Procedure Code	Procedure Description	Pricing Indicator	Rate Type	Mod1	Mod2	Mod3	Mod4	Max Fee	Max Fee Eff. Date	Max Fee End Date	PA
0001F	HEART FAILURE COMPOSITE	PRXOVR	DEF					NA	NA	NA	N
0001F	HEART FAILURE COMPOSITE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0002F	TOBACCO USE; SMOKING; ASSESS	PRXOVR	DEF					NA	NA	NA	N
0002F	TOBACCO USE; SMOKING; ASSESS	MAXFEE	DEF					NA			N
0003F	TOBACCO USE; NON-SMOKING	PRXOVR	DEF					NA	NA	NA	N
0003F	TOBACCO USE; NON-SMOKING	MAXFEE	DEF					NA			N
0004F	TOBACCO USE TXMNT COUNSELING	PRXOVR	DEF					NA	NA	NA	N
0004F	TOBACCO USE TXMNT COUNSELING	MAXFEE	DEF					NA			N
0005F	OSTEOARTHRITIS COMPOSITE	PRXOVR	DEF					NA	NA	NA	N
0005F	OSTEOARTHRITIS COMPOSITE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0006F	STATIN THERAPY; PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
0006F	STATIN THERAPY; PRESCRIBED	MAXFEE	DEF					NA			N
0007F	BETA-BLOCKER THX PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
0007F	BETA-BLOCKER THX PRESCRIBED	MAXFEE	DEF					NA			N
0008F	ACE INHIBITOR THX PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
0008F	ACE INHIBITOR THX PRESCRIBED	MAXFEE	DEF					NA			N
0009F	ASSESS ANGINAL SYMPTOM/LEVEL	PRXOVR	DEF					NA	NA	NA	N
0009F	ASSESS ANGINAL SYMPTOM/LEVEL	MAXFEE	DEF					NA			N
0010F	ASSESS ANGINAL SYMPTOM/LEVEL	PRXOVR	DEF					NA	NA	NA	N
0010F	ASSESS ANGINAL SYMPTOM/LEVEL	MAXFEE	DEF					NA			N
0011F	ORAL ANTIPLAT THX PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
0011F	ORAL ANTIPLAT THX PRESCRIBED	MAXFEE	DEF					NA			N
0012F	CAP BACTERIAL ASSESS	PRXOVR	DEF					NA	NA	NA	N
0012F	CAP BACTERIAL ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0014F	COMP PREOP ASSESS CAT SURG	PRXOVR	DEF					NA	NA	NA	N
0014F	COMP PREOP ASSESS CAT SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0015F	MELAN FOLLOW-UP COMPLETE	PRXOVR	DEF					NA	NA	NA	N
0015F	MELAN FOLLOW-UP COMPLETE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0500F	INITIAL PRENATAL CARE VISIT	PRXOVR	DEF					NA	NA	NA	N
0500F	INITIAL PRENATAL CARE VISIT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0501F	PRENATAL FLOW SHEET	PRXOVR	DEF					NA	NA	NA	N
0501F	PRENATAL FLOW SHEET	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0502F	SUBSEQUENT PRENATAL CARE	PRXOVR	DEF					NA	NA	NA	N
0502F	SUBSEQUENT PRENATAL CARE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0503F	POSTPARTUM CARE VISIT	PRXOVR	DEF					NA	NA	NA	N
0503F	POSTPARTUM CARE VISIT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0505F	HEMODIALYSIS PLAN DOCD	PRXOVR	DEF					NA	NA	NA	N
0505F	HEMODIALYSIS PLAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0507F	PERITON DIALYSIS PLAN DOCD	PRXOVR	DEF					NA	NA	NA	N
0507F	PERITON DIALYSIS PLAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0509F	URINE INCON PLAN DOCD	PRXOVR	DEF					NA	NA	NA	N
0509F	URINE INCON PLAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0513F	ELEV BP PLAN OF CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0513F	ELEV BP PLAN OF CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0514F	CARE PLAN HGB DOCD ESA PT	PRXOVR	DEF					NA	NA	NA	N
0514F	CARE PLAN HGB DOCD ESA PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0516F	ANEMIA PLAN OF CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0516F	ANEMIA PLAN OF CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0517F	GLAUCOMA PLAN OF CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0517F	GLAUCOMA PLAN OF CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0518F	FALL PLAN OF CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0518F	FALL PLAN OF CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0519F	PLAND CHEMO DOCD B/4 TXMNT	PRXOVR	DEF					NA	NA	NA	N
0519F	PLAND CHEMO DOCD B/4 TXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0520F	RAD DOS LIMTS B/4 3D RAD	PRXOVR	DEF					NA	NA	NA	N
0520F	RAD DOS LIMTS B/4 3D RAD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0521F	PLAN OF CARE 4 PAIN DOCD	PRXOVR	DEF					NA	NA	NA	N
0521F	PLAN OF CARE 4 PAIN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0525F	INITIAL VISIT FOR EPISODE	PRXOVR	DEF					NA	NA	NA	N
0525F	INITIAL VISIT FOR EPISODE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0526F	SUBS VISIT FOR EPISODE	PRXOVR	DEF					NA	NA	NA	N
0526F	SUBS VISIT FOR EPISODE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0528F	RCMND FLW-UP 10 YRS DOCD	PRXOVR	DEF					NA	NA	NA	N
0528F	RCMND FLW-UP 10 YRS DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0529F	INTRVL 3/>YR PTS CLNSCP DOCD	PRXOVR	DEF					NA	NA	NA	N
0529F	INTRVL 3/>YR PTS CLNSCP DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0535F	DYSPNEA MNGMNT PLAN DOCD	PRXOVR	DEF					NA	NA	NA	N
0535F	DYSPNEA MNGMNT PLAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0540F	GLUCO MNGMNT PLAN DOCD	PRXOVR	DEF					NA	NA	NA	N
0540F	GLUCO MNGMNT PLAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0545F	FOLLOW UP CARE PLAN MDD DOCD	PRXOVR	DEF					NA	NA	NA	N
0545F	FOLLOW UP CARE PLAN MDD DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0550F	CYTOPATH REPORT NONGYN SPCMN	PRXOVR	DEF					NA	NA	NA	N
0550F	CYTOPATH REPORT NONGYN SPCMN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0551F	CYTOPATH REPORT NON ROUTINE	PRXOVR	DEF					NA	NA	NA	N
0551F	CYTOPATH REPORT NON ROUTINE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0555F	SYMPTOM MGMNT PLAN CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0555F	SYMPTOM MGMNT PLAN CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0556F	PLAN CARE LIPID CONTROL DOCD	PRXOVR	DEF					NA	NA	NA	N
0556F	PLAN CARE LIPID CONTROL DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0557F	PLAN CAREMNG ANGNL SYMPTDOCD	PRXOVR	DEF					NA	NA	NA	N
0557F	PLAN CAREMNG ANGNL SYMPTDOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0575F	HIV RNA PLAN CARE DOCD	PRXOVR	DEF					NA	NA	NA	N
0575F	HIV RNA PLAN CARE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0580F	MULTIDISCIPLINARY CARE PLAN	PRXOVR	DEF					NA	NA	NA	N
0580F	MULTIDISCIPLINARY CARE PLAN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0581F	PT TRNSFRD FROM ANESTH TO CC	PRXOVR	DEF					NA	NA	NA	N
0581F	PT TRNSFRD FROM ANESTH TO CC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0582F	NO TRNSFR FROM ANESTH TO CC	PRXOVR	DEF					NA	NA	NA	N
0582F	NO TRNSFR FROM ANESTH TO CC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0583F	TRANSFER CARE CHECKLIST USED	PRXOVR	DEF					NA	NA	NA	N
0583F	TRANSFER CARE CHECKLIST USED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
0584F	NO TRANSFERCARE CHKLIST USED	PRXOVR	DEF					NA	NA	NA	N
0584F	NO TRANSFERCARE CHKLIST USED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1000F	TOBACCO USE ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1000F	TOBACCO USE ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1001F	TOBACCO USE; NON-SMOKING	PRXOVR	DEF					NA	NA	NA	N
1001F	TOBACCO USE; NON-SMOKING	MAXFEE	DEF					NA			N
1002F	ASSESS ANGINAL SYMPTOM/LEVEL	PRXOVR	DEF					NA	NA	NA	N
1002F	ASSESS ANGINAL SYMPTOM/LEVEL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1003F	LEVEL OF ACTIVITY ASSESS	PRXOVR	DEF					NA	NA	NA	N
1003F	LEVEL OF ACTIVITY ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1004F	CLIN SYMP VOL OVRLD ASSESS	PRXOVR	DEF					NA	NA	NA	N
1004F	CLIN SYMP VOL OVRLD ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1005F	ASTHMA SYMPTOMS EVALUATE	PRXOVR	DEF					NA	NA	NA	N
1005F	ASTHMA SYMPTOMS EVALUATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1006F	OSTEOARTHRITIS ASSESS	PRXOVR	DEF					NA	NA	NA	N
1006F	OSTEOARTHRITIS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1007F	ANTI-INFLM/ANLGSC OTC ASSESS	PRXOVR	DEF					NA	NA	NA	N
1007F	ANTI-INFLM/ANLGSC OTC ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1008F	GI/RENAL RISK ASSESS	PRXOVR	DEF					NA	NA	NA	N
1008F	GI/RENAL RISK ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1010F	SEVERITY ANGINA BY ACTVTY	PRXOVR	DEF					NA	NA	NA	N
1010F	SEVERITY ANGINA BY ACTVTY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1011F	ANGINA PRESENT	PRXOVR	DEF					NA	NA	NA	N
1011F	ANGINA PRESENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1012F	ANGINA ABSENT	PRXOVR	DEF					NA	NA	NA	N
1012F	ANGINA ABSENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1015F	COPD SYMPTOMS ASSESS	PRXOVR	DEF					NA	NA	NA	N
1015F	COPD SYMPTOMS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1018F	ASSESS DYSPNEA NOT PRESENT	PRXOVR	DEF					NA	NA	NA	N
1018F	ASSESS DYSPNEA NOT PRESENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1019F	ASSESS DYSPNEA PRESENT	PRXOVR	DEF					NA	NA	NA	N
1019F	ASSESS DYSPNEA PRESENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1022F	PNEUMO IMM STATUS ASSESS	PRXOVR	DEF					NA	NA	NA	N
1022F	PNEUMO IMM STATUS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1026F	CO-MORBID CONDITION ASSESS	PRXOVR	DEF					NA	NA	NA	N
1026F	CO-MORBID CONDITION ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1030F	INFLUENZA IMM STATUS ASSESS	PRXOVR	DEF					NA	NA	NA	N
1030F	INFLUENZA IMM STATUS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1031F	SMOKING & 2ND HAND ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1031F	SMOKING & 2ND HAND ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1032F	SMOKER/EXPOSED 2ND HND SMOKE	PRXOVR	DEF					NA	NA	NA	N
1032F	SMOKER/EXPOSED 2ND HND SMOKE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1033F	TOBACCO NONSMOKER NOR 2NDHND	PRXOVR	DEF					NA	NA	NA	N
1033F	TOBACCO NONSMOKER NOR 2NDHND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1034F	CURRENT TOBACCO SMOKER	PRXOVR	DEF					NA	NA	NA	N
1034F	CURRENT TOBACCO SMOKER	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
1035F	SMOKELESS TOBACCO USER	PRXOVR	DEF					NA	NA	NA	N
1035F	SMOKELESS TOBACCO USER	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
1036F	TOBACCO NON-USER	PRXOVR	DEF					NA	NA	NA	N
1036F	TOBACCO NON-USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1038F	PERSISTENT ASTHMA	PRXOVR	DEF					NA	NA	NA	N
1038F	PERSISTENT ASTHMA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1039F	INTERMITTENT ASTHMA	PRXOVR	DEF					NA	NA	NA	N
1039F	INTERMITTENT ASTHMA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1040F	DSM-5 INFO MDD DOCD	PRXOVR	DEF					NA	NA	NA	N
1040F	DSM-5 INFO MDD DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1050F	HISTORY OF MOLE CHANGES	PRXOVR	DEF					NA	NA	NA	N
1050F	HISTORY OF MOLE CHANGES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1052F	TYPE LOCATION ACTIVITYASSESS	PRXOVR	DEF					NA	NA	NA	N
1052F	TYPE LOCATION ACTIVITYASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1055F	VISUAL FUNCT STATUS ASSESS	PRXOVR	DEF					NA	NA	NA	N
1055F	VISUAL FUNCT STATUS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1060F	DOC PERM/CONT/PAROX ATR FIB	PRXOVR	DEF					NA	NA	NA	N
1060F	DOC PERM/CONT/PAROX ATR FIB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1061F	DOC LACK PERM&CONT&PAROX FIB	PRXOVR	DEF					NA	NA	NA	N
1061F	DOC LACK PERM&CONT&PAROX FIB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1065F	ISCHM STROKE SYMP LT3 HRSB/4	PRXOVR	DEF					NA	NA	NA	N
1065F	ISCHM STROKE SYMP LT3 HRSB/4	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1066F	ISCHM STROKE SYMP GE3 HRSB/4	PRXOVR	DEF					NA	NA	NA	N
1066F	ISCHM STROKE SYMP GE3 HRSB/4	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1070F	ALARM SYMP ASSESSED-ABSENT	PRXOVR	DEF					NA	NA	NA	N
1070F	ALARM SYMP ASSESSED-ABSENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1071F	ALARM SYMP ASSESSED-1+ PRSNT	PRXOVR	DEF					NA	NA	NA	N
1071F	ALARM SYMP ASSESSED-1+ PRSNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1080F	DECIS MKR/ADVNCD PLAN DOC'D	PRXOVR	DEF					NA	NA	NA	N
