/BRAIN W/O & W/DYE PRXOVR DEF         NA NA NA N
70470 CT HEAD/BRAIN W/O & W/DYE MAXFEE DEF         162.60 1/1/2018 12/31/2299 N
70470 CT HEAD/BRAIN W/O & W/DYE MAXFEE DEF 26       48.78 1/1/2018 12/31/2299 N
70470 CT HEAD/BRAIN W/O & W/DYE MAXFEE DEF TC       113.82 1/1/2018 12/31/2299 N
70480 CT ORBIT/EAR/FOSSA W/O DYE PRXOVR DEF         NA NA NA N
70480 CT ORBIT/EAR/FOSSA W/O DYE MAXFEE DEF         157 1/1/2018 12/31/2299 N
70480 CT ORBIT/EAR/FOSSA W/O DYE MAXFEE DEF 26       47.10 1/1/2018 12/31/2299 N
70480 CT ORBIT/EAR/FOSSA W/O DYE MAXFEE DEF TC       109.90 1/1/2018 12/31/2299 N
70481 CT ORBIT/EAR/FOSSA W/DYE PRXOVR DEF         NA NA NA N
70481 CT ORBIT/EAR/FOSSA W/DYE MAXFEE DEF         177.47 1/1/2024 12/31/2299 N
70481 CT ORBIT/EAR/FOSSA W/DYE MAXFEE DEF TC       133.10 1/1/2024 12/31/2299 N
70481 CT ORBIT/EAR/FOSSA W/DYE MAXFEE DEF 26       44.37 1/1/2024 12/31/2299 N
70482 CT ORBIT/EAR/FOSSA W/O&W/DYE PRXOVR DEF         NA NA NA N
70482 CT ORBIT/EAR/FOSSA W/O&W/DYE MAXFEE DEF         206.99 1/1/2024 12/31/2299 N
70482 CT ORBIT/EAR/FOSSA W/O&W/DYE MAXFEE DEF TC       155.24 1/1/2024 12/31/2299 N
70482 CT ORBIT/EAR/FOSSA W/O&W/DYE MAXFEE DEF 26       51.75 1/1/2024 12/31/2299 N
70486 CT MAXILLOFACIAL W/O DYE PRXOVR DEF         NA NA NA N
70486 CT MAXILLOFACIAL W/O DYE MAXFEE DEF         118.49 1/1/2018 12/31/2299 N
70486 CT MAXILLOFACIAL W/O DYE MAXFEE DEF 26       35.55 1/1/2018 12/31/2299 N
70486 CT MAXILLOFACIAL W/O DYE MAXFEE DEF TC       82.94 1/1/2018 12/31/2299 N
70487 CT MAXILLOFACIAL W/DYE PRXOVR DEF         NA NA NA N
70487 CT MAXILLOFACIAL W/DYE MAXFEE DEF TC       100.08 1/1/2018 12/31/2299 N
70487 CT MAXILLOFACIAL W/DYE MAXFEE DEF         142.97 1/1/2018 12/31/2299 N
70487 CT MAXILLOFACIAL W/DYE MAXFEE DEF 26       42.89 1/1/2018 12/31/2299 N
70488 CT MAXILLOFACIAL W/O & W/DYE PRXOVR DEF         NA NA NA N
70488 CT MAXILLOFACIAL W/O & W/DYE MAXFEE DEF         173.56 1/1/2018 12/31/2299 N
70488 CT MAXILLOFACIAL W/O & W/DYE MAXFEE DEF 26       52.07 1/1/2018 12/31/2299 N
70488 CT MAXILLOFACIAL W/O & W/DYE MAXFEE DEF TC       121.49 1/1/2018 12/31/2299 N
70490 CT SOFT TISSUE NECK W/O DYE PRXOVR DEF         NA NA NA N
70490 CT SOFT TISSUE NECK W/O DYE MAXFEE DEF         157 1/1/2018 12/31/2299 N
70490 CT SOFT TISSUE NECK W/O DYE MAXFEE DEF 26       47.10 1/1/2018 12/31/2299 N
70490 CT SOFT TISSUE NECK W/O DYE MAXFEE DEF TC       109.90 1/1/2018 12/31/2299 N
70491 CT SOFT TISSUE NECK W/DYE PRXOVR DEF         NA NA NA N
70491 CT SOFT TISSUE NECK W/DYE MAXFEE DEF         198.99 1/1/2024 12/31/2299 N
70491 CT SOFT TISSUE NECK W/DYE MAXFEE DEF TC       139.29 1/1/2024 12/31/2299 N
70491 CT SOFT TISSUE NECK W/DYE MAXFEE DEF 26       59.70 1/1/2024 12/31/2299 N
70492 CT SFT TSUE NCK W/O & W/DYE PRXOVR DEF         NA NA NA N
70492 CT SFT TSUE NCK W/O & W/DYE MAXFEE DEF         218.59 1/1/2024 12/31/2299 N
70492 CT SFT TSUE NCK W/O & W/DYE MAXFEE DEF TC       163.94 1/1/2024 12/31/2299 N
70492 CT SFT TSUE NCK W/O & W/DYE MAXFEE DEF 26       54.65 1/1/2024 12/31/2299 N
70496 CT ANGIOGRAPHY HEAD PRXOVR DEF         NA NA NA N
70496 CT ANGIOGRAPHY HEAD MAXFEE DEF         250.20 1/1/2018 12/31/2299 N
70496 CT ANGIOGRAPHY HEAD MAXFEE DEF 26       62.55 1/1/2018 12/31/2299 N
70496 CT ANGIOGRAPHY HEAD MAXFEE DEF TC       187.65 1/1/2018 12/31/2299 N
70498 CT ANGIOGRAPHY NECK PRXOVR DEF         NA NA NA N
70498 CT ANGIOGRAPHY NECK MAXFEE DEF         248.71 1/1/2018 12/31/2299 N
70498 CT ANGIOGRAPHY NECK MAXFEE DEF 26       62.18 1/1/2018 12/31/2299 N
70498 CT ANGIOGRAPHY NECK MAXFEE DEF TC       186.53 1/1/2018 12/31/2299 N
70540 MRI ORBIT/FACE/NECK W/O DYE PRXOVR DEF         NA NA NA N
70540 MRI ORBIT/FACE/NECK W/O DYE MAXFEE DEF         223.29 1/1/2024 12/31/2299 N
70540 MRI ORBIT/FACE/NECK W/O DYE MAXFEE DEF TC       178.63 1/1/2024 12/31/2299 N
70540 MRI ORBIT/FACE/NECK W/O DYE MAXFEE DEF 26       44.66 1/1/2024 12/31/2299 N
70541 MAGNETIC IMAGE; HEAD (MRA) PRXOVR DEF         NA NA NA N
70541 MAGNETIC IMAGE; HEAD (MRA) MAXFEE DEF         NA     N
70542 MRI ORBIT/FACE/NECK W/DYE PRXOVR DEF         NA NA NA N
70542 MRI ORBIT/FACE/NECK W/DYE MAXFEE DEF         265.25 1/1/2024 12/31/2299 N
70542 MRI ORBIT/FACE/NECK W/DYE MAXFEE DEF TC       212.20 1/1/2024 12/31/2299 N
70542 MRI ORBIT/FACE/NECK W/DYE MAXFEE DEF 26       53.05 1/1/2024 12/31/2299 N
70543 MRI ORBT/FAC/NCK W/O &W/DYE PRXOVR DEF         NA NA NA N
70543 MRI ORBT/FAC/NCK W/O &W/DYE MAXFEE DEF         335.39 1/1/2024 12/31/2299 N
70543 MRI ORBT/FAC/NCK W/O &W/DYE MAXFEE DEF TC       268.31 1/1/2024 12/31/2299 N
70543 MRI ORBT/FAC/NCK W/O &W/DYE MAXFEE DEF 26       67.08 1/1/2024 12/31/2299 N
70544 MR ANGIOGRAPHY HEAD W/O DYE PRXOVR DEF         NA NA NA N
70544 MR ANGIOGRAPHY HEAD W/O DYE MAXFEE DEF         211.67 1/1/2024 12/31/2299 N
70544 MR ANGIOGRAPHY HEAD W/O DYE MAXFEE DEF TC       169.34 1/1/2024 12/31/2299 N
70544 MR ANGIOGRAPHY HEAD W/O DYE MAXFEE DEF 26       42.33 1/1/2024 12/31/2299 N
70545 MR ANGIOGRAPHY HEAD W/DYE PRXOVR DEF         NA NA NA N
70545 MR ANGIOGRAPHY HEAD W/DYE MAXFEE DEF         223.52 1/1/2024 12/31/2299 N
70545 MR ANGIOGRAPHY HEAD W/DYE MAXFEE DEF TC       178.82 1/1/2024 12/31/2299 N
70545 MR ANGIOGRAPHY HEAD W/DYE MAXFEE DEF 26       44.70 1/1/2024 12/31/2299 N
70546 MR ANGIOGRAPH HEAD W/O&W/DYE PRXOVR DEF         NA NA NA N
70546 MR ANGIOGRAPH HEAD W/O&W/DYE MAXFEE DEF         323.04 1/1/2024 12/31/2299 N
70546 MR ANGIOGRAPH HEAD W/O&W/DYE MAXFEE DEF TC       258.43 1/1/2024 12/31/2299 N
70546 MR ANGIOGRAPH HEAD W/O&W/DYE MAXFEE DEF 26       64.61 1/1/2024 12/31/2299 N
70547 MR ANGIOGRAPHY NECK W/O DYE PRXOVR DEF         NA NA NA N
70547 MR ANGIOGRAPHY NECK W/O DYE MAXFEE DEF         211.98 1/1/2024 12/31/2299 N
70547 MR ANGIOGRAPHY NECK W/O DYE MAXFEE DEF TC       169.58 1/1/2024 12/31/2299 N
70547 MR ANGIOGRAPHY NECK W/O DYE MAXFEE DEF 26       42.40 1/1/2024 12/31/2299 N
70548 MR ANGIOGRAPHY NECK W/DYE PRXOVR DEF         NA NA NA N
70548 MR ANGIOGRAPHY NECK W/DYE MAXFEE DEF         242.44 1/1/2024 12/31/2299 N
70548 MR ANGIOGRAPHY NECK W/DYE MAXFEE DEF TC       193.95 1/1/2024 12/31/2299 N
70548 MR ANGIOGRAPHY NECK W/DYE MAXFEE DEF 26       48.49 1/1/2024 12/31/2299 N
70549 MR ANGIOGRAPH NECK W/O&W/DYE PRXOVR DEF         NA NA NA N
70549 MR ANGIOGRAPH NECK W/O&W/DYE MAXFEE DEF         374.79 1/1/2024 12/31/2299 N
70549 MR ANGIOGRAPH NECK W/O&W/DYE MAXFEE DEF TC       299.83 1/1/2024 12/31/2299 N
70549 MR ANGIOGRAPH NECK W/O&W/DYE MAXFEE DEF 26       74.96 1/1/2024 12/31/2299 N