1080F	DECIS MKR/ADVNCD PLAN DOC'D	MAXFEE	DEF					NA			N
1090F	PRES/ABSN URINE INCON ASSESS	PRXOVR	DEF					NA	NA	NA	N
1090F	PRES/ABSN URINE INCON ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1091F	URINE INCON CHARACTERIZED	PRXOVR	DEF					NA	NA	NA	N
1091F	URINE INCON CHARACTERIZED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1100F	PTFALLS ASSESS-DOCD GE2>/YR	PRXOVR	DEF					NA	NA	NA	N
1100F	PTFALLS ASSESS-DOCD GE2>/YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1101F	PT FALLS ASSESS-DOCD LE1/YR	PRXOVR	DEF					NA	NA	NA	N
1101F	PT FALLS ASSESS-DOCD LE1/YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1110F	PT LFT INPT FAC W/IN 60 DAYS	PRXOVR	DEF					NA	NA	NA	N
1110F	PT LFT INPT FAC W/IN 60 DAYS	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
1111F	DSCHRG MED/CURRENT MED MERGE	PRXOVR	DEF					NA	NA	NA	N
1111F	DSCHRG MED/CURRENT MED MERGE	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
1116F	AURIC/PERI PAIN ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1116F	AURIC/PERI PAIN ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1118F	GERD SYMPS ASSESSED 12 MONTH	PRXOVR	DEF					NA	NA	NA	N
1118F	GERD SYMPS ASSESSED 12 MONTH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1119F	INIT EVAL FOR CONDITION	PRXOVR	DEF					NA	NA	NA	N
1119F	INIT EVAL FOR CONDITION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1121F	SUBS EVAL FOR CONDITION	PRXOVR	DEF					NA	NA	NA	N
1121F	SUBS EVAL FOR CONDITION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1123F	ACP DISCUSS/DSCN MKR DOCD	PRXOVR	DEF					NA	NA	NA	N
1123F	ACP DISCUSS/DSCN MKR DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1124F	ACP DISCUSS-NO DSCNMKR DOCD	PRXOVR	DEF					NA	NA	NA	N
1124F	ACP DISCUSS-NO DSCNMKR DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1125F	AMNT PAIN NOTED PAIN PRSNT	PRXOVR	DEF					NA	NA	NA	N
1125F	AMNT PAIN NOTED PAIN PRSNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1126F	AMNT PAIN NOTED NONE PRSNT	PRXOVR	DEF					NA	NA	NA	N
1126F	AMNT PAIN NOTED NONE PRSNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1127F	NEW EPISODE FOR CONDITION	PRXOVR	DEF					NA	NA	NA	N
1127F	NEW EPISODE FOR CONDITION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1128F	SUBS EPISODE FOR CONDITION	PRXOVR	DEF					NA	NA	NA	N
1128F	SUBS EPISODE FOR CONDITION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1130F	BK PAIN & FXN ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1130F	BK PAIN & FXN ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1134F	EPSD BK PAIN FOR 6 WKS/<	PRXOVR	DEF					NA	NA	NA	N
1134F	EPSD BK PAIN FOR 6 WKS/<	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1135F	EPSD BK PAIN FOR >6 WKS	PRXOVR	DEF					NA	NA	NA	N
1135F	EPSD BK PAIN FOR >6 WKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1136F	EPSD BK PAIN FOR 12 WKS/<	PRXOVR	DEF					NA	NA	NA	N
1136F	EPSD BK PAIN FOR 12 WKS/<	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1137F	EPSD BK PAIN FOR >12 WKS	PRXOVR	DEF					NA	NA	NA	N
1137F	EPSD BK PAIN FOR >12 WKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1150F	DOC PT RSK DEATH W/IN 1YR	PRXOVR	DEF					NA	NA	NA	N
1150F	DOC PT RSK DEATH W/IN 1YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1151F	DOC NO PT RSK DEATH W/IN 1YR	PRXOVR	DEF					NA	NA	NA	N
1151F	DOC NO PT RSK DEATH W/IN 1YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1152F	DOC ADVNCD DIS COMFORT 1ST	PRXOVR	DEF					NA	NA	NA	N
1152F	DOC ADVNCD DIS COMFORT 1ST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1153F	DOC ADVNCD DIS CMFRT NOT 1ST	PRXOVR	DEF					NA	NA	NA	N
1153F	DOC ADVNCD DIS CMFRT NOT 1ST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1157F	ADVNC CARE PLAN IN RCRD	PRXOVR	DEF					NA	NA	NA	N
1157F	ADVNC CARE PLAN IN RCRD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1158F	ADVNC CARE PLAN TLK DOCD	PRXOVR	DEF					NA	NA	NA	N
1158F	ADVNC CARE PLAN TLK DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1159F	MED LIST DOCD IN RCRD	PRXOVR	DEF					NA	NA	NA	N
1159F	MED LIST DOCD IN RCRD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1160F	RVW MEDS BY RX/DR IN RCRD	PRXOVR	DEF					NA	NA	NA	N
1160F	RVW MEDS BY RX/DR IN RCRD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1170F	FXNL STATUS ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1170F	FXNL STATUS ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1175F	FUNCTION STAT ASSESSED RVWD	PRXOVR	DEF					NA	NA	NA	N
1175F	FUNCTION STAT ASSESSED RVWD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1180F	THROMBOEMB RISK ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1180F	THROMBOEMB RISK ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1181F	NEUROPSYCHIA SYMPTS ASSESSED	PRXOVR	DEF					NA	NA	NA	N
1181F	NEUROPSYCHIA SYMPTS ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1182F	NEUROPSYCHI SYMPT 1+PRESENT	PRXOVR	DEF					NA	NA	NA	N
1182F	NEUROPSYCHI SYMPT 1+PRESENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1183F	NEUROPSYCHIATRIC SYMP ABSENT	PRXOVR	DEF					NA	NA	NA	N
1183F	NEUROPSYCHIATRIC SYMP ABSENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1200F	SEIZURE TYPE& FREQU DOCD	PRXOVR	DEF					NA	NA	NA	N
1200F	SEIZURE TYPE& FREQU DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1205F	EPI ETIOL SYND RVWD AND DOCD	PRXOVR	DEF					NA	NA	NA	N
1205F	EPI ETIOL SYND RVWD AND DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1220F	PT SCREENED FOR DEPRESSION	PRXOVR	DEF					NA	NA	NA	N
1220F	PT SCREENED FOR DEPRESSION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1400F	PRKNS DIAG RVIEWED	PRXOVR	DEF					NA	NA	NA	N
1400F	PRKNS DIAG RVIEWED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1450F	SYMPTOMS IMPROVED/CONSIST	PRXOVR	DEF					NA	NA	NA	N
1450F	SYMPTOMS IMPROVED/CONSIST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1451F	SYMPT SHOW CLIN IMPORT DROP	PRXOVR	DEF					NA	NA	NA	N
1451F	SYMPT SHOW CLIN IMPORT DROP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1460F	QUAL CARD DIAG PRIOR 12 MONS	PRXOVR	DEF					NA	NA	NA	N
1460F	QUAL CARD DIAG PRIOR 12 MONS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1461F	NO QUAL CARD DIAG PRIOR12MON	PRXOVR	DEF					NA	NA	NA	N
1461F	NO QUAL CARD DIAG PRIOR12MON	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1490F	DEM SEVERITY CLASSIFIED MILD	PRXOVR	DEF					NA	NA	NA	N
1490F	DEM SEVERITY CLASSIFIED MILD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1491F	DEM SEVERITY CLASSIFIED MOD	PRXOVR	DEF					NA	NA	NA	N
1491F	DEM SEVERITY CLASSIFIED MOD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1493F	DEM SEVERITY CLASS SEVERE	PRXOVR	DEF					NA	NA	NA	N
1493F	DEM SEVERITY CLASS SEVERE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1494F	COGNIT ASSESSED AND REVIEWED	PRXOVR	DEF					NA	NA	NA	N
1494F	COGNIT ASSESSED AND REVIEWED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1500F	SYMPTOM&SIGN SYMM POLYNEURO	PRXOVR	DEF					NA	NA	NA	N
1500F	SYMPTOM&SIGN SYMM POLYNEURO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1501F	NOT INITIAL EVAL FOR COND	PRXOVR	DEF					NA	NA	NA	N
1501F	NOT INITIAL EVAL FOR COND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1502F	PT QUERIED PAIN FXN W/ INSTR	PRXOVR	DEF					NA	NA	NA	N
1502F	PT QUERIED PAIN FXN W/ INSTR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1503F	PT QUERIED SYMP RESP INSUFF	PRXOVR	DEF					NA	NA	NA	N
1503F	PT QUERIED SYMP RESP INSUFF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1504F	PT HAS RESP INSUFFICIENCY	PRXOVR	DEF					NA	NA	NA	N
1504F	PT HAS RESP INSUFFICIENCY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
1505F	PT HAS NO RESP INSUFFICIENCY	PRXOVR	DEF					NA	NA	NA	N
1505F	PT HAS NO RESP INSUFFICIENCY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2000F	BLOOD PRESSURE MEASURE	PRXOVR	DEF					NA	NA	NA	N
2000F	BLOOD PRESSURE MEASURE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2001F	WEIGHT RECORD	PRXOVR	DEF					NA	NA	NA	N
2001F	WEIGHT RECORD	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
2002F	CLIN SIGN VOL OVRLD ASSESS	PRXOVR	DEF					NA	NA	NA	N
2002F	CLIN SIGN VOL OVRLD ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2003F	AUSCULTATION HEART PERFORM	PRXOVR	DEF					NA	NA	NA	N
2003F	AUSCULTATION HEART PERFORM	MAXFEE	DEF					NA			N
2004F	INITIAL EXAM INVOLVED JOINTS	PRXOVR	DEF					NA	NA	NA	N
2004F	INITIAL EXAM INVOLVED JOINTS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2010F	VITAL SIGNS RECORDED	PRXOVR	DEF					NA	NA	NA	N
2010F	VITAL SIGNS RECORDED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2014F	MENTAL STATUS ASSESS	PRXOVR	DEF					NA	NA	NA	N
2014F	MENTAL STATUS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2015F	ASTHMA IMPAIRMENT ASSESSED	PRXOVR	DEF					NA	NA	NA	N
2015F	ASTHMA IMPAIRMENT ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2016F	ASTHMA RISK ASSESSED	PRXOVR	DEF					NA	NA	NA	N
2016F	ASTHMA RISK ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2018F	HYDRATION STATUS ASSESS	PRXOVR	DEF					NA	NA	NA	N
2018F	HYDRATION STATUS ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2019F	DILATED MACUL EXAM DONE	PRXOVR	DEF					NA	NA	NA	N
2019F	DILATED MACUL EXAM DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2020F	DILATED FUNDUS EVAL DONE	PRXOVR	DEF					NA	NA	NA	N
2020F	DILATED FUNDUS EVAL DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2021F	DILAT MACULAR EXAM DONE	PRXOVR	DEF					NA	NA	NA	N
2021F	DILAT MACULAR EXAM DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2022F	DILAT RTA XM EVC RTNOPTHY	PRXOVR	DEF					NA	NA	NA	N
2022F	DILAT RTA XM EVC RTNOPTHY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2024F	7 FLD RTA PHOTO EVC RTNOPTHY	PRXOVR	DEF					NA	NA	NA	N
2024F	7 FLD RTA PHOTO EVC RTNOPTHY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2026F	EYE IMG VALID EVC RTNOPTHY	PRXOVR	DEF					NA	NA	NA	N
2026F	EYE IMG VALID EVC RTNOPTHY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2027F	OPTIC NERVE HEAD EVAL DONE	PRXOVR	DEF					NA	NA	NA	N
2027F	OPTIC NERVE HEAD EVAL DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2028F	FOOT EXAM PERFORMED	PRXOVR	DEF					NA	NA	NA	N
2028F	FOOT EXAM PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2029F	COMPLETE PHYS SKIN EXAM DONE	PRXOVR	DEF					NA	NA	NA	N
2029F	COMPLETE PHYS SKIN EXAM DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2030F	H2O STAT DOCD NORMAL	PRXOVR	DEF					NA	NA	NA	N
2030F	H2O STAT DOCD NORMAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2031F	H2O STAT DOCD DEHYDRATED	PRXOVR	DEF					NA	NA	NA	N
2031F	H2O STAT DOCD DEHYDRATED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2035F	TYMP MEMB MOTION EXAMD	PRXOVR	DEF					NA	NA	NA	N
2035F	TYMP MEMB MOTION EXAMD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2040F	BK PN XM ON INIT VISIT DATE	PRXOVR	DEF					NA	NA	NA	N
2040F	BK PN XM ON INIT VISIT DATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2044F	DOC MNTL TST B/4 BK TRXMNT	PRXOVR	DEF					NA	NA	NA	N
2044F	DOC MNTL TST B/4 BK TRXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2050F	WOUND CHAR SIZE ETC DOCD	PRXOVR	DEF					NA	NA	NA	N
2050F	WOUND CHAR SIZE ETC DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
2060F	PT TALK EVAL HLTHWKR RE MDD	PRXOVR	DEF					NA	NA	NA	N
2060F	PT TALK EVAL HLTHWKR RE MDD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3000F	BLOOD PRESS </= 140/90 MMHG	PRXOVR	DEF					NA	NA	NA	N
3000F	BLOOD PRESS </= 140/90 MMHG	MAXFEE	DEF					NA			N
3002F	BLOOD PRESSURE > 140/90 MMHG	PRXOVR	DEF					NA	NA	NA	N
3002F	BLOOD PRESSURE > 140/90 MMHG	MAXFEE	DEF					NA			N
3006F	CXR DOC REV	PRXOVR	DEF					NA	NA	NA	N
3006F	CXR DOC REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3008F	BODY MASS INDEX DOCD	PRXOVR	DEF					NA	NA	NA	N
3008F	BODY MASS INDEX DOCD	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3011F	LIPID PANEL DOC REV	PRXOVR	DEF					NA	NA	NA	N
3011F	LIPID PANEL DOC REV	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3014F	SCREEN MAMMO DOC REV	PRXOVR	DEF					NA	NA	NA	N
3014F	SCREEN MAMMO DOC REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3015F	CERV CANCER SCREEN DOCD	PRXOVR	DEF					NA	NA	NA	N
3015F	CERV CANCER SCREEN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3016F	PT SCRND UNHLTHY OH USE	PRXOVR	DEF					NA	NA	NA	N
3016F	PT SCRND UNHLTHY OH USE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3017F	COLORECTAL CA SCREEN DOC REV	PRXOVR	DEF					NA	NA	NA	N
3017F	COLORECTAL CA SCREEN DOC REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3018F	PRE-PRXD RSK ET AL DOCD	PRXOVR	DEF					NA	NA	NA	N
3018F	PRE-PRXD RSK ET AL DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3019F	LVEF ASSESS PLANPOST DSCHRGE	PRXOVR	DEF					NA	NA	NA	N
3019F	LVEF ASSESS PLANPOST DSCHRGE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3020F	LVF ASSESS	PRXOVR	DEF					NA	NA	NA	N
3020F	LVF ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3021F	LVEF MOD/SEVER DEPRS SYST	PRXOVR	DEF					NA	NA	NA	N
3021F	LVEF MOD/SEVER DEPRS SYST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3022F	LVEF >=40% SYSTOLIC	PRXOVR	DEF					NA	NA	NA	N
3022F	LVEF >=40% SYSTOLIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3023F	SPIROM DOC REV	PRXOVR	DEF					NA	NA	NA	N
3023F	SPIROM DOC REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3025F	SPIROM FEV/FVC <70% W/COPD	PRXOVR	DEF					NA	NA	NA	N
3025F	SPIROM FEV/FVC <70% W/COPD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3027F	SPIROM FEV/FVC>=70%/W/OCOPD	PRXOVR	DEF					NA	NA	NA	N
3027F	SPIROM FEV/FVC>=70%/W/OCOPD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3028F	O2 SATURATION DOC REV	PRXOVR	DEF					NA	NA	NA	N
3028F	O2 SATURATION DOC REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3035F	O2 SATURATION<=88%/PAO<=55	PRXOVR	DEF					NA	NA	NA	N
3035F	O2 SATURATION<=88%/PAO<=55	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3037F	O2 SATURATION >88%/PAO>55 HG	PRXOVR	DEF					NA	NA	NA	N
3037F	O2 SATURATION >88%/PAO>55 HG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3038F	PULM FX W/IN 12 MON B/4 SURG	PRXOVR	DEF					NA	NA	NA	N
3038F	PULM FX W/IN 12 MON B/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3040F	FEV <40% PREDICTED VALUE	PRXOVR	DEF					NA	NA	NA	N
3040F	FEV <40% PREDICTED VALUE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3042F	FEV >=40% PREDICTED VALUE	PRXOVR	DEF					NA	NA	NA	N
3042F	FEV >=40% PREDICTED VALUE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3044F	HG A1C LEVEL LT 7.0%	PRXOVR	DEF					NA	NA	NA	N
3044F	HG A1C LEVEL LT 7.0%	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3045F	HG A1C LEVEL 7.0-9.0%	PRXOVR	DEF					NA	NA	NA	N
3045F	HG A1C LEVEL 7.0-9.0%	MAXFEE	DEF					NA			N
3046F	HEMOGLOBIN A1C LEVEL >9.0%	PRXOVR	DEF					NA	NA	NA	N
3046F	HEMOGLOBIN A1C LEVEL >9.0%	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3047F	HEMOGLOBIN A1C LEVEL = 9.0%	PRXOVR	DEF					NA	NA	NA	N
3047F	HEMOGLOBIN A1C LEVEL = 9.0%	MAXFEE	DEF					NA			N
3048F	LDL-C <100 MG/DL	PRXOVR	DEF					NA	NA	NA	N
3048F	LDL-C <100 MG/DL	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3049F	LDL-C 100-129 MG/DL	PRXOVR	DEF					NA	NA	NA	N
3049F	LDL-C 100-129 MG/DL	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3050F	LDL-C >= 130 MG/DL	PRXOVR	DEF					NA	NA	NA	N
3050F	LDL-C >= 130 MG/DL	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3055F	LVEF LESS THAN/EQUAL TO 35%	PRXOVR	DEF					NA	NA	NA	N
3055F	LVEF LESS THAN/EQUAL TO 35%	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3056F	LVEF GREATER THAN 35%	PRXOVR	DEF					NA	NA	NA	N
3056F	LVEF GREATER THAN 35%	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3060F	POS MICROALBUMINURIA REV	PRXOVR	DEF					NA	NA	NA	N
3060F	POS MICROALBUMINURIA REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3061F	NEG MICROALBUMINURIA REV	PRXOVR	DEF					NA	NA	NA	N
3061F	NEG MICROALBUMINURIA REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3062F	POS MACROALBUMINURIA REV	PRXOVR	DEF					NA	NA	NA	N
3062F	POS MACROALBUMINURIA REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3066F	NEPHROPATHY DOC TX	PRXOVR	DEF					NA	NA	NA	N
3066F	NEPHROPATHY DOC TX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3072F	LOW RISK FOR RETINOPATHY	PRXOVR	DEF					NA	NA	NA	N
3072F	LOW RISK FOR RETINOPATHY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3073F	PRE-SURG EYE MEASURES DOCD	PRXOVR	DEF					NA	NA	NA	N
3073F	PRE-SURG EYE MEASURES DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3074F	SYST BP LT 130 MM HG	PRXOVR	DEF					NA	NA	NA	N
3074F	SYST BP LT 130 MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3075F	SYST BP GE 130 - 139MM HG	PRXOVR	DEF					NA	NA	NA	N
3075F	SYST BP GE 130 - 139MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3076F	SYST BP < 140 MM HG	PRXOVR	DEF					NA	NA	NA	N
3076F	SYST BP < 140 MM HG	MAXFEE	DEF					NA			N
3077F	SYST BP >= 140 MM HG	PRXOVR	DEF					NA	NA	NA	N
3077F	SYST BP >= 140 MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3078F	DIAST BP <80 MM HG	PRXOVR	DEF					NA	NA	NA	N
3078F	DIAST BP <80 MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3079F	DIAST BP 80-89 MM HG	PRXOVR	DEF					NA	NA	NA	N
3079F	DIAST BP 80-89 MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3080F	DIAST BP >= 90 MM HG	PRXOVR	DEF					NA	NA	NA	N
3080F	DIAST BP >= 90 MM HG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
3082F	KT/V <1.2	PRXOVR	DEF					NA	NA	NA	N
3082F	KT/V <1.2	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3083F	KT/V =/> 1.2 & <1.7	PRXOVR	DEF					NA	NA	NA	N
3083F	KT/V =/> 1.2 & <1.7	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3084F	KT/V >= 1.7	PRXOVR	DEF					NA	NA	NA	N
3084F	KT/V >= 1.7	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3085F	SUICIDE RISK ASSESSED	PRXOVR	DEF					NA	NA	NA	N
3085F	SUICIDE RISK ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3088F	MDD MILD	PRXOVR	DEF					NA	NA	NA	N
3088F	MDD MILD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3089F	MDD MODERATE	PRXOVR	DEF					NA	NA	NA	N
3089F	MDD MODERATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3090F	MDD SEVERE W/O PSYCH	PRXOVR	DEF					NA	NA	NA	N
3090F	MDD SEVERE W/O PSYCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3091F	MDD SEVERE W/PSYCH	PRXOVR	DEF					NA	NA	NA	N
3091F	MDD SEVERE W/PSYCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3092F	MDD IN REMISSION	PRXOVR	DEF					NA	NA	NA	N
3092F	MDD IN REMISSION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3093F	DOC NEW DIAG 1ST/ADDL MDD	PRXOVR	DEF					NA	NA	NA	N
3093F	DOC NEW DIAG 1ST/ADDL MDD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3095F	CENTRAL DEXA RESULTS DOCD	PRXOVR	DEF					NA	NA	NA	N
3095F	CENTRAL DEXA RESULTS DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3096F	CENTRAL DEXA ORDERED	PRXOVR	DEF					NA	NA	NA	N
3096F	CENTRAL DEXA ORDERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3100F	IMAGE TEST REF CAROT DIAM	PRXOVR	DEF					NA	NA	NA	N
3100F	IMAGE TEST REF CAROT DIAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3110F	PRES/ABSN HMRHG/LESION DOCD	PRXOVR	DEF					NA	NA	NA	N
3110F	PRES/ABSN HMRHG/LESION DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3111F	CT/MRI BRAIN DONE W/IN 24HRS	PRXOVR	DEF					NA	NA	NA	N
3111F	CT/MRI BRAIN DONE W/IN 24HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3112F	CT/MRI BRAIN DONE 24 HRS	PRXOVR	DEF					NA	NA	NA	N
3112F	CT/MRI BRAIN DONE 24 HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3115F	QUANT RESULTS ACTIVITY &SYMP	PRXOVR	DEF					NA	NA	NA	N
3115F	QUANT RESULTS ACTIVITY &SYMP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3117F	HF ASSESSMENT TOOL COMPLETED	PRXOVR	DEF					NA	NA	NA	N
3117F	HF ASSESSMENT TOOL COMPLETED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3118F	NY HEART ASSOC CLASS DOCD	PRXOVR	DEF					NA	NA	NA	N
3118F	NY HEART ASSOC CLASS DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3119F	NO EVAL ACTIVITY CLIN SYMP	PRXOVR	DEF					NA	NA	NA	N
3119F	NO EVAL ACTIVITY CLIN SYMP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3120F	12-LEAD ECG PERFORMED	PRXOVR	DEF					NA	NA	NA	N
3120F	12-LEAD ECG PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3125F	ESOPH BX RPRT W/DYSPL INFO	PRXOVR	DEF					NA	NA	NA	N
3125F	ESOPH BX RPRT W/DYSPL INFO	MAXFEE	DEF					NA			N
3126F	ESOPH BX RPRT W/DYSPL INFO	PRXOVR	DEF					NA	NA	NA	N
3126F	ESOPH BX RPRT W/DYSPL INFO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3130F	UPPER GI ENDOSCOPY PERFORMED	PRXOVR	DEF					NA	NA	NA	N
3130F	UPPER GI ENDOSCOPY PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3132F	DOC REF UPPER GI ENDOSCOPY	PRXOVR	DEF					NA	NA	NA	N
3132F	DOC REF UPPER GI ENDOSCOPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3140F	UPPER GI ENDO SHOWS BARRTTS	PRXOVR	DEF					NA	NA	NA	N
3140F	UPPER GI ENDO SHOWS BARRTTS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3141F	UPPER GI ENDO NOT BARRTTS	PRXOVR	DEF					NA	NA	NA	N
3141F	UPPER GI ENDO NOT BARRTTS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3142F	BARIUM SWALLOW TEST ORDERED	PRXOVR	DEF					NA	NA	NA	N
3142F	BARIUM SWALLOW TEST ORDERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3150F	FORCEPS ESOPH BIOPSY DONE	PRXOVR	DEF					NA	NA	NA	N
3150F	FORCEPS ESOPH BIOPSY DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3155F	CYTOGEN TEST MARROW B/4 TX	PRXOVR	DEF					NA	NA	NA	N
3155F	CYTOGEN TEST MARROW B/4 TX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3160F	DOC FE+ STORES B/4 EPO THX	PRXOVR	DEF					NA	NA	NA	N
3160F	DOC FE+ STORES B/4 EPO THX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3170F	BASELIN FLO CYTOMETRY B/4 TX	PRXOVR	DEF					NA	NA	NA	N
3170F	BASELIN FLO CYTOMETRY B/4 TX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3200F	BARIUM SWALLOW TEST NOT REQ	PRXOVR	DEF					NA	NA	NA	N
3200F	BARIUM SWALLOW TEST NOT REQ	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3210F	GRP A STREP TEST PERFORMED	PRXOVR	DEF					NA	NA	NA	N
3210F	GRP A STREP TEST PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3215F	PT IMMUNITY TO HEP A DOCD	PRXOVR	DEF					NA	NA	NA	N
3215F	PT IMMUNITY TO HEP A DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3216F	PT IMMUNITY TO HEP B DOCD	PRXOVR	DEF					NA	NA	NA	N
3216F	PT IMMUNITY TO HEP B DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3218F	RNA TSTNG HEP C DOCD DONE	PRXOVR	DEF					NA	NA	NA	N
3218F	RNA TSTNG HEP C DOCD DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3220F	HEP C QUANT RNA TSTNG DOCD	PRXOVR	DEF					NA	NA	NA	N
3220F	HEP C QUANT RNA TSTNG DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3230F	NOTE HRING TST W/IN 6 MON	PRXOVR	DEF					NA	NA	NA	N
3230F	NOTE HRING TST W/IN 6 MON	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3250F	NONPRIM LOC ANAT BX SITE TUM	PRXOVR	DEF					NA	NA	NA	N
3250F	NONPRIM LOC ANAT BX SITE TUM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3260F	PT CAT/PN CAT/HIST GRD DOCD	PRXOVR	DEF					NA	NA	NA	N
3260F	PT CAT/PN CAT/HIST GRD DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3265F	RNA TSTNG HEPC VIR ORD/DOCD	PRXOVR	DEF					NA	NA	NA	N
3265F	RNA TSTNG HEPC VIR ORD/DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3266F	HEPC GN TSTNG DOCD B/4TXMNT	PRXOVR	DEF					NA	NA	NA	N
3266F	HEPC GN TSTNG DOCD B/4TXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3267F	PATH RPRT W/ PT PN CAT ET AL	PRXOVR	DEF					NA	NA	NA	N