71010 CHEST X-RAY 1 VIEW FRONTAL PRXOVR DEF         NA NA NA N
71010 CHEST X-RAY 1 VIEW FRONTAL MAXFEE DEF         19.10 1/1/2018 12/31/2299 N
71010 CHEST X-RAY 1 VIEW FRONTAL MAXFEE DEF 26       5.73 1/1/2018 12/31/2299 N
71010 CHEST X-RAY 1 VIEW FRONTAL MAXFEE DEF TC       13.37 1/1/2018 12/31/2299 N
71015 CHEST X-RAY STEREO FRONTAL PRXOVR DEF         NA NA NA N
71015 CHEST X-RAY STEREO FRONTAL MAXFEE DEF         22.20 1/1/2018 12/31/2299 N
71015 CHEST X-RAY STEREO FRONTAL MAXFEE DEF 26       6.66 1/1/2018 12/31/2299 N
71015 CHEST X-RAY STEREO FRONTAL MAXFEE DEF TC       15.54 1/1/2018 12/31/2299 N
71020 CHEST X-RAY 2VW FRONTAL&LATL PRXOVR DEF         NA NA NA N
71020 CHEST X-RAY 2VW FRONTAL&LATL MAXFEE DEF         24.41 1/1/2018 12/31/2299 N
71020 CHEST X-RAY 2VW FRONTAL&LATL MAXFEE DEF 26       8.54 1/1/2018 12/31/2299 N
71020 CHEST X-RAY 2VW FRONTAL&LATL MAXFEE DEF TC       15.87 1/1/2018 12/31/2299 N
71021 CHEST X-RAY FRNT LAT LORDOTC PRXOVR DEF         NA NA NA N
71021 CHEST X-RAY FRNT LAT LORDOTC MAXFEE DEF         30.38 1/1/2018 12/31/2299 N
71021 CHEST X-RAY FRNT LAT LORDOTC MAXFEE DEF 26       10.63 1/1/2018 12/31/2299 N
71021 CHEST X-RAY FRNT LAT LORDOTC MAXFEE DEF TC       19.75 1/1/2018 12/31/2299 N
71022 CHEST X-RAY FRNT LAT OBLIQUE PRXOVR DEF         NA NA NA N
71022 CHEST X-RAY FRNT LAT OBLIQUE MAXFEE DEF         31.86 1/1/2018 12/31/2299 N
71022 CHEST X-RAY FRNT LAT OBLIQUE MAXFEE DEF 26       9.56 1/1/2018 12/31/2299 N
71022 CHEST X-RAY FRNT LAT OBLIQUE MAXFEE DEF TC       22.30 1/1/2018 12/31/2299 N
71023 CHEST X-RAY AND FLUOROSCOPY PRXOVR DEF         NA NA NA N
71023 CHEST X-RAY AND FLUOROSCOPY MAXFEE DEF         35.86 1/1/2018 12/31/2299 N
71023 CHEST X-RAY AND FLUOROSCOPY MAXFEE DEF 26       10.76 1/1/2018 12/31/2299 N
71023 CHEST X-RAY AND FLUOROSCOPY MAXFEE DEF TC       25.10 1/1/2018 12/31/2299 N
71030 CHEST X-RAY 4/> VIEWS PRXOVR DEF         NA NA NA N
71030 CHEST X-RAY 4/> VIEWS MAXFEE DEF         33.22 1/1/2018 12/31/2299 N
71030 CHEST X-RAY 4/> VIEWS MAXFEE DEF 26       9.97 1/1/2018 12/31/2299 N
71030 CHEST X-RAY 4/> VIEWS MAXFEE DEF TC       23.25 1/1/2018 12/31/2299 N
71034 CHEST X-RAY&FLUORO 4/> VIEWS PRXOVR DEF         NA NA NA N
71034 CHEST X-RAY&FLUORO 4/> VIEWS MAXFEE DEF         56.65 1/1/2018 12/31/2299 N
71034 CHEST X-RAY&FLUORO 4/> VIEWS MAXFEE DEF 26       19.83 1/1/2018 12/31/2299 N
71034 CHEST X-RAY&FLUORO 4/> VIEWS MAXFEE DEF TC       36.82 1/1/2018 12/31/2299 N
71035 CHEST X-RAY SPECIAL VIEWS PRXOVR DEF         NA NA NA N
71035 CHEST X-RAY SPECIAL VIEWS MAXFEE DEF         20.99 1/1/2018 12/31/2299 N
71035 CHEST X-RAY SPECIAL VIEWS MAXFEE DEF 26       7.35 1/1/2018 12/31/2299 N
71035 CHEST X-RAY SPECIAL VIEWS MAXFEE DEF TC       13.64 1/1/2018 12/31/2299 N
71036 X-RAY GUIDANCE FOR BIOPSY PRXOVR DEF         NA NA NA N
71036 X-RAY GUIDANCE FOR BIOPSY MAXFEE DEF         NA     N
71040 CONTRAST X-RAY OF BRONCHI PRXOVR DEF         NA NA NA N
71040 CONTRAST X-RAY OF BRONCHI MAXFEE DEF         NA     N
71060 CONTRAST X-RAY OF BRONCHI PRXOVR DEF         NA NA NA N
71060 CONTRAST X-RAY OF BRONCHI MAXFEE DEF         NA     N
71090 X-RAY & PACEMAKER INSERTION PRXOVR DEF         NA NA NA N
71090 X-RAY & PACEMAKER INSERTION MAXFEE DEF         NA     N
74000 X-RAY EXAM OF ABDOMEN PRXOVR DEF         NA NA NA N
74000 X-RAY EXAM OF ABDOMEN MAXFEE DEF         20.35 1/1/2018 12/31/2299 N
74000 X-RAY EXAM OF ABDOMEN MAXFEE DEF 26       7.12 1/1/2018 12/31/2299 N
74000 X-RAY EXAM OF ABDOMEN MAXFEE DEF TC       13.23 1/1/2018 12/31/2299 N
74010 X-RAY EXAM OF ABDOMEN PRXOVR DEF         NA NA NA N
74010 X-RAY EXAM OF ABDOMEN MAXFEE DEF TC       14.79 1/1/2018 12/31/2299 N
74010 X-RAY EXAM OF ABDOMEN MAXFEE DEF         24.65 1/1/2018 12/31/2299 N
74010 X-RAY EXAM OF ABDOMEN MAXFEE DEF 26       9.86 1/1/2018 12/31/2299 N
74020 X-RAY EXAM OF ABDOMEN PRXOVR DEF         NA NA NA N
74020 X-RAY EXAM OF ABDOMEN MAXFEE DEF         26.55 1/1/2018 12/31/2299 N
74020 X-RAY EXAM OF ABDOMEN MAXFEE DEF 26       10.62 1/1/2018 12/31/2299 N
74020 X-RAY EXAM OF ABDOMEN MAXFEE DEF TC       15.93 1/1/2018 12/31/2299 N
74221 X-RAY XM ESOPHAGUS 2CNTRST PRXOVR DEF         NA NA NA N
74221 X-RAY XM ESOPHAGUS 2CNTRST MAXFEE DEF         86.67 1/1/2024 12/31/2299 N
74221 X-RAY XM ESOPHAGUS 2CNTRST MAXFEE DEF TC       56.34 1/1/2024 12/31/2299 N
74221 X-RAY XM ESOPHAGUS 2CNTRST MAXFEE DEF 26       30.33 1/1/2024 12/31/2299 N
74248 X-RAY SM INT F-THRU STD PRXOVR DEF         NA NA NA N
74248 X-RAY SM INT F-THRU STD MAXFEE DEF         66.10 1/1/2024 12/31/2299 N
74248 X-RAY SM INT F-THRU STD MAXFEE DEF TC       39.66 1/1/2024 12/31/2299 N
74248 X-RAY SM INT F-THRU STD MAXFEE DEF 26       26.44 1/1/2024 12/31/2299 N
75552 HEART MRI FOR MORPH W/O DYE PRXOVR DEF         NA NA NA N
75552 HEART MRI FOR MORPH W/O DYE MAXFEE DEF         NA     N
75553 HEART MRI FOR MORPH W/DYE PRXOVR DEF         NA NA NA N
75553 HEART MRI FOR MORPH W/DYE MAXFEE DEF         NA     N
75554 CARDIAC MRI/FUNCTION PRXOVR DEF         NA NA NA N
75554 CARDIAC MRI/FUNCTION MAXFEE DEF         NA     N
75555 CARDIAC MRI/LIMITED STUDY PRXOVR DEF         NA NA NA N
75555 CARDIAC MRI/LIMITED STUDY MAXFEE DEF         NA     N
75942 LLIAC ANEURYSM ENDOVAS RPR PRXOVR DEF         NA NA NA N
75942 LLIAC ANEURYSM ENDOVAS RPR MAXFEE DEF         NA     N
75952 ENDOVASC REPAIR ABDOM AORTA PRXOVR DEF         NA NA NA N
75952 ENDOVASC REPAIR ABDOM AORTA MAXFEE DEF         193.37 1/1/2018 12/31/2299 N
75952 ENDOVASC REPAIR ABDOM AORTA MAXFEE DEF 26       174.03 1/1/2018 12/31/2299 N
75952 ENDOVASC REPAIR ABDOM AORTA MAXFEE DEF TC       19.34 1/1/2018 12/31/2299 N
75953 ABDOM ANEURYSM ENDOVAS RPR PRXOVR DEF         NA NA NA N
75953 ABDOM ANEURYSM ENDOVAS RPR MAXFEE DEF         193.37 1/1/2018 12/31/2299 N
75953 ABDOM ANEURYSM ENDOVAS RPR MAXFEE DEF 26       48.34 1/1/2018 12/31/2299 N
75953 ABDOM ANEURYSM ENDOVAS RPR MAXFEE DEF TC       145.03 1/1/2018 12/31/2299 N
75954 ILIAC ANEURYSM ENDOVAS RPR PRXOVR DEF         NA NA NA N
75954 ILIAC ANEURYSM ENDOVAS RPR MAXFEE DEF         322.05 1/1/2018 12/31/2299 N
75954 ILIAC ANEURYSM ENDOVAS RPR MAXFEE DEF 26       64.41 1/1/2018 12/31/2299 N
75954 ILIAC ANEURYSM ENDOVAS RPR MAXFEE DEF TC       257.64 1/1/2018 12/31/2299 N
75989 ABSCESS DRAINAGE UNDER X-RAY PRXOVR DEF         NA NA NA N
75989 ABSCESS DRAINAGE UNDER X-RAY MAXFEE DEF         103.25 1/1/2018 12/31/2299 N
75989 ABSCESS DRAINAGE UNDER X-RAY MAXFEE DEF 26       41.30 1/1/2018 12/31/2299 N
75989 ABSCESS DRAINAGE UNDER X-RAY MAXFEE DEF TC       61.95 1/1/2018 12/31/2299 N