3267F	PATH RPRT W/ PT PN CAT ET AL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3268F	PSA/T/GLSC DOCD B/4 TXMNT	PRXOVR	DEF					NA	NA	NA	N
3268F	PSA/T/GLSC DOCD B/4 TXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3269F	BONE SCN B/4 TXMNT/AFTR DX	PRXOVR	DEF					NA	NA	NA	N
3269F	BONE SCN B/4 TXMNT/AFTR DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3270F	NO BONE SCN B/4 TXMNT/AFTRDX	PRXOVR	DEF					NA	NA	NA	N
3270F	NO BONE SCN B/4 TXMNT/AFTRDX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3271F	LOW RISK PROSTATE CANCER	PRXOVR	DEF					NA	NA	NA	N
3271F	LOW RISK PROSTATE CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3272F	MED RISK PROSTATE CANCER	PRXOVR	DEF					NA	NA	NA	N
3272F	MED RISK PROSTATE CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3273F	HIGH RISK PROSTATE CANCER	PRXOVR	DEF					NA	NA	NA	N
3273F	HIGH RISK PROSTATE CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3274F	PROST CNCR RSK NOT LW/MD/HGH	PRXOVR	DEF					NA	NA	NA	N
3274F	PROST CNCR RSK NOT LW/MD/HGH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3278F	SERUM LVLS CA/IPTH/LPD ORD	PRXOVR	DEF					NA	NA	NA	N
3278F	SERUM LVLS CA/IPTH/LPD ORD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3279F	HGB LVL >= 13 G/DL	PRXOVR	DEF					NA	NA	NA	N
3279F	HGB LVL >= 13 G/DL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3280F	HGB LVL 11-12.9 G/DL	PRXOVR	DEF					NA	NA	NA	N
3280F	HGB LVL 11-12.9 G/DL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3281F	HGB LVL <11 G/DL	PRXOVR	DEF					NA	NA	NA	N
3281F	HGB LVL <11 G/DL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3284F	IOP DOWN >15% OF PRE-SVC LVL	PRXOVR	DEF					NA	NA	NA	N
3284F	IOP DOWN >15% OF PRE-SVC LVL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3285F	IOP DOWN <15% OF PRE-SVC LVL	PRXOVR	DEF					NA	NA	NA	N
3285F	IOP DOWN <15% OF PRE-SVC LVL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3288F	FALL RISK ASSESSMENT DOCD	PRXOVR	DEF					NA	NA	NA	N
3288F	FALL RISK ASSESSMENT DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3290F	PT=D(RH)- AND UNSENSITIZED	PRXOVR	DEF					NA	NA	NA	N
3290F	PT=D(RH)- AND UNSENSITIZED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3291F	PT=D(RH)+ OR SENSITIZED	PRXOVR	DEF					NA	NA	NA	N
3291F	PT=D(RH)+ OR SENSITIZED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3292F	HIV TSTNG ASKED/DOCD/REVWD	PRXOVR	DEF					NA	NA	NA	N
3292F	HIV TSTNG ASKED/DOCD/REVWD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3293F	ABO RH BLOOD TYPING DOCD	PRXOVR	DEF					NA	NA	NA	N
3293F	ABO RH BLOOD TYPING DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3294F	GRP B STREP SCREENING DOCD	PRXOVR	DEF					NA	NA	NA	N
3294F	GRP B STREP SCREENING DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3300F	AJCC STAGE DOCD B/4 THXPY	PRXOVR	DEF					NA	NA	NA	N
3300F	AJCC STAGE DOCD B/4 THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3301F	CANCER STAGE DOCD METAST	PRXOVR	DEF					NA	NA	NA	N
3301F	CANCER STAGE DOCD METAST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3302F	AJCC STAGE 0 DOC'D	PRXOVR	DEF					NA	NA	NA	N
3302F	AJCC STAGE 0 DOC'D	MAXFEE	DEF					NA			N
3303F	AJCC STAGE IA DOC'D	PRXOVR	DEF					NA	NA	NA	N
3303F	AJCC STAGE IA DOC'D	MAXFEE	DEF					NA			N
3304F	AJCC STAGE IB DOC'D	PRXOVR	DEF					NA	NA	NA	N
3304F	AJCC STAGE IB DOC'D	MAXFEE	DEF					NA			N
3305F	AJCC STAGE IC DOC'D	PRXOVR	DEF					NA	NA	NA	N
3305F	AJCC STAGE IC DOC'D	MAXFEE	DEF					NA			N
3306F	AJCC STAGE IIA DOC'D	PRXOVR	DEF					NA	NA	NA	N
3306F	AJCC STAGE IIA DOC'D	MAXFEE	DEF					NA			N
3307F	AJCC STAGE IIB DOC'D	PRXOVR	DEF					NA	NA	NA	N
3307F	AJCC STAGE IIB DOC'D	MAXFEE	DEF					NA			N
3308F	AJCC STAGE IIC DOC'D	PRXOVR	DEF					NA	NA	NA	N
3308F	AJCC STAGE IIC DOC'D	MAXFEE	DEF					NA			N
3309F	AJCC STAGE IIIA DOC'D	PRXOVR	DEF					NA	NA	NA	N
3309F	AJCC STAGE IIIA DOC'D	MAXFEE	DEF					NA			N
3310F	AJCC STAGE IIIB DOC'D	PRXOVR	DEF					NA	NA	NA	N
3310F	AJCC STAGE IIIB DOC'D	MAXFEE	DEF					NA			N
3311F	AJCC STAGE IIIC DOC'D	PRXOVR	DEF					NA	NA	NA	N
3311F	AJCC STAGE IIIC DOC'D	MAXFEE	DEF					NA			N
3312F	AJCC STAGE IVA DOC'D	PRXOVR	DEF					NA	NA	NA	N
3312F	AJCC STAGE IVA DOC'D	MAXFEE	DEF					NA			N
3313F	AJCC STAGE IVB DOC'D	PRXOVR	DEF					NA	NA	NA	N
3313F	AJCC STAGE IVB DOC'D	MAXFEE	DEF					NA			N
3314F	AJCC STAGE IVC DOC'D	PRXOVR	DEF					NA	NA	NA	N
3314F	AJCC STAGE IVC DOC'D	MAXFEE	DEF					NA			N
3315F	ER+ OR PR+ BREAST CANCER	PRXOVR	DEF					NA	NA	NA	N
3315F	ER+ OR PR+ BREAST CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3316F	ER- OR PR- BREAST CANCER	PRXOVR	DEF					NA	NA	NA	N
3316F	ER- OR PR- BREAST CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3317F	PATH RPT MALIG CANCER DOCD	PRXOVR	DEF					NA	NA	NA	N
3317F	PATH RPT MALIG CANCER DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3318F	PATH RPT MALIG CANCER DOCD	PRXOVR	DEF					NA	NA	NA	N
3318F	PATH RPT MALIG CANCER DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3319F	X-RAY/CT/ULTRSND ET AL ORD	PRXOVR	DEF					NA	NA	NA	N
3319F	X-RAY/CT/ULTRSND ET AL ORD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3320F	NO XRAY/CT/ ET AL ORDD	PRXOVR	DEF					NA	NA	NA	N
3320F	NO XRAY/CT/ ET AL ORDD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3321F	AJCC CNCR 0/IA MELAN DOCD	PRXOVR	DEF					NA	NA	NA	N
3321F	AJCC CNCR 0/IA MELAN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3322F	MELANOMAAJCC STAGE 0 OR IA	PRXOVR	DEF					NA	NA	NA	N
3322F	MELANOMAAJCC STAGE 0 OR IA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3323F	CLIN NODE STGNG DOCDB/4 SURG	PRXOVR	DEF					NA	NA	NA	N
3323F	CLIN NODE STGNG DOCDB/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3324F	MRI CT SCAN ORD RVWD RQSTD	PRXOVR	DEF					NA	NA	NA	N
3324F	MRI CT SCAN ORD RVWD RQSTD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3325F	PREOP ASSES 4 CATARACT SURG	PRXOVR	DEF					NA	NA	NA	N
3325F	PREOP ASSES 4 CATARACT SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3328F	PRFRMNC DOCD 2 WKS B/4 SURG	PRXOVR	DEF					NA	NA	NA	N
3328F	PRFRMNC DOCD 2 WKS B/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3330F	IMAGING STUDY ORDERED (BKP)	PRXOVR	DEF					NA	NA	NA	N
3330F	IMAGING STUDY ORDERED (BKP)	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3331F	BK IMAGING TST NOT ORDERED	PRXOVR	DEF					NA	NA	NA	N
3331F	BK IMAGING TST NOT ORDERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3340F	MAMMO ASSESS INC XRAY DOCD	PRXOVR	DEF					NA	NA	NA	N
3340F	MAMMO ASSESS INC XRAY DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3341F	MAMMO ASSESS NEGATIVE DOCD	PRXOVR	DEF					NA	NA	NA	N
3341F	MAMMO ASSESS NEGATIVE DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3342F	MAMMO ASSESS BENGN DOCD	PRXOVR	DEF					NA	NA	NA	N
3342F	MAMMO ASSESS BENGN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3343F	MAMMO PROBABLY BENGN DOCD	PRXOVR	DEF					NA	NA	NA	N
3343F	MAMMO PROBABLY BENGN DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3344F	MAMMO ASSESS SUSP DOCD	PRXOVR	DEF					NA	NA	NA	N
3344F	MAMMO ASSESS SUSP DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3345F	MAMMO ASSESS HGHLYMALIG DOC	PRXOVR	DEF					NA	NA	NA	N
3345F	MAMMO ASSESS HGHLYMALIG DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3350F	MAMMO BX PROVEN MALIG DOCD	PRXOVR	DEF					NA	NA	NA	N
3350F	MAMMO BX PROVEN MALIG DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3351F	NEG SCRN DEP SYMP BY DEPTOOL	PRXOVR	DEF					NA	NA	NA	N
3351F	NEG SCRN DEP SYMP BY DEPTOOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3352F	NO SIG DEP SYMP BY DEP TOOL	PRXOVR	DEF					NA	NA	NA	N
3352F	NO SIG DEP SYMP BY DEP TOOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3353F	MILD-MOD DEP SYMP BY DEPTOOL	PRXOVR	DEF					NA	NA	NA	N
3353F	MILD-MOD DEP SYMP BY DEPTOOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3354F	CLIN SIG DEP SYM BY DEP TOOL	PRXOVR	DEF					NA	NA	NA	N
3354F	CLIN SIG DEP SYM BY DEP TOOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3370F	AJCC BRST CNCR STAGE 0 DOCD	PRXOVR	DEF					NA	NA	NA	N
3370F	AJCC BRST CNCR STAGE 0 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3372F	AJCC BRST CNCR STAGE 1 DOCD	PRXOVR	DEF					NA	NA	NA	N
3372F	AJCC BRST CNCR STAGE 1 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3374F	AJCC BRST CNCR STAGE 1 DOCD	PRXOVR	DEF					NA	NA	NA	N
3374F	AJCC BRST CNCR STAGE 1 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3376F	AJCC BRSTCNCR STAGE 2 DOCD	PRXOVR	DEF					NA	NA	NA	N
3376F	AJCC BRSTCNCR STAGE 2 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3378F	AJCC BRSTCNCR STAGE 3 DOCD	PRXOVR	DEF					NA	NA	NA	N
3378F	AJCC BRSTCNCR STAGE 3 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3380F	AJCC BRSTCNCR STAGE 4 DOCD	PRXOVR	DEF					NA	NA	NA	N
3380F	AJCC BRSTCNCR STAGE 4 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3382F	AJCC CLN CNCR STAGE 0 DOCD	PRXOVR	DEF					NA	NA	NA	N
3382F	AJCC CLN CNCR STAGE 0 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3384F	AJCC CLN CNCR STAGE 1 DOCD	PRXOVR	DEF					NA	NA	NA	N
3384F	AJCC CLN CNCR STAGE 1 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3386F	AJCC CLN CNCR STAGE 2 DOCD	PRXOVR	DEF					NA	NA	NA	N
3386F	AJCC CLN CNCR STAGE 2 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3388F	AJCC CLN CNCR STAGE 3 DOCD	PRXOVR	DEF					NA	NA	NA	N
3388F	AJCC CLN CNCR STAGE 3 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3390F	AJCC CLN CNCR STAGE 4 DOCD	PRXOVR	DEF					NA	NA	NA	N
3390F	AJCC CLN CNCR STAGE 4 DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3394F	QUANT HER2 IHC EVAL BRST CX	PRXOVR	DEF					NA	NA	NA	N
3394F	QUANT HER2 IHC EVAL BRST CX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3395F	QUANT NONHER2 IHC BRST CX	PRXOVR	DEF					NA	NA	NA	N
3395F	QUANT NONHER2 IHC BRST CX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3450F	DYSPNEA SCRND NO-MILD DYSP	PRXOVR	DEF					NA	NA	NA	N
3450F	DYSPNEA SCRND NO-MILD DYSP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3451F	DYSPNEA SCRND MOD-HIGH DYSP	PRXOVR	DEF					NA	NA	NA	N
3451F	DYSPNEA SCRND MOD-HIGH DYSP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3452F	DYSPNEA NOT SCREENED	PRXOVR	DEF					NA	NA	NA	N
3452F	DYSPNEA NOT SCREENED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3455F	TB SCRNG DONE-INTERPD 6MON	PRXOVR	DEF					NA	NA	NA	N
3455F	TB SCRNG DONE-INTERPD 6MON	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3470F	RA DISEASE ACTIVITY LOW	PRXOVR	DEF					NA	NA	NA	N
3470F	RA DISEASE ACTIVITY LOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3471F	RA DISEASE ACTIVITY MOD	PRXOVR	DEF					NA	NA	NA	N
3471F	RA DISEASE ACTIVITY MOD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3472F	RA DISEASE ACTIVITY HIGH	PRXOVR	DEF					NA	NA	NA	N
3472F	RA DISEASE ACTIVITY HIGH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3475F	DISEASE PROGN RA POOR DOCD	PRXOVR	DEF					NA	NA	NA	N
3475F	DISEASE PROGN RA POOR DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3476F	DISEASE PROGN RA GOOD DOCD	PRXOVR	DEF					NA	NA	NA	N
3476F	DISEASE PROGN RA GOOD DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3490F	HISTORY AIDS-DEFINING COND	PRXOVR	DEF					NA	NA	NA	N
3490F	HISTORY AIDS-DEFINING COND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3491F	HIV UNSURE BABY OF HIV+MOMS	PRXOVR	DEF					NA	NA	NA	N
3491F	HIV UNSURE BABY OF HIV+MOMS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3492F	HISTORY CD4+ CELL COUNT <350	PRXOVR	DEF					NA	NA	NA	N
3492F	HISTORY CD4+ CELL COUNT <350	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3493F	NO HIST CD4+ CELL COUNT <350	PRXOVR	DEF					NA	NA	NA	N
3493F	NO HIST CD4+ CELL COUNT <350	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3494F	CD4+CELL COUNT <200CELLS/MM3	PRXOVR	DEF					NA	NA	NA	N
3494F	CD4+CELL COUNT <200CELLS/MM3	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3495F	CD4+CELL CNT 200-499 CELLS	PRXOVR	DEF					NA	NA	NA	N
3495F	CD4+CELL CNT 200-499 CELLS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3496F	CD4+ CELL COUNT >= 500 CELLS	PRXOVR	DEF					NA	NA	NA	N
3496F	CD4+ CELL COUNT >= 500 CELLS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3497F	CD4+ CELL PERCENTAGE <15%	PRXOVR	DEF					NA	NA	NA	N
3497F	CD4+ CELL PERCENTAGE <15%	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3498F	CD4+ CELL >=15% (HIV)	PRXOVR	DEF					NA	NA	NA	N
3498F	CD4+ CELL >=15% (HIV)	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3500F	CD4+CELL CNT/% DOCD AS DONE	PRXOVR	DEF					NA	NA	NA	N
3500F	CD4+CELL CNT/% DOCD AS DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3502F	HIV RNA VRL LD <LMTS QUANTIF	PRXOVR	DEF					NA	NA	NA	N
3502F	HIV RNA VRL LD <LMTS QUANTIF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3503F	HIV RNA VRL LDNOT<LMTS QUNTF	PRXOVR	DEF					NA	NA	NA	N
3503F	HIV RNA VRL LDNOT<LMTS QUNTF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3510F	DOC TB SCRNG-RSLTS INTERPD	PRXOVR	DEF					NA	NA	NA	N
3510F	DOC TB SCRNG-RSLTS INTERPD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3511F	CHLMYD/GONRH TSTS DOCD DONE	PRXOVR	DEF					NA	NA	NA	N
3511F	CHLMYD/GONRH TSTS DOCD DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3512F	SYPH SCRNG DOCD AS DONE	PRXOVR	DEF					NA	NA	NA	N
3512F	SYPH SCRNG DOCD AS DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3513F	HEP B SCRNG DOCD AS DONE	PRXOVR	DEF					NA	NA	NA	N
3513F	HEP B SCRNG DOCD AS DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3514F	HEP C SCRNG DOCD AS DONE	PRXOVR	DEF					NA	NA	NA	N
3514F	HEP C SCRNG DOCD AS DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3515F	PT HAS DOCD IMMUN TO HEP C	PRXOVR	DEF					NA	NA	NA	N
3515F	PT HAS DOCD IMMUN TO HEP C	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3517F	HBV ASSESS&RESULTS INTRP 1YR	PRXOVR	DEF					NA	NA	NA	N
3517F	HBV ASSESS&RESULTS INTRP 1YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3520F	CDIFFICILE TESTING PERFORMED	PRXOVR	DEF					NA	NA	NA	N
3520F	CDIFFICILE TESTING PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3550F	LOW RSK THROMBOEMBOLISM	PRXOVR	DEF					NA	NA	NA	N
3550F	LOW RSK THROMBOEMBOLISM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3551F	INTRMED RSK THROMBOEMBOLISM	PRXOVR	DEF					NA	NA	NA	N
3551F	INTRMED RSK THROMBOEMBOLISM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3552F	HGH RISK FOR THROMBOEMBOLISM	PRXOVR	DEF					NA	NA	NA	N
3552F	HGH RISK FOR THROMBOEMBOLISM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3555F	PT INR MEASUREMENT PERFORMED	PRXOVR	DEF					NA	NA	NA	N
3555F	PT INR MEASUREMENT PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3570F	RPRT BONE SCINT XREF W XRAY	PRXOVR	DEF					NA	NA	NA	N
3570F	RPRT BONE SCINT XREF W XRAY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3572F	PT CONSID POSS RISK FX	PRXOVR	DEF					NA	NA	NA	N
3572F	PT CONSID POSS RISK FX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3573F	PT NOT CONSID POSS RISK FX	PRXOVR	DEF					NA	NA	NA	N
3573F	PT NOT CONSID POSS RISK FX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3650F	EEG ORDERED RVWD REQSTD	PRXOVR	DEF					NA	NA	NA	N
3650F	EEG ORDERED RVWD REQSTD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3700F	PSYCH DISORDERS ASSESSED	PRXOVR	DEF					NA	NA	NA	N
3700F	PSYCH DISORDERS ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3720F	COGNIT IMPAIRMENT ASSESSED	PRXOVR	DEF					NA	NA	NA	N
3720F	COGNIT IMPAIRMENT ASSESSED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3725F	SCREEN DEPRESSION PERFORMED	PRXOVR	DEF					NA	NA	NA	N
3725F	SCREEN DEPRESSION PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3750F	PTNOTRCVNGSTEROID>=10MG/DAY	PRXOVR	DEF					NA	NA	NA	N
3750F	PTNOTRCVNGSTEROID>=10MG/DAY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3751F	ELECTRODIAG POLYNEURO 6 MN	PRXOVR	DEF					NA	NA	NA	N
3751F	ELECTRODIAG POLYNEURO 6 MN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3752F	NO ELECTRODIAG POLYNEURO 6MN	PRXOVR	DEF					NA	NA	NA	N
3752F	NO ELECTRODIAG POLYNEURO 6MN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3753F	PT HAS SYMP&SIGNS NEUROPATHY	PRXOVR	DEF					NA	NA	NA	N
3753F	PT HAS SYMP&SIGNS NEUROPATHY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3754F	SCREENING TESTS DM DONE	PRXOVR	DEF					NA	NA	NA	N
3754F	SCREENING TESTS DM DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3755F	COG&BEHAV IMPRMNT SCRNG DONE	PRXOVR	DEF					NA	NA	NA	N
3755F	COG&BEHAV IMPRMNT SCRNG DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3756F	PT W/PSEUDOBULB AFFECT/ALS	PRXOVR	DEF					NA	NA	NA	N
3756F	PT W/PSEUDOBULB AFFECT/ALS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3757F	PT W/O PSEUDOBULBAFFECT/ALS	PRXOVR	DEF					NA	NA	NA	N
3757F	PT W/O PSEUDOBULBAFFECT/ALS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3758F	PT REF PULM FX TEST/PEAKFLOW	PRXOVR	DEF					NA	NA	NA	N
3758F	PT REF PULM FX TEST/PEAKFLOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3759F	PT SCRN DYSPHAG/WT LOSS/NUTR	PRXOVR	DEF					NA	NA	NA	N
3759F	PT SCRN DYSPHAG/WT LOSS/NUTR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3760F	PT W/DYSPHAG/WT LOSS/NUTR	PRXOVR	DEF					NA	NA	NA	N
3760F	PT W/DYSPHAG/WT LOSS/NUTR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3761F	PT W/O DYSPHAG/WT LOSS/NUTR	PRXOVR	DEF					NA	NA	NA	N
3761F	PT W/O DYSPHAG/WT LOSS/NUTR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3762F	PATIENT IS DYSARTHRIC	PRXOVR	DEF					NA	NA	NA	N
3762F	PATIENT IS DYSARTHRIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3763F	PATIENT IS NOT DYSARTHRIC	PRXOVR	DEF					NA	NA	NA	N
3763F	PATIENT IS NOT DYSARTHRIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3775F	ADENOMA DETECTED SCREENING	PRXOVR	DEF					NA	NA	NA	N
3775F	ADENOMA DETECTED SCREENING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
3776F	ADENOMA NOT DETECT SCREENING	PRXOVR	DEF					NA	NA	NA	N
3776F	ADENOMA NOT DETECT SCREENING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4000F	TOBACCO USE TXMNT COUNSELING	PRXOVR	DEF					NA	NA	NA	N
4000F	TOBACCO USE TXMNT COUNSELING	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
4001F	TOBACCO USE TXMNT PHARMACOL	PRXOVR	DEF					NA	NA	NA	N
4001F	TOBACCO USE TXMNT PHARMACOL	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
4002F	STATIN THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4002F	STATIN THERAPY RX	MAXFEE	DEF					NA			N
4003F	PT ED WRITE/ORAL PTS W/ HF	PRXOVR	DEF					NA	NA	NA	N
4003F	PT ED WRITE/ORAL PTS W/ HF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4004F	PT TOBACCO SCREEN RCVD TLK	PRXOVR	DEF					NA	NA	NA	N
4004F	PT TOBACCO SCREEN RCVD TLK	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
4005F	PHARM THX FOR OP RXD	PRXOVR	DEF					NA	NA	NA	N
4005F	PHARM THX FOR OP RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4006F	BETA-BLOCKER THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4006F	BETA-BLOCKER THERAPY RX	MAXFEE	DEF					NA			N
4007F	AREDS/ANITOX VIT/MIN RX'D	PRXOVR	DEF					NA	NA	NA	N
4007F	AREDS/ANITOX VIT/MIN RX'D	MAXFEE	DEF					NA			N
4008F	BETA-BLOCKER THERAPY RXD/TKN	PRXOVR	DEF					NA	NA	NA	N
4008F	BETA-BLOCKER THERAPY RXD/TKN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4009F	ACE/ARB INHIBITOR THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4009F	ACE/ARB INHIBITOR THERAPY RX	MAXFEE	DEF					NA			N
4010F	ACE/ARB THERAPY RXD/TAKEN	PRXOVR	DEF					NA	NA	NA	N
4010F	ACE/ARB THERAPY RXD/TAKEN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4011F	ORAL ANTIPLATELET THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4011F	ORAL ANTIPLATELET THERAPY RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4012F	WARFARIN THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4012F	WARFARIN THERAPY RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4013F	STATIN THERAPY/CURRENTLY TKN	PRXOVR	DEF					NA	NA	NA	N
4013F	STATIN THERAPY/CURRENTLY TKN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4014F	WRITTEN DISCHARGE INSTR PRVD	PRXOVR	DEF					NA	NA	NA	N
4014F	WRITTEN DISCHARGE INSTR PRVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4015F	PERSIST ASTHMA MEDICINE CTRL	PRXOVR	DEF					NA	NA	NA	N
4015F	PERSIST ASTHMA MEDICINE CTRL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4016F	ANTI-INFLM/ANLGSC AGENT RX	PRXOVR	DEF					NA	NA	NA	N
4016F	ANTI-INFLM/ANLGSC AGENT RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4017F	GI PROPHYLAXIS FOR NSAID RX	PRXOVR	DEF					NA	NA	NA	N
4017F	GI PROPHYLAXIS FOR NSAID RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4018F	THERAPY EXERCISE JOINT RX	PRXOVR	DEF					NA	NA	NA	N
4018F	THERAPY EXERCISE JOINT RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4019F	DOC RECPT COUNSL VIT D/CALC+	PRXOVR	DEF					NA	NA	NA	N
4019F	DOC RECPT COUNSL VIT D/CALC+	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4025F	INHALED BRONCHODILATOR RX	PRXOVR	DEF					NA	NA	NA	N
4025F	INHALED BRONCHODILATOR RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4030F	OXYGEN THERAPY RX	PRXOVR	DEF					NA	NA	NA	N
4030F	OXYGEN THERAPY RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4033F	PULMONARY REHAB REC	PRXOVR	DEF					NA	NA	NA	N
4033F	PULMONARY REHAB REC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4035F	INFLUENZA IMM REC	PRXOVR	DEF					NA	NA	NA	N
4035F	INFLUENZA IMM REC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4037F	INFLUENZA IMM ORDER/ADMIN	PRXOVR	DEF					NA	NA	NA	N
4037F	INFLUENZA IMM ORDER/ADMIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4040F	PNEUMOC VAC/ADMIN/RCVD	PRXOVR	DEF					NA	NA	NA	N
4040F	PNEUMOC VAC/ADMIN/RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4041F	DOC ORDER CEFAZOLIN/CEFUROX	PRXOVR	DEF					NA	NA	NA	N
4041F	DOC ORDER CEFAZOLIN/CEFUROX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4042F	DOC ANTIBIO NOT GIVEN	PRXOVR	DEF					NA	NA	NA	N
4042F	DOC ANTIBIO NOT GIVEN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4043F	DOC ORDER GIVEN STOP ANTIBIO	PRXOVR	DEF					NA	NA	NA	N
4043F	DOC ORDER GIVEN STOP ANTIBIO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4044F	DOC ORDER GIVEN VTE PROPHYLX	PRXOVR	DEF					NA	NA	NA	N
4044F	DOC ORDER GIVEN VTE PROPHYLX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4045F	EMPIRIC ANTIBIOTIC RX	PRXOVR	DEF					NA	NA	NA	N
4045F	EMPIRIC ANTIBIOTIC RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4046F	DOC ANTIBIO GIVEN B/4 SURG	PRXOVR	DEF					NA	NA	NA	N
4046F	DOC ANTIBIO GIVEN B/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4047F	DOC ANTIBIO GIVEN B/4 SURG	PRXOVR	DEF					NA	NA	NA	N
4047F	DOC ANTIBIO GIVEN B/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4048F	DOC ANTIBIO GIVEN B/4 SURG	PRXOVR	DEF					NA	NA	NA	N
4048F	DOC ANTIBIO GIVEN B/4 SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4049F	DOC ORDER GIVEN STOP ANTIBIO	PRXOVR	DEF					NA	NA	NA	N
4049F	DOC ORDER GIVEN STOP ANTIBIO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4050F	HT CARE PLAN DOC	PRXOVR	DEF					NA	NA	NA	N
4050F	HT CARE PLAN DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4051F	REFERRED FOR AN AV FISTULA	PRXOVR	DEF					NA	NA	NA	N
4051F	REFERRED FOR AN AV FISTULA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4052F	HEMODIALYSIS VIA AV FISTULA	PRXOVR	DEF					NA	NA	NA	N
4052F	HEMODIALYSIS VIA AV FISTULA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4053F	HEMODIALYSIS VIA AV GRAFT	PRXOVR	DEF					NA	NA	NA	N