75998 FLUOROGUIDE FOR VEIN DEVICE PRXOVR DEF         NA NA NA N
75998 FLUOROGUIDE FOR VEIN DEVICE MAXFEE DEF         NA     N
76003 NEEDLE LOCALIZATION BY X-RAY PRXOVR DEF         NA NA NA N
76003 NEEDLE LOCALIZATION BY X-RAY MAXFEE DEF         NA     N
76005 FLUOROGUIDE FOR SPINE INJECT PRXOVR DEF         NA NA NA N
76005 FLUOROGUIDE FOR SPINE INJECT MAXFEE DEF         NA     N
76006 X-RAY STRESS VIEW PRXOVR DEF         NA NA NA N
76006 X-RAY STRESS VIEW MAXFEE DEF         NA     N
76012 PERCUT VERTEBROPLASTY FLUOR PRXOVR DEF         NA NA NA N
76012 PERCUT VERTEBROPLASTY FLUOR MAXFEE DEF         NA     N
76013 PERCUT VERTEBROPLASTY; CT PRXOVR DEF         NA NA NA N
76013 PERCUT VERTEBROPLASTY; CT MAXFEE DEF         NA     N
76020 X-RAYS FOR BONE AGE PRXOVR DEF         NA NA NA N
76020 X-RAYS FOR BONE AGE MAXFEE DEF         NA     N
76040 X-RAYS; BONE EVALUATION PRXOVR DEF         NA NA NA N
76040 X-RAYS; BONE EVALUATION MAXFEE DEF         NA     N
76061 X-RAYS; BONE SURVEY PRXOVR DEF         NA NA NA N
76061 X-RAYS; BONE SURVEY MAXFEE DEF         NA     N
76062 X-RAYS; BONE SURVEY PRXOVR DEF         NA NA NA N
76062 X-RAYS; BONE SURVEY MAXFEE DEF         NA     N
76065 X-RAYS; BONE EVALUATION PRXOVR DEF         NA NA NA N
76065 X-RAYS; BONE EVALUATION MAXFEE DEF         NA     N
76066 JOINT SURVEY; SINGLE VIEW PRXOVR DEF         NA NA NA N
76066 JOINT SURVEY; SINGLE VIEW MAXFEE DEF         NA     N
76070 CT BONE DENSITY; AXIAL PRXOVR DEF         NA NA NA N
76070 CT BONE DENSITY; AXIAL MAXFEE DEF         NA     N
76075 DXA BONE DENSITY; AXIAL PRXOVR DEF         NA NA NA N
76075 DXA BONE DENSITY; AXIAL MAXFEE DEF         NA     N
76076 DXA BONE DENSITY/PERIPHERAL PRXOVR DEF         NA NA NA N
76076 DXA BONE DENSITY/PERIPHERAL MAXFEE DEF         NA     N
76077 DXA BONE DENSITY/V-FRACTURE PRXOVR DEF         NA NA NA N
76077 DXA BONE DENSITY/V-FRACTURE MAXFEE DEF         NA     N
76078 RADIOGRAPHIC ABSORPTIOMETRY PRXOVR DEF         NA NA NA N
76078 RADIOGRAPHIC ABSORPTIOMETRY MAXFEE DEF         NA     N
76080 X-RAY EXAM OF FISTULA PRXOVR DEF         NA NA NA N
76080 X-RAY EXAM OF FISTULA MAXFEE DEF         49.22 1/1/2018 12/31/2299 N
76080 X-RAY EXAM OF FISTULA MAXFEE DEF 26       19.69 1/1/2018 12/31/2299 N
76080 X-RAY EXAM OF FISTULA MAXFEE DEF TC       29.53 1/1/2018 12/31/2299 N
76082 COMPUTER MAMMOGRAM ADD-ON PRXOVR DEF         NA NA NA N
76082 COMPUTER MAMMOGRAM ADD-ON MAXFEE DEF         NA     N
76083 COMPUTER MAMMOGRAM ADD-ON PRXOVR DEF         NA NA NA N
76083 COMPUTER MAMMOGRAM ADD-ON MAXFEE DEF         NA     N
76085 COMPUTER MAMMOGRAM ADD-ON PRXOVR DEF         NA NA NA N
76085 COMPUTER MAMMOGRAM ADD-ON MAXFEE DEF         NA     N
76086 X-RAY OF MAMMARY DUCT PRXOVR DEF         NA NA NA N
76086 X-RAY OF MAMMARY DUCT MAXFEE DEF         NA     N
76088 X-RAY OF MAMMARY DUCTS PRXOVR DEF         NA NA NA N
76088 X-RAY OF MAMMARY DUCTS MAXFEE DEF         NA     N
76090 MAMMOGRAM; ONE BREAST PRXOVR DEF         NA NA NA N
76090 MAMMOGRAM; ONE BREAST MAXFEE DEF         NA     N
76091 MAMMOGRAM; BOTH BREASTS PRXOVR DEF         NA NA NA N
76091 MAMMOGRAM; BOTH BREASTS MAXFEE DEF         NA     N
76092 MAMMOGRAM; SCREENING PRXOVR DEF         NA NA NA N
76092 MAMMOGRAM; SCREENING MAXFEE DEF         NA     N
76093 MAGNETIC IMAGE; BREAST PRXOVR DEF         NA NA NA N
76093 MAGNETIC IMAGE; BREAST MAXFEE DEF         NA     N
76094 MAGNETIC IMAGE; BOTH BREASTS PRXOVR DEF         NA NA NA N
76094 MAGNETIC IMAGE; BOTH BREASTS MAXFEE DEF         NA     N
76095 STEREOTACTIC BREAST BIOPSY PRXOVR DEF         NA NA NA N
76095 STEREOTACTIC BREAST BIOPSY MAXFEE DEF         NA     N
76096 X-RAY OF NEEDLE WIRE; BREAST PRXOVR DEF         NA NA NA N
76096 X-RAY OF NEEDLE WIRE; BREAST MAXFEE DEF         NA     N
76100 X-RAY EXAM OF BODY SECTION PRXOVR DEF         NA NA NA N
76100 X-RAY EXAM OF BODY SECTION MAXFEE DEF         65.24 1/1/2024 12/31/2299 N
76100 X-RAY EXAM OF BODY SECTION MAXFEE DEF TC       45.67 1/1/2024 12/31/2299 N
76100 X-RAY EXAM OF BODY SECTION MAXFEE DEF 26       19.57 1/1/2024 12/31/2299 N
88300 SURGICAL PATH GROSS PRXOVR DEF         NA NA NA N
88300 SURGICAL PATH GROSS MAXFEE DEF         11.84 4/1/2019 12/31/2299 N
88300 SURGICAL PATH GROSS MAXFEE DEF TC       8.45 4/1/2019 12/31/2299 N
88300 SURGICAL PATH GROSS MAXFEE DEF 26       3.40 4/1/2019 12/31/2299 N
88302 TISSUE EXAM BY PATHOLOGIST PRXOVR DEF         NA NA NA N
88302 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF         22.10 4/1/2019 12/31/2299 N
88302 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF TC       16.61 4/1/2019 12/31/2299 N
88302 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF 26       5.48 4/1/2019 12/31/2299 N
88304 TISSUE EXAM BY PATHOLOGIST PRXOVR DEF         NA NA NA N
88304 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF         29.21 4/1/2019 12/31/2299 N
88304 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF TC       20.33 4/1/2019 12/31/2299 N
88304 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF 26       8.87 4/1/2019 12/31/2299 N
88305 TISSUE EXAM BY PATHOLOGIST PRXOVR DEF         NA NA NA N
88305 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF         49.83 4/1/2019 12/31/2299 N
88305 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF TC       20.82 4/1/2019 12/31/2299 N
88305 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF 26       29.01 4/1/2019 12/31/2299 N
88307 TISSUE EXAM BY PATHOLOGIST PRXOVR DEF         NA NA NA N
88307 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF         188.97 4/1/2019 12/31/2299 N
88307 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF TC       125.33 4/1/2019 12/31/2299 N
88307 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF 26       63.64 4/1/2019 12/31/2299 N
88309 TISSUE EXAM BY PATHOLOGIST PRXOVR DEF         NA NA NA N
88309 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF         287.76 4/1/2019 12/31/2299 N
88309 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF TC       174.87 4/1/2019 12/31/2299 N
88309 TISSUE EXAM BY PATHOLOGIST MAXFEE DEF 26       112.89 4/1/2019 12/31/2299 N
88311 DECALCIFY TISSUE PRXOVR DEF         NA NA NA N
88311 DECALCIFY TISSUE MAXFEE DEF         16.12 4/1/2019 12/31/2299 N
88311 DECALCIFY TISSUE MAXFEE DEF TC       6.46 4/1/2019 12/31/2299 N
88311 DECALCIFY TISSUE MAXFEE DEF 26       9.66 4/1/2019 12/31/2299 N
88312 SPECIAL STAINS GROUP 1 PRXOVR DEF         NA NA NA N
88312 SPECIAL STAINS GROUP 1 MAXFEE DEF         69.44 4/1/2019 12/31/2299 N