4053F	HEMODIALYSIS VIA AV GRAFT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4054F	HEMODIALYSIS VIA CATHETER	PRXOVR	DEF					NA	NA	NA	N
4054F	HEMODIALYSIS VIA CATHETER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4055F	PT RCVNG PERITON DIALYSIS	PRXOVR	DEF					NA	NA	NA	N
4055F	PT RCVNG PERITON DIALYSIS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4056F	APPROP ORAL REHYD RECOMMD	PRXOVR	DEF					NA	NA	NA	N
4056F	APPROP ORAL REHYD RECOMMD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4058F	PED GASTRO ED GIVEN CAREGVR	PRXOVR	DEF					NA	NA	NA	N
4058F	PED GASTRO ED GIVEN CAREGVR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4060F	PSYCH SVCS PROVIDED	PRXOVR	DEF					NA	NA	NA	N
4060F	PSYCH SVCS PROVIDED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4062F	PT REFERRAL PSYCH DOCD	PRXOVR	DEF					NA	NA	NA	N
4062F	PT REFERRAL PSYCH DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4063F	ANTIDEPRES RXTHXPY NOT RXD	PRXOVR	DEF					NA	NA	NA	N
4063F	ANTIDEPRES RXTHXPY NOT RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4064F	ANTIDEPRESSANT RX	PRXOVR	DEF					NA	NA	NA	N
4064F	ANTIDEPRESSANT RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4065F	ANTIPSYCHOTIC RX	PRXOVR	DEF					NA	NA	NA	N
4065F	ANTIPSYCHOTIC RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4066F	ECT PROVIDED	PRXOVR	DEF					NA	NA	NA	N
4066F	ECT PROVIDED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4067F	PT REFERRAL FOR ECT DOCD	PRXOVR	DEF					NA	NA	NA	N
4067F	PT REFERRAL FOR ECT DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4069F	VTE PROPHYLAXIS RCVD	PRXOVR	DEF					NA	NA	NA	N
4069F	VTE PROPHYLAXIS RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4070F	DVT PROPHYLX RECVD DAY 2	PRXOVR	DEF					NA	NA	NA	N
4070F	DVT PROPHYLX RECVD DAY 2	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4073F	ORAL ANTIPLAT THX RX DISCHRG	PRXOVR	DEF					NA	NA	NA	N
4073F	ORAL ANTIPLAT THX RX DISCHRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4075F	ANTICOAG THX RX AT DISCHRG	PRXOVR	DEF					NA	NA	NA	N
4075F	ANTICOAG THX RX AT DISCHRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4077F	DOC T-PA ADMIN CONSIDERED	PRXOVR	DEF					NA	NA	NA	N
4077F	DOC T-PA ADMIN CONSIDERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4079F	DOC REHAB SVCS CONSIDERED	PRXOVR	DEF					NA	NA	NA	N
4079F	DOC REHAB SVCS CONSIDERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4084F	ASPIRIN RECVD W/IN 24 HRS	PRXOVR	DEF					NA	NA	NA	N
4084F	ASPIRIN RECVD W/IN 24 HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4086F	ASPIRIN/CLOPIDOGREL RXD	PRXOVR	DEF					NA	NA	NA	N
4086F	ASPIRIN/CLOPIDOGREL RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4090F	PT RCVNG EPO THXPY	PRXOVR	DEF					NA	NA	NA	N
4090F	PT RCVNG EPO THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4095F	PT NOT RCVNG EPO THXPY	PRXOVR	DEF					NA	NA	NA	N
4095F	PT NOT RCVNG EPO THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4100F	BIPHOS THXPY VEIN ORD/RECVD	PRXOVR	DEF					NA	NA	NA	N
4100F	BIPHOS THXPY VEIN ORD/RECVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4110F	INT MAM ART USED FOR CABG	PRXOVR	DEF					NA	NA	NA	N
4110F	INT MAM ART USED FOR CABG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4115F	BETA BLCKR ADMIN W/IN 24 HRS	PRXOVR	DEF					NA	NA	NA	N
4115F	BETA BLCKR ADMIN W/IN 24 HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4120F	ANTIBIOT RXD/GIVEN	PRXOVR	DEF					NA	NA	NA	N
4120F	ANTIBIOT RXD/GIVEN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4124F	ANTIBIOT NOT RXD/GIVEN	PRXOVR	DEF					NA	NA	NA	N
4124F	ANTIBIOT NOT RXD/GIVEN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4130F	TOPICAL PREP RX AOE	PRXOVR	DEF					NA	NA	NA	N
4130F	TOPICAL PREP RX AOE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4131F	SYST ANTIMICROBIAL THX RX	PRXOVR	DEF					NA	NA	NA	N
4131F	SYST ANTIMICROBIAL THX RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4132F	NO SYST ANTIMICROBIAL THX RX	PRXOVR	DEF					NA	NA	NA	N
4132F	NO SYST ANTIMICROBIAL THX RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4133F	ANTIHIST/DECONG RX/RECOM	PRXOVR	DEF					NA	NA	NA	N
4133F	ANTIHIST/DECONG RX/RECOM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4134F	NO ANTIHIST/DECONG RX/RECOM	PRXOVR	DEF					NA	NA	NA	N
4134F	NO ANTIHIST/DECONG RX/RECOM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4135F	SYSTEMIC CORTICOSTEROIDS RX	PRXOVR	DEF					NA	NA	NA	N
4135F	SYSTEMIC CORTICOSTEROIDS RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4136F	SYST CORTICOSTEROIDS NOT RX	PRXOVR	DEF					NA	NA	NA	N
4136F	SYST CORTICOSTEROIDS NOT RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4140F	INHALED CORTICOSTEROIDS RXD	PRXOVR	DEF					NA	NA	NA	N
4140F	INHALED CORTICOSTEROIDS RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4142F	CORTICOSTER SPARNG THRPY RXD	PRXOVR	DEF					NA	NA	NA	N
4142F	CORTICOSTER SPARNG THRPY RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4144F	ALT LONG-TERM CNTRL MED RXD	PRXOVR	DEF					NA	NA	NA	N
4144F	ALT LONG-TERM CNTRL MED RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4145F	2+ ANTI-HYPRTNSV AGENTS TKN	PRXOVR	DEF					NA	NA	NA	N
4145F	2+ ANTI-HYPRTNSV AGENTS TKN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4148F	HEP A VAC INJXN ADMIN/RECVD	PRXOVR	DEF					NA	NA	NA	N
4148F	HEP A VAC INJXN ADMIN/RECVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4149F	HEP B VAC INJXN ADMIN/RECVD	PRXOVR	DEF					NA	NA	NA	N
4149F	HEP B VAC INJXN ADMIN/RECVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4150F	PT RECVNG ANTIVIR TXMNT HEPC	PRXOVR	DEF					NA	NA	NA	N
4150F	PT RECVNG ANTIVIR TXMNT HEPC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4151F	PT NOT RECVNG ANTIV HEP C	PRXOVR	DEF					NA	NA	NA	N
4151F	PT NOT RECVNG ANTIV HEP C	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4152F	DOC'D PEGINTF/RIB THXY CONSD	PRXOVR	DEF					NA	NA	NA	N
4152F	DOC'D PEGINTF/RIB THXY CONSD	MAXFEE	DEF					NA			N
4153F	COMBO PEGINTF/RIB RX	PRXOVR	DEF					NA	NA	NA	N
4153F	COMBO PEGINTF/RIB RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4154F	HEP A VAC SERIES RECOMMENDED	PRXOVR	DEF					NA	NA	NA	N
4154F	HEP A VAC SERIES RECOMMENDED	MAXFEE	DEF					NA			N
4155F	HEP A VAC SERIES PREV RECVD	PRXOVR	DEF					NA	NA	NA	N
4155F	HEP A VAC SERIES PREV RECVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4156F	HEP B VAC SERIES RECOMMENDED	PRXOVR	DEF					NA	NA	NA	N
4156F	HEP B VAC SERIES RECOMMENDED	MAXFEE	DEF					NA			N
4157F	HEP B VAC SERIES PREV RECVD	PRXOVR	DEF					NA	NA	NA	N
4157F	HEP B VAC SERIES PREV RECVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4158F	PT EDU RE ALCOH DRNKNG DONE	PRXOVR	DEF					NA	NA	NA	N
4158F	PT EDU RE ALCOH DRNKNG DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4159F	CONTRCP TALK B/4 ANTIV TXMNT	PRXOVR	DEF					NA	NA	NA	N
4159F	CONTRCP TALK B/4 ANTIV TXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4163F	PT COUNS 4 TXMNT OPT PROST	PRXOVR	DEF					NA	NA	NA	N
4163F	PT COUNS 4 TXMNT OPT PROST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4164F	ADJV HRMNL THXPY RXD	PRXOVR	DEF					NA	NA	NA	N
4164F	ADJV HRMNL THXPY RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4165F	3D-CRT/IMRT RECEIVED	PRXOVR	DEF					NA	NA	NA	N
4165F	3D-CRT/IMRT RECEIVED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4167F	HD BED TILTED 1ST DAY VENT	PRXOVR	DEF					NA	NA	NA	N
4167F	HD BED TILTED 1ST DAY VENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4168F	PT CARE ICU&VENT W/IN 24HRS	PRXOVR	DEF					NA	NA	NA	N
4168F	PT CARE ICU&VENT W/IN 24HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4169F	NO PT CARE ICU/VENT IN 24HRS	PRXOVR	DEF					NA	NA	NA	N
4169F	NO PT CARE ICU/VENT IN 24HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4171F	PT RCVNG ESA THXPY	PRXOVR	DEF					NA	NA	NA	N
4171F	PT RCVNG ESA THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4172F	PT NOT RCVNG ESA THXPY	PRXOVR	DEF					NA	NA	NA	N
4172F	PT NOT RCVNG ESA THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4174F	COUNS POTENT GLAUC IMPCT	PRXOVR	DEF					NA	NA	NA	N
4174F	COUNS POTENT GLAUC IMPCT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4175F	VIS 20/40/> W/IN 90 DAYS	PRXOVR	DEF					NA	NA	NA	N
4175F	VIS 20/40/> W/IN 90 DAYS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4176F	TALK RE UV LIGHT PT/CRGVR	PRXOVR	DEF					NA	NA	NA	N
4176F	TALK RE UV LIGHT PT/CRGVR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4177F	TALK PT/CRGVR RE AREDS PREV	PRXOVR	DEF					NA	NA	NA	N
4177F	TALK PT/CRGVR RE AREDS PREV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4178F	ANTID GLBLN RCVD W/IN 26WKS	PRXOVR	DEF					NA	NA	NA	N
4178F	ANTID GLBLN RCVD W/IN 26WKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4179F	TAMOXIFEN/AI PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
4179F	TAMOXIFEN/AI PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4180F	ADJV THXPYRXD/RCVD COLON CA	PRXOVR	DEF					NA	NA	NA	N
4180F	ADJV THXPYRXD/RCVD COLON CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4181F	CONFORMAL RADN THXPY RCVD	PRXOVR	DEF					NA	NA	NA	N
4181F	CONFORMAL RADN THXPY RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4182F	NO CONFORMAL RADN THXPY	PRXOVR	DEF					NA	NA	NA	N
4182F	NO CONFORMAL RADN THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4185F	CONTINUOUS PPI OR H2RA RCVD	PRXOVR	DEF					NA	NA	NA	N
4185F	CONTINUOUS PPI OR H2RA RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4186F	NO CONT PPI OR H2RA RCVD	PRXOVR	DEF					NA	NA	NA	N
4186F	NO CONT PPI OR H2RA RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4187F	ANTI RHEUM DRUGTHXPYRXD/GVN	PRXOVR	DEF					NA	NA	NA	N
4187F	ANTI RHEUM DRUGTHXPYRXD/GVN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4188F	APPROP ACE/ARB TSTNG DONE	PRXOVR	DEF					NA	NA	NA	N
4188F	APPROP ACE/ARB TSTNG DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4189F	APPROP DIGOXIN TSTNG DONE	PRXOVR	DEF					NA	NA	NA	N
4189F	APPROP DIGOXIN TSTNG DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4190F	APPROP DIURETIC TSTNG DONE	PRXOVR	DEF					NA	NA	NA	N
4190F	APPROP DIURETIC TSTNG DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4191F	APPROP ANTICONVULS TSTNG	PRXOVR	DEF					NA	NA	NA	N
4191F	APPROP ANTICONVULS TSTNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4192F	PT NOT RCVNG GLUCOCO THXPY	PRXOVR	DEF					NA	NA	NA	N
4192F	PT NOT RCVNG GLUCOCO THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4193F	PT RCV <10MG DAILY PREDNISO	PRXOVR	DEF					NA	NA	NA	N
4193F	PT RCV <10MG DAILY PREDNISO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4194F	PT RCV >=10MG DAILY PREDNISO	PRXOVR	DEF					NA	NA	NA	N
4194F	PT RCV >=10MG DAILY PREDNISO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4195F	PT RCVNG ANTI-RHEUM THXPY RA	PRXOVR	DEF					NA	NA	NA	N
4195F	PT RCVNG ANTI-RHEUM THXPY RA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4196F	PTNOT RCVNG ANTI-RHM THXPYRA	PRXOVR	DEF					NA	NA	NA	N
4196F	PTNOT RCVNG ANTI-RHM THXPYRA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4200F	EXTERNAL BEAM TO PROST ONLY	PRXOVR	DEF					NA	NA	NA	N
4200F	EXTERNAL BEAM TO PROST ONLY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4201F	EXTRNL BEAM OTHER THAN PROST	PRXOVR	DEF					NA	NA	NA	N
4201F	EXTRNL BEAM OTHER THAN PROST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4210F	ACE/ARB THXPY FOR MOS/>	PRXOVR	DEF					NA	NA	NA	N
4210F	ACE/ARB THXPY FOR MOS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4220F	DIGOXIN THXPY FOR 6 MOS/>	PRXOVR	DEF					NA	NA	NA	N
4220F	DIGOXIN THXPY FOR 6 MOS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4221F	DIURETIC THXPY FOR 6 MOS/>	PRXOVR	DEF					NA	NA	NA	N
4221F	DIURETIC THXPY FOR 6 MOS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4230F	ANTICONV THXPY FOR 6 MOS/>	PRXOVR	DEF					NA	NA	NA	N
4230F	ANTICONV THXPY FOR 6 MOS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4240F	INSTR XRCZ BACK PAIN 12 WKS	PRXOVR	DEF					NA	NA	NA	N
4240F	INSTR XRCZ BACK PAIN 12 WKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4242F	SPRVSD XRCZ BACK PN >12 WKS	PRXOVR	DEF					NA	NA	NA	N
4242F	SPRVSD XRCZ BACK PN >12 WKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4245F	PT INSTR NRML ACTIVITIES	PRXOVR	DEF					NA	NA	NA	N
4245F	PT INSTR NRML ACTIVITIES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4248F	PT INSTR NO BD REST 4 DAYS/>	PRXOVR	DEF					NA	NA	NA	N
4248F	PT INSTR NO BD REST 4 DAYS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4250F	WRMNG 4 SURG NORMOTHERMIA	PRXOVR	DEF					NA	NA	NA	N
4250F	WRMNG 4 SURG NORMOTHERMIA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4255F	ANESTH 60 MIN/> AS DOCD	PRXOVR	DEF					NA	NA	NA	N
4255F	ANESTH 60 MIN/> AS DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4256F	ANESTHE <60 MIN AS DOCD	PRXOVR	DEF					NA	NA	NA	N
4256F	ANESTHE <60 MIN AS DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4260F	WOUND SRFC CULTURETECH USED	PRXOVR	DEF					NA	NA	NA	N
4260F	WOUND SRFC CULTURETECH USED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4261F	TECH OTHER THAN SURFC CULTR	PRXOVR	DEF					NA	NA	NA	N
4261F	TECH OTHER THAN SURFC CULTR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4265F	WET-DRY DRESSINGS RX RECMD	PRXOVR	DEF					NA	NA	NA	N
4265F	WET-DRY DRESSINGS RX RECMD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4266F	NO WET-DRY DRSSINGS RX RECMD	PRXOVR	DEF					NA	NA	NA	N
4266F	NO WET-DRY DRSSINGS RX RECMD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4267F	COMPRSSION THXPY PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
4267F	COMPRSSION THXPY PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4268F	PT ED RE COMP THXPY RCVD	PRXOVR	DEF					NA	NA	NA	N
4268F	PT ED RE COMP THXPY RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4269F	APPROPOS MTHD OFFLOADING RXD	PRXOVR	DEF					NA	NA	NA	N
4269F	APPROPOS MTHD OFFLOADING RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4270F	PT RCVNG ANTI R-VIRAL THXPY	PRXOVR	DEF					NA	NA	NA	N
4270F	PT RCVNG ANTI R-VIRAL THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4271F	PT RCVNG ANTI R-VIRAL THXPY	PRXOVR	DEF					NA	NA	NA	N
4271F	PT RCVNG ANTI R-VIRAL THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4274F	FLU IMMUNO ADMIND RCVD	PRXOVR	DEF					NA	NA	NA	N
4274F	FLU IMMUNO ADMIND RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4275F	HEP B VAC INJ ADMIN/RCVD	PRXOVR	DEF					NA	NA	NA	N
4275F	HEP B VAC INJ ADMIN/RCVD	MAXFEE	DEF					NA			N
4276F	POTENT ANTIVIR THXPY RXD	PRXOVR	DEF					NA	NA	NA	N
4276F	POTENT ANTIVIR THXPY RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4279F	PCP PROPHYLAXIS RXD	PRXOVR	DEF					NA	NA	NA	N
4279F	PCP PROPHYLAXIS RXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4280F	PCP PROPHYLAX RXD 3MON LOW %	PRXOVR	DEF					NA	NA	NA	N
4280F	PCP PROPHYLAX RXD 3MON LOW %	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4290F	PT SCRNED FOR INJ DRUG USE	PRXOVR	DEF					NA	NA	NA	N
4290F	PT SCRNED FOR INJ DRUG USE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4293F	PT SCRND HGH-RISK SEX BEHAV	PRXOVR	DEF					NA	NA	NA	N
4293F	PT SCRND HGH-RISK SEX BEHAV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4300F	PT RCVNG WARF THXPY	PRXOVR	DEF					NA	NA	NA	N
4300F	PT RCVNG WARF THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4301F	PT NOT RCVNG WARF THXPY	PRXOVR	DEF					NA	NA	NA	N
4301F	PT NOT RCVNG WARF THXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4305F	PT ED RE FT CARE INSPCT RCVD	PRXOVR	DEF					NA	NA	NA	N
4305F	PT ED RE FT CARE INSPCT RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4306F	PT TLK PSYCH & RX OPD ADDIC	PRXOVR	DEF					NA	NA	NA	N
4306F	PT TLK PSYCH & RX OPD ADDIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4320F	PT TALK PSYCHSOC&RX OH DPND	PRXOVR	DEF					NA	NA	NA	N
4320F	PT TALK PSYCHSOC&RX OH DPND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4322F	CRGVR PROV W/ ED ADDL RSRCS	PRXOVR	DEF					NA	NA	NA	N
4322F	CRGVR PROV W/ ED ADDL RSRCS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4324F	PT QUERIED PRKNS COMPLIC	PRXOVR	DEF					NA	NA	NA	N
4324F	PT QUERIED PRKNS COMPLIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4325F	MED TXMNT OPTIONS RVWD W/PT	PRXOVR	DEF					NA	NA	NA	N
4325F	MED TXMNT OPTIONS RVWD W/PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4326F	PT ASKED RE SYMP AUTO DYSFXN	PRXOVR	DEF					NA	NA	NA	N
4326F	PT ASKED RE SYMP AUTO DYSFXN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4328F	PT ASKED RE SLEEP DISTURB	PRXOVR	DEF					NA	NA	NA	N
4328F	PT ASKED RE SLEEP DISTURB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4330F	CNSLNG EPI SPEC SFTY ISSUES	PRXOVR	DEF					NA	NA	NA	N
4330F	CNSLNG EPI SPEC SFTY ISSUES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4340F	CNSLNG CHLDBRNG WOMEN EPI	PRXOVR	DEF					NA	NA	NA	N
4340F	CNSLNG CHLDBRNG WOMEN EPI	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4350F	CNSLNG PROVIDED SYMP MNGMNT	PRXOVR	DEF					NA	NA	NA	N
4350F	CNSLNG PROVIDED SYMP MNGMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4400F	REHAB THXPY OPTIONS W/PT	PRXOVR	DEF					NA	NA	NA	N
4400F	REHAB THXPY OPTIONS W/PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4450F	SELF-CARE ED PROVIDED TO PT	PRXOVR	DEF					NA	NA	NA	N
4450F	SELF-CARE ED PROVIDED TO PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4470F	ICD COUNSELING PROVIDED	PRXOVR	DEF					NA	NA	NA	N
4470F	ICD COUNSELING PROVIDED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4480F	PT RCVNG ACE/ARB B-BLOCKERTX	PRXOVR	DEF					NA	NA	NA	N
4480F	PT RCVNG ACE/ARB B-BLOCKERTX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4481F	PT RCVNG ACE/ARB BLKER <3MOS	PRXOVR	DEF					NA	NA	NA	N
4481F	PT RCVNG ACE/ARB BLKER <3MOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4500F	REF TO OUTPT CARD REHAB PROG	PRXOVR	DEF					NA	NA	NA	N
4500F	REF TO OUTPT CARD REHAB PROG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4510F	PREV CARDREHAB QUALCARDEVENT	PRXOVR	DEF					NA	NA	NA	N
4510F	PREV CARDREHAB QUALCARDEVENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4525F	NEUROPSYCHIA INTERVEN ORDER	PRXOVR	DEF					NA	NA	NA	N
4525F	NEUROPSYCHIA INTERVEN ORDER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4526F	NEUROPSYCHIA INTERVEN RCVD	PRXOVR	DEF					NA	NA	NA	N
4526F	NEUROPSYCHIA INTERVEN RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4540F	DISEASE MODIF PHARMACOTHXPY	PRXOVR	DEF					NA	NA	NA	N
4540F	DISEASE MODIF PHARMACOTHXPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4541F	PT OFFERED TX FOR PSEUDOBULB	PRXOVR	DEF					NA	NA	NA	N
4541F	PT OFFERED TX FOR PSEUDOBULB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4550F	NONINVAS RESP SUPPORT TALK	PRXOVR	DEF					NA	NA	NA	N
4550F	NONINVAS RESP SUPPORT TALK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4551F	NUTRITIONAL SUPPORT OFFERED	PRXOVR	DEF					NA	NA	NA	N
4551F	NUTRITIONAL SUPPORT OFFERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4552F	PT REF FOR SPEECH LANG PATH	PRXOVR	DEF					NA	NA	NA	N
4552F	PT REF FOR SPEECH LANG PATH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4553F	PT ASST RE END LIFE ISSUES	PRXOVR	DEF					NA	NA	NA	N
4553F	PT ASST RE END LIFE ISSUES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4554F	PT RECVD INHAL ANESTHETIC	PRXOVR	DEF					NA	NA	NA	N
4554F	PT RECVD INHAL ANESTHETIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4555F	PT RECVD NO INHAL ANESTHIC	PRXOVR	DEF					NA	NA	NA	N
4555F	PT RECVD NO INHAL ANESTHIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4556F	PT W/3+ POST-OP NAUSEA&VOM	PRXOVR	DEF					NA	NA	NA	N
4556F	PT W/3+ POST-OP NAUSEA&VOM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4557F	PT W/O 3+ POST-OPNAUSEA&VOM	PRXOVR	DEF					NA	NA	NA	N
4557F	PT W/O 3+ POST-OPNAUSEA&VOM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4558F	PT RECVD 2 RX ANTI-EMET AGT	PRXOVR	DEF					NA	NA	NA	N
4558F	PT RECVD 2 RX ANTI-EMET AGT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4559F	1 BODYTEMP >=35.5CW/IN 30MIN	PRXOVR	DEF					NA	NA	NA	N
4559F	1 BODYTEMP >=35.5CW/IN 30MIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4560F	ANESTH W/O GEN/NEURAX ANESTH	PRXOVR	DEF					NA	NA	NA	N
4560F	ANESTH W/O GEN/NEURAX ANESTH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4561F	PT W/ CORONARY ARTERY STENT	PRXOVR	DEF					NA	NA	NA	N
4561F	PT W/ CORONARY ARTERY STENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4562F	PT W/O CORONARY ARTERY STENT	PRXOVR	DEF					NA	NA	NA	N
4562F	PT W/O CORONARY ARTERY STENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
4563F	PT RECVD ASPIRIN W/IN 24 HRS	PRXOVR	DEF					NA	NA	NA	N
4563F	PT RECVD ASPIRIN W/IN 24 HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5005F	PT COUNSLD ON EXAM FOR MOLES	PRXOVR	DEF					NA	NA	NA	N
5005F	PT COUNSLD ON EXAM FOR MOLES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5010F	MACUL RESULT PHY/QHP MNG DM	PRXOVR	DEF					NA	NA	NA	N
5010F	MACUL RESULT PHY/QHP MNG DM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5015F	DOC FX & TEST/TXMNT FOR OP	PRXOVR	DEF					NA	NA	NA	N
5015F	DOC FX & TEST/TXMNT FOR OP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5020F	TXMNTS 2 PHYS/QHP BY 1 MON	PRXOVR	DEF					NA	NA	NA	N
5020F	TXMNTS 2 PHYS/QHP BY 1 MON	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5050F	PLAN 2 MAIN DR BY 1 MONTH	PRXOVR	DEF					NA	NA	NA	N
5050F	PLAN 2 MAIN DR BY 1 MONTH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5060F	FNDNGS MAMMO 2PT W/IN 3 DAYS	PRXOVR	DEF					NA	NA	NA	N
5060F	FNDNGS MAMMO 2PT W/IN 3 DAYS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5062F	MAMMO RESULT COM TO PT 5 DAY	PRXOVR	DEF					NA	NA	NA	N
5062F	MAMMO RESULT COM TO PT 5 DAY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5100F	RSK FX REF W/N 24 HRS XRAY	PRXOVR	DEF					NA	NA	NA	N
5100F	RSK FX REF W/N 24 HRS XRAY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5200F	EVAL APPROS SURG THXPY EPI	PRXOVR	DEF					NA	NA	NA	N
5200F	EVAL APPROS SURG THXPY EPI	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
5250F	ASTHMA DISCHARGE PLAN PRESNT	PRXOVR	DEF					NA	NA	NA	N
5250F	ASTHMA DISCHARGE PLAN PRESNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6005F	CARE LEVEL RATIONALE DOC	PRXOVR	DEF					NA	NA	NA	N
6005F	CARE LEVEL RATIONALE DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6010F	DYSPHAG TEST DONE B/4 EATING	PRXOVR	DEF					NA	NA	NA	N
6010F	DYSPHAG TEST DONE B/4 EATING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6015F	DYSPHAG TEST DONE B/4 EATING	PRXOVR	DEF					NA	NA	NA	N
6015F	DYSPHAG TEST DONE B/4 EATING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6020F	NPO (NOTHING-MOUTH) ORDERED	PRXOVR	DEF					NA	NA	NA	N
6020F	NPO (NOTHING-MOUTH) ORDERED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6030F	MAX STERILE BARRIERS FLWD	PRXOVR	DEF					NA	NA	NA	N
6030F	MAX STERILE BARRIERS FLWD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6040F	APPRO RAD DS DVCS TECHS DOCD	PRXOVR	DEF					NA	NA	NA	N
6040F	APPRO RAD DS DVCS TECHS DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6045F	RADXPS IN END RPRT4FLURO PXD	PRXOVR	DEF					NA	NA	NA	N
6045F	RADXPS IN END RPRT4FLURO PXD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6070F	PT ASKED/CNSLD AED EFFECTS	PRXOVR	DEF					NA	NA	NA	N
6070F	PT ASKED/CNSLD AED EFFECTS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6080F	PT/CAREGIVER QUERIED FALLS	PRXOVR	DEF					NA	NA	NA	N