88312 SPECIAL STAINS GROUP 1 MAXFEE DEF TC       49.04 4/1/2019 12/31/2299 N
88312 SPECIAL STAINS GROUP 1 MAXFEE DEF 26       20.40 4/1/2019 12/31/2299 N
88313 SPECIAL STAINS GROUP 2 PRXOVR DEF         NA NA NA N
88313 SPECIAL STAINS GROUP 2 MAXFEE DEF         50.04 4/1/2019 12/31/2299 N
88313 SPECIAL STAINS GROUP 2 MAXFEE DEF TC       40.88 4/1/2019 12/31/2299 N
88313 SPECIAL STAINS GROUP 2 MAXFEE DEF 26       9.17 4/1/2019 12/31/2299 N
88314 HISTOCHEMICAL STAINS ADD-ON PRXOVR DEF         NA NA NA N
88314 HISTOCHEMICAL STAINS ADD-ON MAXFEE DEF         60.85 4/1/2019 12/31/2299 N
88314 HISTOCHEMICAL STAINS ADD-ON MAXFEE DEF TC       43.60 4/1/2019 12/31/2299 N
88314 HISTOCHEMICAL STAINS ADD-ON MAXFEE DEF 26       17.25 4/1/2019 12/31/2299 N
88318 CHEMICAL HISTOCHEMISTRY PRXOVR DEF         NA NA NA N
88318 CHEMICAL HISTOCHEMISTRY MAXFEE DEF         NA     N
88319 ENZYME HISTOCHEMISTRY PRXOVR DEF         NA NA NA N
88319 ENZYME HISTOCHEMISTRY MAXFEE DEF         62.99 4/1/2019 12/31/2299 N
88319 ENZYME HISTOCHEMISTRY MAXFEE DEF TC       42.61 4/1/2019 12/31/2299 N
88319 ENZYME HISTOCHEMISTRY MAXFEE DEF 26       20.38 4/1/2019 12/31/2299 N
88321 CONSLTJ&REPRT SLD PREP ELSWR PRXOVR DEF         NA NA NA N
88321 CONSLTJ&REPRT SLD PREP ELSWR MAXFEE FAC         64.07 4/1/2019 12/31/2299 N
88321 CONSLTJ&REPRT SLD PREP ELSWR MAXFEE NFF         75.70 4/1/2019 12/31/2299 N
88323 CONSLTJ&REPRT MATRL PREP SLD PRXOVR DEF         NA NA NA N
88323 CONSLTJ&REPRT MATRL PREP SLD MAXFEE DEF         89.62 4/1/2019 12/31/2299 N
88323 CONSLTJ&REPRT MATRL PREP SLD MAXFEE DEF TC       23.05 4/1/2019 12/31/2299 N
88323 CONSLTJ&REPRT MATRL PREP SLD MAXFEE DEF 26       66.56 4/1/2019 12/31/2299 N
88325 CONSLTJ COMPRE RVW REC REPRT PRXOVR DEF         NA NA NA N
88325 CONSLTJ COMPRE RVW REC REPRT MAXFEE FAC         114.14 4/1/2019 12/31/2299 N
88325 CONSLTJ COMPRE RVW REC REPRT MAXFEE NFF         136.43 4/1/2019 12/31/2299 N
88329 PATH CONSLTJ DRG SURG PRXOVR DEF         NA NA NA N
88329 PATH CONSLTJ DRG SURG MAXFEE FAC         27.66 4/1/2019 12/31/2299 N
88329 PATH CONSLTJ DRG SURG MAXFEE NFF         38.06 4/1/2019 12/31/2299 N
88331 PATH CONSLTJ SURG 1 BLK 1SPC PRXOVR DEF         NA NA NA N
88331 PATH CONSLTJ SURG 1 BLK 1SPC MAXFEE DEF         71.03 4/1/2019 12/31/2299 N
88331 PATH CONSLTJ SURG 1 BLK 1SPC MAXFEE DEF TC       22.80 4/1/2019 12/31/2299 N
88331 PATH CONSLTJ SURG 1 BLK 1SPC MAXFEE DEF 26       48.22 4/1/2019 12/31/2299 N
88332 PATH CONSLTJ SURG EA ADD BLK PRXOVR DEF         NA NA NA N
88332 PATH CONSLTJ SURG EA ADD BLK MAXFEE DEF         38.60 4/1/2019 12/31/2299 N
88332 PATH CONSLTJ SURG EA ADD BLK MAXFEE DEF TC       14.88 4/1/2019 12/31/2299 N
88332 PATH CONSLTJ SURG EA ADD BLK MAXFEE DEF 26       23.72 4/1/2019 12/31/2299 N
88333 PATH CONSLTJ SURG CYTO XM 1 PRXOVR DEF         NA NA NA N
88333 PATH CONSLTJ SURG CYTO XM 1 MAXFEE DEF         65.60 4/1/2019 12/31/2299 N
88333 PATH CONSLTJ SURG CYTO XM 1 MAXFEE DEF TC       17.36 4/1/2019 12/31/2299 N
88333 PATH CONSLTJ SURG CYTO XM 1 MAXFEE DEF 26       48.24 4/1/2019 12/31/2299 N
88334 PATH CONSLTJ SURG CYTO XM EA PRXOVR DEF         NA NA NA N
88334 PATH CONSLTJ SURG CYTO XM EA MAXFEE DEF         40.61 4/1/2019 12/31/2299 N
88334 PATH CONSLTJ SURG CYTO XM EA MAXFEE DEF TC       11.15 4/1/2019 12/31/2299 N
88334 PATH CONSLTJ SURG CYTO XM EA MAXFEE DEF 26       29.46 4/1/2019 12/31/2299 N
88341 IMHCHEM/IMCYTCHM EA ADD ANTB PRXOVR DEF         NA NA NA N
88341 IMHCHEM/IMCYTCHM EA ADD ANTB MAXFEE DEF         66.24 4/1/2019 12/31/2299 N
88341 IMHCHEM/IMCYTCHM EA ADD ANTB MAXFEE DEF TC       44.57 4/1/2019 12/31/2299 N
88341 IMHCHEM/IMCYTCHM EA ADD ANTB MAXFEE DEF 26       21.68 4/1/2019 12/31/2299 N
88342 IMHCHEM/IMCYTCHM 1ST ANTB PRXOVR DEF         NA NA NA N
88342 IMHCHEM/IMCYTCHM 1ST ANTB MAXFEE DEF         78.20 4/1/2019 12/31/2299 N
88342 IMHCHEM/IMCYTCHM 1ST ANTB MAXFEE DEF TC       51.03 4/1/2019 12/31/2299 N
88342 IMHCHEM/IMCYTCHM 1ST ANTB MAXFEE DEF 26       27.18 4/1/2019 12/31/2299 N
88343 IMMUNOHISTO ANTIBOD ADD SLID PRXOVR DEF         NA NA NA N
88343 IMMUNOHISTO ANTIBOD ADD SLID MAXFEE DEF         NA     N
88344 IMHCHEM/IMCYTCHM EA MLT ANTB PRXOVR DEF         NA NA NA N
88344 IMHCHEM/IMCYTCHM EA MLT ANTB MAXFEE DEF         124.40 4/1/2019 12/31/2299 N
88344 IMHCHEM/IMCYTCHM EA MLT ANTB MAXFEE DEF TC       94.61 4/1/2019 12/31/2299 N
88344 IMHCHEM/IMCYTCHM EA MLT ANTB MAXFEE DEF 26       29.79 4/1/2019 12/31/2299 N
88346 IMFLUOR 1ST 1ANTB STAIN PX PRXOVR DEF         NA NA NA N
88346 IMFLUOR 1ST 1ANTB STAIN PX MAXFEE DEF         67.37 4/1/2019 12/31/2299 N
88346 IMFLUOR 1ST 1ANTB STAIN PX MAXFEE DEF TC       39.89 4/1/2019 12/31/2299 N
88346 IMFLUOR 1ST 1ANTB STAIN PX MAXFEE DEF 26       27.48 4/1/2019 12/31/2299 N
88347 IMMUNOFLUORESCENT STUDY PRXOVR DEF         NA NA NA N
88347 IMMUNOFLUORESCENT STUDY MAXFEE DEF         NA     N
88348 ELECTRON MICROSCOPY DX PRXOVR DEF         NA NA NA N
88348 ELECTRON MICROSCOPY DX MAXFEE DEF         246.80 4/1/2019 12/31/2299 N
88348 ELECTRON MICROSCOPY DX MAXFEE DEF TC       188.78 4/1/2019 12/31/2299 N
88348 ELECTRON MICROSCOPY DX MAXFEE DEF 26       58.01 4/1/2019 12/31/2299 N
88349 SCANNING ELECTRON MICROSCOPY PRXOVR DEF         NA NA NA N
88349 SCANNING ELECTRON MICROSCOPY MAXFEE DEF         NA     N
88350 IMFLUOR EA ADDL 1ANTB STN PX PRXOVR DEF         NA NA NA N
88350 IMFLUOR EA ADDL 1ANTB STN PX MAXFEE DEF         51.95 4/1/2019 12/31/2299 N
88350 IMFLUOR EA ADDL 1ANTB STN PX MAXFEE DEF TC       29.96 4/1/2019 12/31/2299 N
88350 IMFLUOR EA ADDL 1ANTB STN PX MAXFEE DEF 26       21.98 4/1/2019 12/31/2299 N
88355 M/PHMTRC ALYS SKELETAL MUSC PRXOVR DEF         NA NA NA N
88355 M/PHMTRC ALYS SKELETAL MUSC MAXFEE DEF         96.05 4/1/2019 12/31/2299 N
88355 M/PHMTRC ALYS SKELETAL MUSC MAXFEE DEF TC       33.45 4/1/2019 12/31/2299 N
88355 M/PHMTRC ALYS SKELETAL MUSC MAXFEE DEF 26       62.60 4/1/2019 12/31/2299 N
88356 ANALYSIS NERVE PRXOVR DEF         NA NA NA N
88356 ANALYSIS NERVE MAXFEE DEF         160.70 4/1/2019 12/31/2299 N
88356 ANALYSIS NERVE MAXFEE DEF TC       65.93 4/1/2019 12/31/2299 N
88356 ANALYSIS NERVE MAXFEE DEF 26       94.77 4/1/2019 12/31/2299 N
88358 ANALYSIS TUMOR PRXOVR DEF         NA NA NA N
88358 ANALYSIS TUMOR MAXFEE DEF         68.54 4/1/2019 12/31/2299 N
88358 ANALYSIS TUMOR MAXFEE DEF TC       32.96 4/1/2019 12/31/2299 N
88358 ANALYSIS TUMOR MAXFEE DEF 26       35.60 4/1/2019 12/31/2299 N
88360 TUMOR IMMUNOHISTOCHEM/MANUAL PRXOVR DEF         NA NA NA N
88360 TUMOR IMMUNOHISTOCHEM/MANUAL MAXFEE DEF         95.58 4/1/2019 12/31/2299 N
88360 TUMOR IMMUNOHISTOCHEM/MANUAL MAXFEE DEF TC       61.67 4/1/2019 12/31/2299 N
88360 TUMOR IMMUNOHISTOCHEM/MANUAL MAXFEE DEF 26       33.91 4/1/2019 12/31/2299 N
88361 TUMOR IMMUNOHISTOCHEM/COMPUT PRXOVR DEF         NA NA NA N
88361 TUMOR IMMUNOHISTOCHEM/COMPUT MAXFEE DEF         103.95 4/1/2019 12/31/2299 N
88361 TUMOR IMMUNOHISTOCHEM/COMPUT MAXFEE DEF TC       67.86 4/1/2019 12/31/2299 N
88361 TUMOR IMMUNOHISTOCHEM/COMPUT MAXFEE DEF 26       36.09 4/1/2019 12/31/2299 N
88362 NERVE TEASING PREPARATIONS PRXOVR DEF         NA NA NA N
88362 NERVE TEASING PREPARATIONS MAXFEE DEF         151.31 4/1/2019 12/31/2299 N
88362 NERVE TEASING PREPARATIONS MAXFEE DEF TC       67.14 4/1/2019 12/31/2299 N
88362 NERVE TEASING PREPARATIONS MAXFEE DEF 26       84.17 4/1/2019 12/31/2299 N
88363 XM ARCHIVE TISSUE MOLEC ANAL PRXOVR DEF         NA NA NA N
88363 XM ARCHIVE TISSUE MOLEC ANAL MAXFEE FAC         15.14 4/1/2019 12/31/2299 N
88363 XM ARCHIVE TISSUE MOLEC ANAL MAXFEE NFF         17.61 4/1/2019 12/31/2299 N
88364 INSITU HYBRIDIZATION (FISH) PRXOVR DEF         NA NA NA N
88364 INSITU HYBRIDIZATION (FISH) MAXFEE DEF         94.30 4/1/2019 12/31/2299 N
88364 INSITU HYBRIDIZATION (FISH) MAXFEE DEF TC       67.61 4/1/2019 12/31/2299 N
88364 INSITU HYBRIDIZATION (FISH) MAXFEE DEF 26       26.68 4/1/2019 12/31/2299 N
88365 INSITU HYBRIDIZATION (FISH) PRXOVR DEF         NA NA NA N
88365 INSITU HYBRIDIZATION (FISH) MAXFEE DEF         128.08 4/1/2019 12/31/2299 N
88365 INSITU HYBRIDIZATION (FISH) MAXFEE DEF TC       94.36 4/1/2019 12/31/2299 N
88365 INSITU HYBRIDIZATION (FISH) MAXFEE DEF 26       33.72 4/1/2019 12/31/2299 N
88366 INSITU HYBRIDIZATION (FISH) PRXOVR DEF         NA NA NA N
88366 INSITU HYBRIDIZATION (FISH) MAXFEE DEF         186.99 4/1/2019 12/31/2299 N
88366 INSITU HYBRIDIZATION (FISH) MAXFEE DEF TC       139.42 4/1/2019 12/31/2299 N
88366 INSITU HYBRIDIZATION (FISH) MAXFEE DEF 26       47.57 4/1/2019 12/31/2299 N
88367 INSITU HYBRIDIZATION AUTO PRXOVR DEF         NA NA NA N
88367 INSITU HYBRIDIZATION AUTO MAXFEE DEF         76.76 4/1/2019 12/31/2299 N
88367 INSITU HYBRIDIZATION AUTO MAXFEE DEF TC       50.29 4/1/2019 12/31/2299 N
88367 INSITU HYBRIDIZATION AUTO MAXFEE DEF 26       26.47 4/1/2019 12/31/2299 N
88368 INSITU HYBRIDIZATION MANUAL PRXOVR DEF         NA NA NA N
88368 INSITU HYBRIDIZATION MANUAL MAXFEE DEF         86.73 4/1/2019 12/31/2299 N
88368 INSITU HYBRIDIZATION MANUAL MAXFEE DEF TC       54.99 4/1/2019 12/31/2299 N
88368 INSITU HYBRIDIZATION MANUAL MAXFEE DEF 26       31.74 4/1/2019 12/31/2299 N
88369 M/PHMTRC ALYSISHQUANT/SEMIQ PRXOVR DEF         NA NA NA N
88369 M/PHMTRC ALYSISHQUANT/SEMIQ MAXFEE DEF         78.18 4/1/2019 12/31/2299 N
88369 M/PHMTRC ALYSISHQUANT/SEMIQ MAXFEE DEF TC       53.51 4/1/2019 12/31/2299 N
88369 M/PHMTRC ALYSISHQUANT/SEMIQ MAXFEE DEF 26       24.68 4/1/2019 12/31/2299 N
88371 PROTEIN WESTERN BLOT TISSUE PRXOVR DEF         NA NA NA N
88371 PROTEIN WESTERN BLOT TISSUE MAXFEE DEF 26       14.93 1/1/2021 12/31/2299 N
88371 PROTEIN WESTERN BLOT TISSUE MAXFEE DEF         16.67 4/1/2021 12/31/2299 N
88372 PROTEIN ANALYSIS W/PROBE PRXOVR DEF         NA NA NA N
88372 PROTEIN ANALYSIS W/PROBE MAXFEE DEF         19.67 4/1/2019 12/31/2299 N
88372 PROTEIN ANALYSIS W/PROBE MAXFEE DEF 26       13.63 4/1/2019 12/31/2299 N
88373 M/PHMTRC ALYS ISHQUANT/SEMIQ PRXOVR DEF         NA NA NA N
88373 M/PHMTRC ALYS ISHQUANT/SEMIQ MAXFEE DEF         56.38 4/1/2019 12/31/2299 N
88373 M/PHMTRC ALYS ISHQUANT/SEMIQ MAXFEE DEF TC       35.41 4/1/2019 12/31/2299 N
88373 M/PHMTRC ALYS ISHQUANT/SEMIQ MAXFEE DEF 26       20.98 4/1/2019 12/31/2299 N
88374 M/PHMTRC ALYS ISHQUANT/SEMIQ PRXOVR DEF         NA NA NA N
88374 M/PHMTRC ALYS ISHQUANT/SEMIQ MAXFEE DEF         243.53 4/1/2019 12/31/2299 N
88374 M/PHMTRC ALYS ISHQUANT/SEMIQ MAXFEE DEF TC       209.98 4/1/2019 12/31/2299 N
88374 M/PHMTRC ALYS ISHQUANT/SEMIQ MAXFEE DEF 26       33.55 4/1/2019 12/31/2299 N
88375 OPTICAL ENDOMICROSCPY INTERP PRXOVR DEF         NA NA NA N
88375 OPTICAL ENDOMICROSCPY INTERP MANUAL DEF         NA NA NA N
88377 M/PHMTRC ALYS ISHQUANT/SEMIQ PRXOVR DEF         NA NA NA N
88377 M/PHMTRC ALYS ISHQUANT/SEMIQ MAXFEE DEF         290.06 4/1/2019 12/31/2299 N
88377 M/PHMTRC ALYS ISHQUANT/SEMIQ MAXFEE DEF TC       241.20 4/1/2019 12/31/2299 N
88377 M/PHMTRC ALYS ISHQUANT/SEMIQ MAXFEE DEF 26       48.86 4/1/2019 12/31/2299 N
88380 MICRODISSECTION LASER PRXOVR DEF         NA NA NA N
88380 MICRODISSECTION LASER MAXFEE DEF         98.66 4/1/2019 12/31/2299 N
88380 MICRODISSECTION LASER MAXFEE DEF TC       56.75 4/1/2019 12/31/2299 N
88380 MICRODISSECTION LASER MAXFEE DEF 26       41.91 4/1/2019 12/31/2299 N
88381 MICRODISSECTION MANUAL PRXOVR DEF         NA NA NA N
88381 MICRODISSECTION MANUAL MAXFEE DEF         87.03 4/1/2019 12/31/2299 N
88381 MICRODISSECTION MANUAL MAXFEE DEF TC       67.89 4/1/2019 12/31/2299 N
88381 MICRODISSECTION MANUAL MAXFEE DEF 26       19.14 4/1/2019 12/31/2299 N
88384 EVAL MOLECULAR PROBES 11-50 PRXOVR DEF         NA NA NA N
88384 EVAL MOLECULAR PROBES 11-50 MANUAL DEF         NA NA NA N
88385 EVAL MOLECUL PROBES 51-250 PRXOVR DEF         NA NA NA N
88385 EVAL MOLECUL PROBES 51-250 MAXFEE DEF         NA     N
88386 EVAL MOLECUL PROBES 251-500 PRXOVR DEF         NA NA NA N
88386 EVAL MOLECUL PROBES 251-500 MAXFEE DEF         NA     N
88387 TISS EXAM MOLECULAR STUDY PRXOVR DEF         NA NA NA N
88387 TISS EXAM MOLECULAR STUDY MAXFEE DEF         25.81 4/1/2019 12/31/2299 N
88387 TISS EXAM MOLECULAR STUDY MAXFEE DEF TC       4.23 4/1/2019 12/31/2299 N
88387 TISS EXAM MOLECULAR STUDY MAXFEE DEF 26       21.57 4/1/2019 12/31/2299 N
88388 TISS EX MOLECUL STUDY ADD-ON PRXOVR DEF         NA NA NA N
88388 TISS EX MOLECUL STUDY ADD-ON MAXFEE DEF         25.20 4/1/2019 12/31/2299 N
88388 TISS EX MOLECUL STUDY ADD-ON MAXFEE DEF TC       6.95 4/1/2019 12/31/2299 N
88388 TISS EX MOLECUL STUDY ADD-ON MAXFEE DEF 26       18.24 4/1/2019 12/31/2299 N
88399 UNLISTED SURGICAL PATH PX PRXOVR DEF         NA NA NA N
88399 UNLISTED SURGICAL PATH PX MANUAL DEF         NA NA NA N
90480 ADMN SARSCOV2 VACC 1 DOSE PRXOVR DEF         NA NA NA N
90480 ADMN SARSCOV2 VACC 1 DOSE MAXFEE DEF         39.94 9/11/2023 12/31/2299 N
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         148.20 10/1/2023 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
91318 SARSCOV2 VAC 3MCG TRS-SUC IM PRXOVR DEF         NA NA NA N
91318 SARSCOV2 VAC 3MCG TRS-SUC IM MAXFEE DEF         65.55 1/1/2024 12/31/2299 N
91319 SARSCV2 VAC 10MCG TRS-SUC IM PRXOVR DEF         NA NA NA N
91319 SARSCV2 VAC 10MCG TRS-SUC IM MAXFEE DEF         87.78 10/1/2023 12/31/2299 N
91320 SARSCV2 VAC 30MCG TRS-SUC IM PRXOVR DEF         NA NA NA N
91320 SARSCV2 VAC 30MCG TRS-SUC IM MAXFEE DEF         131.10 10/1/2023 12/31/2299 N
91321 SARSCOV2 VAC 25 MCG/.25ML IM PRXOVR DEF         NA NA NA N
91321 SARSCOV2 VAC 25 MCG/.25ML IM MAXFEE DEF         145.92 10/1/2023 12/31/2299 N
91322 SARSCOV2 VAC 50 MCG/0.5ML IM PRXOVR DEF         NA NA NA N
91322 SARSCOV2 VAC 50 MCG/0.5ML IM MAXFEE DEF         145.92 10/1/2023 12/31/2299 N
97810 ACUPUNCT W/O STIMUL 15 MIN PRXOVR DEF         NA NA NA S
97810 ACUPUNCT W/O STIMUL 15 MIN MAXFEE DEF         26.25 1/1/2024 12/31/2299 S
97811 ACUPUNCT W/O STIMUL ADDL 15M PRXOVR DEF         NA NA NA S
97811 ACUPUNCT W/O STIMUL ADDL 15M MAXFEE DEF         18.38 1/1/2024 12/31/2299 S
97813 ACUPUNCT W/STIMUL 15 MIN PRXOVR DEF         NA NA NA S
97813 ACUPUNCT W/STIMUL 15 MIN MAXFEE DEF         32.71 1/1/2024 12/31/2299 S
97814 ACUPUNCT W/STIMUL ADDL 15M PRXOVR DEF         NA NA NA S
97814 ACUPUNCT W/STIMUL ADDL 15M MAXFEE DEF         24.83 1/1/2024 12/31/2299 S
D0120 PERIODIC ORAL EVALUATION MAXFEE DEF         33.56 1/1/2024 12/31/2299 N
D0140 LIMIT ORAL EVAL PROBLM FOCUS MAXFEE DEF         43.15 1/1/2024 12/31/2299 N
D0150 COMPREHENSVE ORAL EVALUATION MAXFEE DEF         50.35 1/1/2024 12/31/2299 N
D0180 COMP PERIODONTAL EVALUATION MAXFEE DEF         50.35 1/1/2024 12/31/2299 Y S
D0210 INTRAOR COMPREHENSIVE SERIES MAXFEE DEF         117.90 1/1/2024 12/31/2299 S
D0220 INTRAORAL PERIAPICAL FIRST MAXFEE DEF         9.83 1/1/2024 12/31/2299 N
D0230 INTRAORAL PERIAPICAL EA ADD MAXFEE DEF         9.83 1/1/2024 12/31/2299 N
D0240 INTRAORAL OCCLUSAL FILM MAXFEE DEF         22.93 1/1/2024 12/31/2299 N
D0250 EXTRAORAL 2D PROJECT IMAGE MAXFEE DEF         14.81 1/1/2024 12/31/2299 N
D0270 DENTAL BITEWING SINGLE IMAGE MAXFEE DEF         5.50 1/1/2024 12/31/2299 N
D0272 DENTAL BITEWINGS TWO IMAGES MAXFEE DEF         19.65 1/1/2024 12/31/2299 S
D0273 BITEWINGS - THREE IMAGES MAXFEE DEF         28.09 1/1/2024 12/31/2299 S
D0274 BITEWINGS FOUR IMAGES MAXFEE DEF         39.30 1/1/2024 12/31/2299 S
D0321 OTHER TMJ IMAGES BY REPORT MAXFEE DEF         56.95 1/1/2024 12/31/2299 N
D0330 PANORAMIC IMAGE MAXFEE DEF         88.52 1/1/2024 12/31/2299 S
D0340 2D CEPHALOMETRIC IMAGE MAXFEE DEF         114.66 1/1/2024 12/31/2299 N
D0350 ORAL/FACIAL PHOTO IMAGES MAXFEE DEF         23.52 1/1/2024 12/31/2299 N
D0367 CONE BEAM CT INTERP BOTH JAW MAXFEE DEF         116.95 1/1/2024 12/31/2299 S
D0372 TOMO COMP SERIES IMAGES MANUAL DEF         NA NA NA N
D0373 TOMO BITEWING IMAGE MANUAL DEF         NA NA NA N
D0374 TOMO PERIAPICAL IMAGE MANUAL DEF         NA NA NA N
D0387 COMP IMAGE CAPTURE ONLY MANUAL DEF         NA NA NA N
D0388 BITEWING IMAGE CAPTURE ONLY MANUAL DEF         NA NA NA N
D0389 PERIOPIC IMAGE CAPTURE ONLY MANUAL DEF         NA NA NA N
D0396 3D PRINT OF 3D SURFACE SCAN MANUAL DEF         NA NA NA N
D0470 DIAGNOSTIC CASTS MAXFEE DEF         42.08 1/1/2024 12/31/2299 N
D0471 DIAGNOSTIC PHOTOGRAPHS MAXFEE DEF         NA     Y
D0604 ANTIGEN TEST PUB HLTH PATHOG MAXFEE DEF         39.51 1/1/2024 12/31/2299 N
D0605 ANTIBODY TEST PUB HLTH PATH MAXFEE DEF         49.75 1/1/2024 12/31/2299 N
D0606 MOLECULAR TEST PUB HLTH PATH MAXFEE DEF         39.51 1/1/2024 12/31/2299 N
D0801 3D DENTAL SCAN DIRECT MANUAL DEF         NA NA NA N
D0802 3D DENTAL SCAN INDIRECT MANUAL DEF         NA NA NA N
D0803 3D FACIAL SCAN DIRECT MANUAL DEF         NA NA NA N
D0804 3D FACIAL SCAN INDIRECT MANUAL DEF         NA NA NA N
D1110 DENTAL PROPHYLAXIS ADULT MAXFEE DEF         65.22 1/1/2024 12/31/2299 N
D1120 DENTAL PROPHYLAXIS CHILD MAXFEE DEF         38.22 1/1/2024 12/31/2299 N
D1203 TOPICAL APP FLUORIDE CHILD MAXFEE DEF         NA     S
D1206 TOPICAL FLUORIDE VARNISH MAXFEE DEF         29.48 1/1/2024 12/31/2299 S
D1208 TOPICAL APP FLUORID EX VRNSH MAXFEE DEF         29.48 1/1/2024 12/31/2299 S
D1301 IMMUNIZATION COUNSELING MAXFEE DEF         12.95 1/1/2024 12/31/2299 N
D1320 TOBACCO COUNSELING MAXFEE DEF         29.48 1/1/2024 12/31/2299 S
D1321 COUNS FOR HIGH RISK SUB USE MAXFEE DEF         29.48 1/1/2024 12/31/2299 N
D1351 DENTAL SEALANT PER TOOTH MAXFEE DEF         43.23 1/1/2024 12/31/2299 S
D1354 INT CARIES MED APP PER TOOTH MAXFEE DEF         29.48 1/1/2024 12/31/2299 S
D1510 SPACE MAINTAINER FXD UNILAT MAXFEE DEF         217.30 1/1/2024 12/31/2299 N
D1515 FIXED BILAT SPACE MAINTAINER MAXFEE DEF         NA     N
D1516 FIXED BILAT SPACE MAINT; MAX MAXFEE DEF         312.03 1/1/2024 12/31/2299 N
D1517 FIXED BILAT SPACE MAINT; MAN MAXFEE DEF         312.03 1/1/2024 12/31/2299 N
D1520 REMOVE UNILAT SPACE MAINTAIN MAXFEE DEF         239.03 1/1/2024 12/31/2299 N
D1525 REMOVE BILAT SPACE MAINTAIN MAXFEE DEF         NA     N
D1526 REMOVE BILAT SPACE MAIN; MAX MAXFEE DEF         147.17 1/1/2024 12/31/2299 N
D1527 REMOVE BILAT SPACE MAIN; MAN MAXFEE DEF         147.17 1/1/2024 12/31/2299 N
D1701 PFIZER VACC ADMIN 1ST DOSE MAXFEE DEF         NA     N
D1702 PFIZER VACC ADMIN 2ND DOSE MAXFEE DEF         NA     N
D1703 MODERNA VACC ADMIN 1ST DOSE MAXFEE DEF         NA     N
D1704 MODERNA VACC ADMIN 2ND DOSE MAXFEE DEF         NA     N
D1707 JANSSEN VACCINE ADMIN MAXFEE DEF         NA     N
D1708 PFIZER VACC ADMIN 3RD DOSE MAXFEE DEF         NA     N
D1709 PFIZER VACCINE ADMIN BOOSTER MAXFEE DEF         NA     N
D1710 MODERNA VACC ADMIN 3RD DOSE MAXFEE DEF         NA     N
D1711 MODERNA VACC ADMIN BOOSTER MAXFEE DEF         NA     N
D1712 JANSSEN VACC ADMIN BOOSTER MAXFEE DEF         NA     N
D1713 PFIZER VACC ADM PED 1ST DOSE MAXFEE DEF         NA     N
D1714 PFIZER VACC ADM PED 2ND DOSE MAXFEE DEF         NA     N
D1781 VAC ADMIN HUMAN PAP DOSE 1 MANUAL DEF         NA NA NA N
D1782 VAC ADMIN HUMAN PAP DOSE 2 MANUAL DEF         NA NA NA N
D1783 VAC ADMIN HUMAN PAP DOSE 3 MANUAL DEF         NA NA NA N
D2110 AMALGAM ONE SURFACE PRIMARY MAXFEE DEF         NA     N
D2120 AMALGAM TWO SURFACES PRIMARY MAXFEE DEF         NA     N
D2130 AMALGAM THREE SURFACES PRIMA MAXFEE DEF         NA     N
D2140 AMALGAM ONE SURFACE PERMANEN MAXFEE DEF         78.60 1/1/2024 12/31/2299 N
D2150 AMALGAM TWO SURFACES PERMANE MAXFEE DEF         103.19 1/1/2024 12/31/2299 N
D2160 AMALGAM THREE SURFACES PERMA MAXFEE DEF         124.22 1/1/2024 12/31/2299 N
D2161 AMALGAM 4 OR > SURFACES PERM MAXFEE DEF         146.27 1/1/2024 12/31/2299 N
D2330 RESIN ONE SURFACE-ANTERIOR MAXFEE DEF         97.86 1/1/2024 12/31/2299 N
D2331 RESIN TWO SURFACES-ANTERIOR MAXFEE DEF         121.33 1/1/2024 12/31/2299 N
D2332 RESIN THREE SURFACES-ANTERIO MAXFEE DEF         146.42 1/1/2024 12/31/2299 N
D2335 RESIN 4/> SURF OR W INCIS AN MAXFEE DEF         181.45 1/1/2024 12/31/2299 N
D2390 ANT RESIN-BASED CMPST CROWN MAXFEE DEF         181.45 1/1/2024 12/31/2299 N
D2391 POST 1 SRFC RESINBASED CMPST MAXFEE DEF         97.86 1/1/2024 12/31/2299 N
D2392 POST 2 SRFC RESINBASED CMPST MAXFEE DEF         103.19 1/1/2024 12/31/2299 N
D2393 POST 3 SRFC RESINBASED CMPST MAXFEE DEF         124.22 1/1/2024 12/31/2299 N
D2394 POST >=4SRFC RESINBASE CMPST MAXFEE DEF         146.27 1/1/2024 12/31/2299 N
D2740 CROWN PORCELAIN/CERAMIC MAXFEE DEF         816.55 1/1/2024 12/31/2299 Y
D2751 CROWN PORCELAIN FUSED BASE M MAXFEE DEF         470.02 1/1/2024 12/31/2299 Y
D2752 CROWN PORCELAIN W/ NOBLE MET MAXFEE DEF         470.02 1/1/2024 12/31/2299 Y
D2920 RE-CEMENT OR RE-BOND CROWN MAXFEE DEF         49.50 1/1/2024 12/31/2299 S
D2928 PREFAB PORC/CER CROWN PERM MAXFEE OTH         194.77 1/1/2024 12/31/2299 N
D2928 PREFAB PORC/CER CROWN PERM MAXFEE DEF         194.77 1/1/2024 12/31/2299 N
D2929 PREFAB PORC/CERAM CROWN PRI MAXFEE OTH         194.77 1/1/2024 12/31/2299 N
D2929 PREFAB PORC/CERAM CROWN PRI MAXFEE DEF         194.77 1/1/2024 12/31/2299 N
D2930 PREFAB STNLSS STEEL CRWN PRI MAXFEE DEF         200.27 1/1/2024 12/31/2299 N
D2931 PREFAB STNLSS STEEL CROWN PE MAXFEE DEF         222.65 1/1/2024 12/31/2299 N
D2933 PREFAB STAINLESS STEEL CROWN MAXFEE DEF         292.38 1/1/2024 12/31/2299 N
D2934 PREFAB STEEL CROWN PRIMARY MAXFEE DEF         300.65 1/1/2024 12/31/2299 N
D2940 PROTECTIVE RESTORATION MAXFEE DEF         34.40 1/1/2024 12/31/2299 S
D2941 INT THERAPEUTIC RESTORATION MAXFEE DEF         34.40 1/1/2024 12/31/2299 S
D2950 CORE BUILD-UP INCL ANY PINS MAXFEE DEF         146.27 1/1/2024 12/31/2299 N
D2951 TOOTH PIN RETENTION MAXFEE DEF         31.51 1/1/2024 12/31/2299 N
D2952 POST AND CORE CAST + CROWN MAXFEE DEF         260.51 1/1/2024 12/31/2299 Y
D2954 PREFAB POST/CORE + CROWN MAXFEE DEF         260.51 1/1/2024 12/31/2299 Y
D2976 BAND STABILIZATION PER TOOTH MAXFEE DEF         20 1/1/2024 12/31/2299 N
D2989 EXCAVATE TOOTH NON-RESTORABL MANUAL DEF         NA NA NA N
D2991 APP OF HYDROXYAPATITE MANUAL DEF         NA NA NA N
D3220 THERAPEUTIC PULPOTOMY MAXFEE DEF         121.81 1/1/2024 12/31/2299 N
D3310 END THXPY; ANTERIOR TOOTH MAXFEE DEF         473.22 1/1/2024 12/31/2299 N
D3320 END THXPY; PREMOLAR TOOTH MAXFEE DEF         569.67 1/1/2024 12/31/2299 N
D3330 END THXPY; MOLAR TOOTH MAXFEE DEF         724.31 1/1/2024 12/31/2299 N
D3351 APEXIFICATION/RECALC INITIAL MAXFEE DEF         114.66 1/1/2024 12/31/2299 N
D3352 APEXIFICATION/RECALC INTERIM MAXFEE DEF         76.44 1/1/2024 12/31/2299 N
D3353 APEXIFICATION/RECALC FINAL MAXFEE DEF         76.44 1/1/2024 12/31/2299 N
D3410 APICOECTOMY - ANTERIOR MAXFEE DEF         195.80 1/1/2024 12/31/2299 N
D4210 GINGIVECTOMY/PLASTY 4 OR MOR MAXFEE DEF         376.85 1/1/2024 12/31/2299 Y
D4211 GINGIVECTOMY/PLASTY 1 TO 3 MAXFEE DEF         227.03 1/1/2024 12/31/2299 Y
D4286 REMOVE NON-RESORB BARRIER PADOLR DEF         NA NA NA Y
D4341 PERIODONTAL SCALING & ROOT MAXFEE DEF         188.62 1/1/2024 12/31/2299 Y
D4342 PERIODONTAL SCALING 1-3TEETH MAXFEE DEF         127.73 1/1/2024 12/31/2299 Y
D4910 PERIODONTAL MAINT PROCEDURES MAXFEE DEF         67.07 1/1/2024 12/31/2299 S
D5110 DENTURES COMPLETE MAXILLARY MAXFEE DEF         764.40 1/1/2024 12/31/2299 Y
D5120 DENTURES COMPLETE MANDIBLE MAXFEE DEF         764.40 1/1/2024 12/31/2299 Y
D5130 DENTURES IMMEDIAT MAXILLARY MAXFEE DEF         764.40 1/1/2024 12/31/2299 Y
D5140 DENTURES IMMEDIAT MANDIBLE MAXFEE DEF         764.40 1/1/2024 12/31/2299 Y
D5211 DENTURES MAXILL PART RESIN MAXFEE DEF         391.76 1/1/2024 12/31/2299 Y
D5212 DENTURES MAND PART RESIN MAXFEE DEF         391.76 1/1/2024 12/31/2299 Y
D5213 DENTURES MAXILL PART METAL MAXFEE DEF         1032.42 1/1/2024 12/31/2299 Y
D5214 DENTURES MANDIBL PART METAL MAXFEE DEF         1032.42 1/1/2024 12/31/2299 Y
D5225 MAXILLARY PART DENTURE FLEX MAXFEE DEF         650 1/1/2024 12/31/2299 Y
D5226 MANDIBULAR PART DENTURE FLEX MAXFEE DEF         650 1/1/2024 12/31/2299 Y
D5510 DENTUR REPR BROKEN COMPL BAS MAXFEE DEF         NA     N
D5511 REP BROKE COMP DENT BASE MAN MAXFEE DEF         133.77 1/1/2024 12/31/2299 N
D5512 REP BROKE COMP DENT BASE MAX MAXFEE DEF         133.77 1/1/2024 12/31/2299 N
D5520 REPLACE DENTURE TEETH COMPLT MAXFEE DEF         133.77 1/1/2024 12/31/2299 N
D5610 DENTURES REPAIR RESIN BASE MAXFEE DEF         NA     N
D5611 REP RESIN PART DENT BASE MAN MAXFEE DEF         133.77 1/1/2024 12/31/2299 N
D5612 REP RESIN PART DENT BASE MAX MAXFEE DEF         133.77 1/1/2024 12/31/2299 N
D5620 REP PART DENTURE CAST FRAME MAXFEE DEF         NA     N
D5621 REP CAST PART FRAME MAN MAXFEE DEF         156.51 1/1/2024 12/31/2299 N
D5622 REP CAST PART FRAME MAX MAXFEE DEF         156.51 1/1/2024 12/31/2299 N
D5630 REP PARTIAL DENTURE CLASP MAXFEE DEF         148.48 1/1/2024 12/31/2299 N
D5640 REPLACE PART DENTURE TEETH MAXFEE DEF         133.77 1/1/2024 12/31/2299 N
D5650 ADD TOOTH TO PARTIAL DENTURE MAXFEE DEF         77 1/1/2024 12/31/2299 N
D5660 ADD CLASP TO PARTIAL DENTURE MAXFEE DEF         81.40 1/1/2024 12/31/2299 N
D5750 DENTURE RELN CMPLT MAX INDIR MAXFEE DEF         335.40 1/1/2024 12/31/2299 N
D5751 DENTURE RELN CMPLT MAND IND MAXFEE DEF         335.95 1/1/2024 12/31/2299 N
D5760 DENTURE RELN PART MAX INDIR MAXFEE DEF         267.54 1/1/2024 12/31/2299 N
D5761 DENTURE RELN PART MAND INDIR MAXFEE DEF         267.54 1/1/2024 12/31/2299 N
D5899 REMOVABLE PROSTHODONTIC PROC MAXFEE DEF         44 1/1/2024 12/31/2299 N
D5913 NASAL PROSTHESIS PADOLR DEF         NA NA NA Y
D5915 ORBITAL PROSTHESIS PADOLR DEF         NA NA NA Y
D5916 OCULAR PROSTHESIS PADOLR DEF         NA NA NA Y
D5931 SURGICAL OBTURATOR PADOLR DEF         NA NA NA Y
D5932 POSTSURGICAL OBTURATOR PADOLR DEF         NA NA NA Y
D5934 MANDIBULAR FLANGE PROSTHESIS PADOLR DEF         NA NA NA Y
D5935 MANDIBULAR DENTURE PROSTH PADOLR DEF         NA NA NA Y
D5955 PALATAL LIFT PROSTHESIS PADOLR DEF         NA NA NA Y
D5999 MAXILLOFACIAL PROSTHESIS PADOLR DEF         NA NA NA Y
D6089 ACCESS/RETORQ IMPLANT SCREW MANUAL DEF         NA NA NA N
D6100 SURG REMOVAL OF IMPLANT BODY MANUAL DEF         NA NA NA E
D6105 REMOVE IMPLANT BODY PADOLR DEF         NA NA NA Y
D6106 TISSUE REGEN RESORBABLE PADOLR DEF         NA NA NA Y
D6107 TISSUE REGEN NON-RESORBABLE PADOLR DEF         NA NA NA Y
D6197 REPLACE MATERIAL PROSTHESIS PADOLR DEF         NA NA NA Y
D7110 ORAL SURGERY SINGLE TOOTH MAXFEE DEF         NA     N
D7120 EACH ADD TOOTH EXTRACTION MAXFEE DEF         NA     N
D7130 TOOTH ROOT REMOVAL MAXFEE DEF         NA     N
D7140 EXTRACTION ERUPTED TOOTH/EXR MAXFEE DEF         113.36 1/1/2024 12/31/2299 N
D7210 REM IMP TOOTH W MUCOPER FLP MAXFEE DEF         113.36 1/1/2024 12/31/2299 S
D7220 IMPACT TOOTH REMOV SOFT TISS MAXFEE DEF         194.92 1/1/2024 12/31/2299 Y N
D7230 IMPACT TOOTH REMOV PART BONY MAXFEE DEF         297.62 1/1/2024 12/31/2299 N
D7240 IMPACT TOOTH REMOV COMP BONY MAXFEE DEF         370.99 1/1/2024 12/31/2299 Y
D7241 IMPACT TOOTH REM BONY W/COMP MAXFEE DEF         382.20 1/1/2024 12/31/2299 Y
D7250 TOOTH ROOT REMOVAL MAXFEE DEF         126.13 1/1/2024 12/31/2299 Y
D7260 ORAL ANTRAL FISTULA CLOSURE MAXFEE DEF         269.50 1/1/2024 12/31/2299 N
D7270 TOOTH REIMPLANTATION MAXFEE DEF         193.13 1/1/2024 12/31/2299 N
D7280 EXPOSURE OF UNERUPTED TOOTH MAXFEE DEF         291.05 1/1/2024 12/31/2299 Y
D7283 PLACE DEVICE IMPACTED TOOTH MAXFEE DEF         82.50 1/1/2024 12/31/2299 Y
D7285 BIOPSY OF ORAL TISSUE HARD MAXFEE DEF         165 1/1/2024 12/31/2299 N
D7286 BIOPSY OF ORAL TISSUE SOFT MAXFEE DEF         143 1/1/2024 12/31/2299 N
D7310 ALVEOPLASTY W/ EXTRACTION MAXFEE DEF         189.30 1/1/2024 12/31/2299 N
D7311 ALVEOLOPLASTY W/EXTRACT 1-3 MAXFEE DEF         94.65 1/1/2024 12/31/2299 N
D7320 ALVEOPLASTY W/O EXTRACTION MAXFEE DEF         230.54 1/1/2024 12/31/2299 N
D7410 RAD EXC LESION UP TO 1.25 CM MAXFEE DEF         0 7/1/1971 12/31/2299 N
D7411 EXCISION BENIGN LESION>1.25C MAXFEE DEF         0 1/1/2004 12/31/2299 N
D7412 EXCISION BENIGN LESION COMPL MAXFEE DEF         0 1/1/2004 12/31/2299 N
D7413 EXCISION MALIG LESION<=1.25C MAXFEE DEF         0 1/1/2004 12/31/2299 N
D7414 EXCISION MALIG LESION>1.25CM MAXFEE DEF         0 1/1/2004 12/31/2299 N
D7415 EXCISION MALIG LES COMPLICAT MAXFEE DEF         0 1/1/2004 12/31/2299 N
D7450 REM ODONTOGEN CYST TO 1.25CM MAXFEE DEF         202.16 1/1/2024 12/31/2299 N
D7451 REM ODONTOGEN CYST > 1.25 CM MAXFEE DEF         440.66 1/1/2024 12/31/2299 N
D7460 REM NONODONTO CYST TO 1.25CM MAXFEE DEF         277.10 1/1/2024 12/31/2299 N
D7461 REM NONODONTO CYST > 1.25 CM MAXFEE DEF         459.19 1/1/2024 12/31/2299 N
D7465 LESION DESTRUCTION MAXFEE DEF         0 1/1/2004 12/31/2299 N
D7470 REM EXOSTOSIS MAXILLA/MANDIB PADOLR DEF         NA NA NA Y
D7471 REM EXOSTOSIS ANY SITE MAXFEE DEF         242.70 1/1/2024 12/31/2299 N
D7472 REMOVAL OF TORUS PALATINUS MAXFEE DEF         242.70 1/1/2024 12/31/2299 N
D7473 REMOVE TORUS MANDIBULARIS MAXFEE DEF         242.70 1/1/2024 12/31/2299 N
D7485 SURG REDUCT OSSEOUSTUBEROSIT MAXFEE DEF         0 1/1/2004 12/31/2299 N
D7509 MARSUPIALIZATION ODON CYST PADOLR DEF         NA NA NA Y
D7510 I&D ABSC INTRAORAL SOFT TISS MAXFEE DEF         145.24 1/1/2024 12/31/2299 N
D7520 I&D ABSCESS EXTRAORAL MAXFEE DEF         164.35 1/1/2024 12/31/2299 N
D7610 MAXILLA OPEN REDUCT SIMPLE MAXFEE DEF         NA     N
D7620 CLSD REDUCT SIMPL MAXILLA FX MAXFEE DEF         NA     N
D7630 OPEN RED SIMPL MANDIBLE FX MAXFEE DEF         NA     N
D7640 CLSD RED SIMPL MANDIBLE FX MAXFEE DEF         NA     N
D7670 CLOSD RDUCTN SPLINT ALVEOLUS MAXFEE DEF         464.66 1/1/2024 12/31/2299 N
D7671 ALVEOLUS OPEN REDUCTION MAXFEE DEF         609.13 1/1/2024 12/31/2299 N
D7710 MAXILLA OPEN REDUCT COMPOUND MAXFEE DEF         NA     N
D7720 CLSD REDUCT COMPD MAXILLA FX MAXFEE DEF         NA     N
D7730 OPEN REDUCT COMPD MANDBLE FX MAXFEE DEF         NA     N
D7740 CLSD REDUCT COMPD MANDBLE FX MAXFEE DEF         NA     N
D7770 OPEN REDUC COMPD ALVEOLUS FX MAXFEE DEF         NA     N
D7899 TMJ UNSPECIFIED THERAPY MAXFEE DEF         530.75 1/1/2024 12/31/2299 Y
D7956 TISS REGEN EDENT RESORB PADOLR DEF         NA NA NA Y
D7957 TISS REGEN EDENT NONRESORB PADOLR DEF         NA NA NA Y
D7960 FRENULECTOMY/FRENECTOMY MAXFEE DEF         131.04 1/1/2024 12/31/2299 N
D7961 BUCCAL/LABIAL FRENECTOMY MAXFEE DEF         131.04 1/1/2024 12/31/2299 N
D7962 LINGUAL FRENECTOMY MAXFEE DEF         131.04 1/1/2024 12/31/2299 N
D7970 EXCISION HYPERPLASTIC TISSUE MAXFEE DEF         72.60 1/1/2024 12/31/2299 N
D8080 COMPRE DENTAL TX ADOLESCENT MAXFEE DEF         1192.46 1/1/2024 12/31/2299 Y
D8210 ORTHODONTIC REM APPLIANCE TX MAXFEE DEF         391.76 1/1/2024 12/31/2299 N
D8220 FIXED APPLIANCE THERAPY HABT MAXFEE DEF         573.30 1/1/2024 12/31/2299 Y
D8670 PERIODIC ORTHODONTC TX VISIT MAXFEE DEF         500.57 1/1/2024 12/31/2299 Y
D8680 ORTHODONTIC RETENTION MAXFEE DEF         391.76 1/1/2024 12/31/2299 Y
D8999 ORTHODONTIC PROCEDURE PADOLR DEF         NA NA NA Y
D9220 GENERAL ANESTHESIA MAXFEE DEF         NA     N
D9222 DEEP ANEST; 1ST 15 MIN MAXFEE DEF         229.32 1/1/2024 12/31/2299 N
D9223 GENERAL ANESTH EA ADDL 15 MI MAXFEE DEF         133.77 1/1/2024 12/31/2299 N
D9230 ANALGESIA MAXFEE DEF         57.33 1/1/2024 12/31/2299 Y N
D9239 IV MOD SEDATION; 1ST 15 MIN MAXFEE DEF         133.77 1/1/2024 12/31/2299 N
D9243 IV SEDATION EA ADDL 15M MAXFEE DEF         76.44 1/1/2024 12/31/2299 N
D9610 DENT THERAPEUTIC DRUG INJECT MAXFEE DEF         27.70 1/1/2024 12/31/2299 N
D9612 THERA PAR DRUGS 2 OR > ADMIN MAXFEE DEF         55.40 1/1/2024 12/31/2299 N
D9920 BEHAVIOR MANAGEMENT MAXFEE DEF         0 1/1/2023 12/31/2299 Y
D9944 OCC GUARD; HARD; FULL ARCH MAXFEE DEF         391.76 1/1/2024 12/31/2299 N
D9945 OCC GUARD; SOFT; FULL ARCH MAXFEE DEF         391.76 1/1/2024 12/31/2299 N
D9946 OCC GUARD; HARD; PART ARCH MAXFEE DEF         391.76 1/1/2024 12/31/2299 N
D9947 SLEEP APNEA APPLIANCE PADOLR DEF         NA NA NA Y
D9948 ADJUST SLEEP APNEA APPLIANCE PADOLR DEF         NA NA NA Y
D9949 REPAIR SLEEP APNEA APPLIANCE PADOLR DEF         NA NA NA Y
D9953 RELINE SLEEP APNEA APPLIANCE MANUAL DEF         NA NA NA N
D9954 FAB/DEL ORAL APPLIANCE THXPY MANUAL DEF         NA NA NA N
D9955 ORAL APP THXPY TITRATION VIS MANUAL DEF         NA NA NA N
D9995 TELEDENTISTRY REAL-TIME MAXFEE DEF         0 3/9/2020 12/31/2299 N
D9997 DENT CASE MGMT SPECIAL NEEDS PADOLR DEF         NA NA NA Y
D9999 ADJUNCTIVE PROCEDURE PADOLR DEF         NA NA NA Y
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
T1015 CLINIC SERVICE PRXOVR DEF         NA NA NA N
T1015 CLINIC SERVICE UCCENC UC2         NA NA NA N
Y7255 SURGICAL REMOVAL OF SUPERNUMERARY PADOLR DEF         NA NA NA Y