6080F	PT/CAREGIVER QUERIED FALLS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6090F	PT/CAREGIVER COUNSEL SAFETY	PRXOVR	DEF					NA	NA	NA	N
6090F	PT/CAREGIVER COUNSEL SAFETY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6100F	VERIFY PT SITE PXD DOCD	PRXOVR	DEF					NA	NA	NA	N
6100F	VERIFY PT SITE PXD DOCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6101F	SAFETY COUNSELING DEMENTIA	PRXOVR	DEF					NA	NA	NA	N
6101F	SAFETY COUNSELING DEMENTIA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6102F	SAFETY COUNSELING DEM ORDER	PRXOVR	DEF					NA	NA	NA	N
6102F	SAFETY COUNSELING DEM ORDER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6110F	COUNSEL PROV DRIVING RISKS	PRXOVR	DEF					NA	NA	NA	N
6110F	COUNSEL PROV DRIVING RISKS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
6150F	PT NOTRCVNG1ST ANTITNF TXMNT	PRXOVR	DEF					NA	NA	NA	N
6150F	PT NOTRCVNG1ST ANTITNF TXMNT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
7010F	PT INFO INTO RECALL SYSTEM	PRXOVR	DEF					NA	NA	NA	N
7010F	PT INFO INTO RECALL SYSTEM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
7020F	MAMMO ASSESS CAT IN DBASE	PRXOVR	DEF					NA	NA	NA	N
7020F	MAMMO ASSESS CAT IN DBASE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
7025F	PT INFOSYS ALARM 4 NXT MAMMO	PRXOVR	DEF					NA	NA	NA	N
7025F	PT INFOSYS ALARM 4 NXT MAMMO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9001F	AORTIC ANEURYSM<5CM DIAM CT	PRXOVR	DEF					NA	NA	NA	N
9001F	AORTIC ANEURYSM<5CM DIAM CT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9002F	AORTIC ANEURYSM 5-5.4CM DIAM	PRXOVR	DEF					NA	NA	NA	N
9002F	AORTIC ANEURYSM 5-5.4CM DIAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9003F	AORTIC ANRYSM5.5-5.9CM DIAM	PRXOVR	DEF					NA	NA	NA	N
9003F	AORTIC ANRYSM5.5-5.9CM DIAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9004F	AORTIC ANRYSM 6/> CM DIAM	PRXOVR	DEF					NA	NA	NA	N
9004F	AORTIC ANRYSM 6/> CM DIAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9005F	ASYMPT CAROT/VRTBRBAS STEN	PRXOVR	DEF					NA	NA	NA	N
9005F	ASYMPT CAROT/VRTBRBAS STEN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9006F	SYMPT STEN-TIA/STRK<120DAYS	PRXOVR	DEF					NA	NA	NA	N
9006F	SYMPT STEN-TIA/STRK<120DAYS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
9007F	OTHER CAROT STEN 120 DAYS/>	PRXOVR	DEF					NA	NA	NA	N
9007F	OTHER CAROT STEN 120 DAYS/>	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
90785	PSYTX COMPLEX INTERACTIVE	PRXOVR	DEF					NA	NA	NA	S
90785	PSYTX COMPLEX INTERACTIVE	MAXFEE	DEF					11.06	1/1/2017	12/31/2299	S
90791	PSYCH DIAGNOSTIC EVALUATION	PRXOVR	DEF					NA	NA	NA	N
90791	PSYCH DIAGNOSTIC EVALUATION	MAXFEE	FAC					73.47	1/1/2014	12/31/2299	N
90791	PSYCH DIAGNOSTIC EVALUATION	MAXFEE	NFF					103.07	1/1/2014	12/31/2299	N
90801	PSY DX INTERVIEW	PRXOVR	DEF					NA	NA	NA	S
90801	PSY DX INTERVIEW	MAXFEE	DEF					NA			S
90804	PSYTX OFFICE 20-30 MIN	PRXOVR	DEF					NA	NA	NA	S
90804	PSYTX OFFICE 20-30 MIN	MAXFEE	DEF					NA			S
90806	PSYTX OFF 45-50 MIN	PRXOVR	DEF					NA	NA	NA	S
90806	PSYTX OFF 45-50 MIN	MAXFEE	DEF					NA			S
90808	PSYTX OFFICE 75-80 MIN	PRXOVR	DEF					NA	NA	NA	S
90808	PSYTX OFFICE 75-80 MIN	MAXFEE	DEF					NA			S
90810	INTAC PSYTX OFF 20-30 MIN	PRXOVR	DEF					NA	NA	NA	S
90810	INTAC PSYTX OFF 20-30 MIN	MAXFEE	DEF					NA			S
90812	INTAC PSYTX OFF 45-50 MIN	PRXOVR	DEF					NA	NA	NA	S
90812	INTAC PSYTX OFF 45-50 MIN	MAXFEE	DEF					NA			S
90814	INTAC PSYTX OFF 75-80 MIN	PRXOVR	DEF					NA	NA	NA	S
90814	INTAC PSYTX OFF 75-80 MIN	MAXFEE	DEF					NA			S
90832	PSYTX W PT 30 MINUTES	PRXOVR	DEF					NA	NA	NA	N
90832	PSYTX W PT 30 MINUTES	MAXFEE	FAC					30.90	1/1/2014	12/31/2299	N
90832	PSYTX W PT 30 MINUTES	MAXFEE	NFF					42.99	1/1/2014	12/31/2299	N
90834	PSYTX W PT 45 MINUTES	PRXOVR	DEF					NA	NA	NA	N
90834	PSYTX W PT 45 MINUTES	MAXFEE	FAC					47.08	1/1/2014	12/31/2299	N
90834	PSYTX W PT 45 MINUTES	MAXFEE	NFF					55.89	1/1/2014	12/31/2299	N
90837	PSYTX W PT 60 MINUTES	PRXOVR	DEF					NA	NA	NA	N
90837	PSYTX W PT 60 MINUTES	MAXFEE	FAC					72.16	1/1/2014	12/31/2299	N
90837	PSYTX W PT 60 MINUTES	MAXFEE	NFF					81.99	1/1/2014	12/31/2299	N
90839	PSYTX CRISIS INITIAL 60 MIN	PRXOVR	DEF					NA	NA	NA	N
90839	PSYTX CRISIS INITIAL 60 MIN	MAXFEE	FAC					92.68	4/1/2015	12/31/2299	N
90839	PSYTX CRISIS INITIAL 60 MIN	MAXFEE	NFF					93.37	4/1/2015	12/31/2299	N
90840	PSYTX CRISIS EA ADDL 30 MIN	PRXOVR	DEF					NA	NA	NA	N
90840	PSYTX CRISIS EA ADDL 30 MIN	MAXFEE	FAC					44.62	4/1/2015	12/31/2299	N
90840	PSYTX CRISIS EA ADDL 30 MIN	MAXFEE	NFF					44.85	4/1/2015	12/31/2299	N
90846	FAMILY PSYTX W/O PT 50 MIN	PRXOVR	DEF					NA	NA	NA	N
90846	FAMILY PSYTX W/O PT 50 MIN	MAXFEE	FAC					52.35	1/1/2014	12/31/2299	N
90846	FAMILY PSYTX W/O PT 50 MIN	MAXFEE	NFF					55.86	1/1/2014	12/31/2299	N
90847	FAMILY PSYTX W/PT 50 MIN	PRXOVR	DEF					NA	NA	NA	N
90847	FAMILY PSYTX W/PT 50 MIN	MAXFEE	FAC					64.49	1/1/2014	12/31/2299	N
90847	FAMILY PSYTX W/PT 50 MIN	MAXFEE	NFF					68.61	1/1/2014	12/31/2299	N
90849	MULTIPLE FAMILY GROUP PSYTX	PRXOVR	DEF					NA	NA	NA	N
90849	MULTIPLE FAMILY GROUP PSYTX	MAXFEE	FAC					16.12	1/1/2014	12/31/2299	N
90849	MULTIPLE FAMILY GROUP PSYTX	MAXFEE	NFF					21.31	1/1/2014	12/31/2299	N
90853	GROUP PSYCHOTHERAPY	PRXOVR	DEF					NA	NA	NA	N
90853	GROUP PSYCHOTHERAPY	MAXFEE	DEF					19.27	7/1/2008	12/31/2299	N
90863	PHARMACOLOGIC MGMT W/PSYTX	PRXOVR	DEF					NA	NA	NA	N
90863	PHARMACOLOGIC MGMT W/PSYTX	MAXFEE	FAC					20.15	1/1/2014	12/31/2299	N
90863	PHARMACOLOGIC MGMT W/PSYTX	MAXFEE	NFF					31.99	1/1/2014	12/31/2299	N
90899	UNLISTED PSYC SVC/THERAPY	PRXOVR	DEF					NA	NA	NA	Y
90899	UNLISTED PSYC SVC/THERAPY	PADOLR	DEF					NA	NA	NA	Y
96101	PSYCHO TESTING BY PSYCH/PHYS	PRXOVR	DEF					NA	NA	NA	S
96101	PSYCHO TESTING BY PSYCH/PHYS	MAXFEE	DEF					NA			S
96101	PSYCHO TESTING BY PSYCH/PHYS	MAXFEE	PSY					NA			S
96105	ASSESSMENT OF APHASIA	PRXOVR	DEF					NA	NA	NA	S
96105	ASSESSMENT OF APHASIA	MAXFEE	DEF					46.36	7/1/2008	12/31/2299	S
96105	ASSESSMENT OF APHASIA	MAXFEE	PSY					54.54	7/1/2008	12/31/2299	S
96110	DEVELOPMENTAL SCREEN W/SCORE	PRXOVR	DEF					NA	NA	NA	S
96110	DEVELOPMENTAL SCREEN W/SCORE	MAXFEE	DEF					7.92	1/1/2012	12/31/2299	S
96110	DEVELOPMENTAL SCREEN W/SCORE	MAXFEE	PSY					9.32	1/1/2012	12/31/2299	S
96111	DEVELOPMENTAL TEST EXTEND	PRXOVR	DEF					NA	NA	NA	S
96111	DEVELOPMENTAL TEST EXTEND	MAXFEE	DEF					NA			S
96111	DEVELOPMENTAL TEST EXTEND	MAXFEE	PSY					NA			S
96112	DEVEL TST PHYS/QHP 1ST HR	PRXOVR	DEF					NA	NA	NA	S
96112	DEVEL TST PHYS/QHP 1ST HR	MAXFEE	FAC					41.71	1/1/2019	12/31/2299	S
96112	DEVEL TST PHYS/QHP 1ST HR	MAXFEE	NFF					56.11	1/1/2019	12/31/2299	S
96112	DEVEL TST PHYS/QHP 1ST HR	MAXFEE	PSY					NA			S
96113	DEVEL TST PHYS/QHP EA ADDL	PRXOVR	DEF					NA	NA	NA	S
96113	DEVEL TST PHYS/QHP EA ADDL	MAXFEE	FAC					20.86	1/1/2019	12/31/2299	S
96113	DEVEL TST PHYS/QHP EA ADDL	MAXFEE	NFF					28.06	1/1/2019	12/31/2299	S
96113	DEVEL TST PHYS/QHP EA ADDL	MAXFEE	PSY					NA			S
96115	NEUROBEHAVIOR STATUS EXAM	PRXOVR	DEF					NA	NA	NA	N
96115	NEUROBEHAVIOR STATUS EXAM	MAXFEE	DEF					NA			N
96115	NEUROBEHAVIOR STATUS EXAM	MAXFEE	PSY					NA			N
96116	NUBHVL XM PHYS/QHP 1ST HR	PRXOVR	DEF					NA	NA	NA	S
96116	NUBHVL XM PHYS/QHP 1ST HR	MAXFEE	FAC					52.06	1/1/2014	12/31/2299	S
96116	NUBHVL XM PHYS/QHP 1ST HR	MAXFEE	NFF					64.10	1/1/2014	12/31/2299	S
96116	NUBHVL XM PHYS/QHP 1ST HR	MAXFEE	PSY					NA			S
96117	NEUROPSYCH TEST BATTERY	PRXOVR	DEF					NA	NA	NA	N
96117	NEUROPSYCH TEST BATTERY	MAXFEE	DEF					NA			N
96117	NEUROPSYCH TEST BATTERY	MAXFEE	PSY					NA			N
96118	NEUROPSYCH TST BY PSYCH/PHYS	PRXOVR	DEF					NA	NA	NA	S
96118	NEUROPSYCH TST BY PSYCH/PHYS	MAXFEE	DEF					NA			S
96118	NEUROPSYCH TST BY PSYCH/PHYS	MAXFEE	PSY					NA			S
96121	NUBHVL XM PHY/QHP EA ADDL HR	PRXOVR	DEF					NA	NA	NA	S
96121	NUBHVL XM PHY/QHP EA ADDL HR	MAXFEE	FAC					47.90	1/1/2019	12/31/2299	S
96121	NUBHVL XM PHY/QHP EA ADDL HR	MAXFEE	NFF					64.10	1/1/2019	12/31/2299	S
96121	NUBHVL XM PHY/QHP EA ADDL HR	MAXFEE	PSY					NA			S
96127	BRIEF EMOTIONAL/BEHAV ASSMT	PRXOVR	DEF					NA	NA	NA	S
96127	BRIEF EMOTIONAL/BEHAV ASSMT	MAXFEE	DEF					3.97	1/1/2016	12/31/2299	S
96127	BRIEF EMOTIONAL/BEHAV ASSMT	MAXFEE	PSY					NA			S
96130	PSYCL TST EVAL PHYS/QHP 1ST	PRXOVR	DEF					NA	NA	NA	S
96130	PSYCL TST EVAL PHYS/QHP 1ST	MAXFEE	FAC					46.15	1/1/2019	12/31/2299	S
96130	PSYCL TST EVAL PHYS/QHP 1ST	MAXFEE	NFF					59.26	1/1/2019	12/31/2299	S
96130	PSYCL TST EVAL PHYS/QHP 1ST	MAXFEE	PSY					NA			S
96131	PSYCL TST EVAL PHYS/QHP EA	PRXOVR	DEF					NA	NA	NA	S
96131	PSYCL TST EVAL PHYS/QHP EA	MAXFEE	FAC					46.15	1/1/2019	12/31/2299	S
96131	PSYCL TST EVAL PHYS/QHP EA	MAXFEE	NFF					59.26	1/1/2019	12/31/2299	S
96131	PSYCL TST EVAL PHYS/QHP EA	MAXFEE	PSY					NA			S
96132	NRPSYC TST EVAL PHYS/QHP 1ST	PRXOVR	DEF					NA	NA	NA	S
96132	NRPSYC TST EVAL PHYS/QHP 1ST	MAXFEE	FAC					77.90	1/1/2019	12/31/2299	S
96132	NRPSYC TST EVAL PHYS/QHP 1ST	MAXFEE	NFF					97.37	1/1/2019	12/31/2299	S
96132	NRPSYC TST EVAL PHYS/QHP 1ST	MAXFEE	PSY					NA			S
96133	NRPSYC TST EVAL PHYS/QHP EA	PRXOVR	DEF					NA	NA	NA	S
96133	NRPSYC TST EVAL PHYS/QHP EA	MAXFEE	FAC					58.85	1/1/2019	12/31/2299	S
96133	NRPSYC TST EVAL PHYS/QHP EA	MAXFEE	NFF					78.31	1/1/2019	12/31/2299	S
96133	NRPSYC TST EVAL PHYS/QHP EA	MAXFEE	PSY					NA			S
96136	PSYCL/NRPSYC TST PHY/QHP 1ST	PRXOVR	DEF					NA	NA	NA	S
96136	PSYCL/NRPSYC TST PHY/QHP 1ST	MAXFEE	FAC					16.66	1/1/2019	12/31/2299	S
96136	PSYCL/NRPSYC TST PHY/QHP 1ST	MAXFEE	NFF					30.86	1/1/2019	12/31/2299	S
96136	PSYCL/NRPSYC TST PHY/QHP 1ST	MAXFEE	PSY					NA			S
96137	PSYCL/NRPSYC TST PHY/QHP EA	PRXOVR	DEF					NA	NA	NA	S
96137	PSYCL/NRPSYC TST PHY/QHP EA	MAXFEE	FAC					15.33	1/1/2019	12/31/2299	S
96137	PSYCL/NRPSYC TST PHY/QHP EA	MAXFEE	NFF					28.39	1/1/2019	12/31/2299	S
96137	PSYCL/NRPSYC TST PHY/QHP EA	MAXFEE	PSY					NA			S
96146	PSYCL/NRPSYC TST AUTO RESULT	PRXOVR	DEF					NA	NA	NA	S
96146	PSYCL/NRPSYC TST AUTO RESULT	MAXFEE	DEF					1.61	1/1/2019	12/31/2299	S
96146	PSYCL/NRPSYC TST AUTO RESULT	MAXFEE	PSY					1.89	1/1/2019	12/31/2299	S
96160	PT-FOCUSED HLTH RISK ASSMT	PRXOVR	DEF					NA	NA	NA	N
96160	PT-FOCUSED HLTH RISK ASSMT	MAXFEE	DEF					3.43	1/1/2017	12/31/2299	N
96161	CAREGIVER HEALTH RISK ASSMT	PRXOVR	DEF					NA	NA	NA	N
96161	CAREGIVER HEALTH RISK ASSMT	MAXFEE	DEF					3.43	1/1/2017	12/31/2299	N
98978	REM THER MNTR DEV SPLY CBT	PRXOVR	DEF					NA	NA	NA	N
98978	REM THER MNTR DEV SPLY CBT	MANUAL	DEF					NA	NA	NA	N
99354	PROLNG SVC O/P 1ST HOUR	PRXOVR	DEF					NA	NA	NA	N
99354	PROLNG SVC O/P 1ST HOUR	MAXFEE	DEF					NA			N
99355	PROLNG SVC O/P EA ADDL 30	PRXOVR	DEF					NA	NA	NA	N
99355	PROLNG SVC O/P EA ADDL 30	MAXFEE	DEF					NA			N
99406	BEHAV CHNG SMOKING 3-10 MIN	PRXOVR	DEF					NA	NA	NA	S
99406	BEHAV CHNG SMOKING 3-10 MIN	MAXFEE	FAC					7.28	1/1/2014	12/31/2299	S
99406	BEHAV CHNG SMOKING 3-10 MIN	MAXFEE	NFF					9.43	1/1/2014	12/31/2299	S
99407	BEHAV CHNG SMOKING > 10 MIN	PRXOVR	DEF					NA	NA	NA	S
99407	BEHAV CHNG SMOKING > 10 MIN	MAXFEE	FAC					15.98	1/1/2014	12/31/2299	S
99407	BEHAV CHNG SMOKING > 10 MIN	MAXFEE	NFF					19	1/1/2014	12/31/2299	S
G0396	ALCOHOL/SUBS INTERV 15-30MN	PRXOVR	DEF					NA	NA	NA	S
G0396	ALCOHOL/SUBS INTERV 15-30MN	MAXFEE	DEF					25.05	9/1/2013	12/31/2299	S
G0397	ALCOHOL/SUBS INTERV >30 MIN	PRXOVR	DEF					NA	NA	NA	S
G0397	ALCOHOL/SUBS INTERV >30 MIN	MAXFEE	DEF					47.68	9/1/2013	12/31/2299	S
G0913	IMPROVE VISUAL FUNCT	PRXOVR	DEF					NA	NA	NA	N
G0913	IMPROVE VISUAL FUNCT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G0914	SURVEY NOT COMPLETE	PRXOVR	DEF					NA	NA	NA	N
G0914	SURVEY NOT COMPLETE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G0915	NO IMPROVE VISUAL FUNCT	PRXOVR	DEF					NA	NA	NA	N
G0915	NO IMPROVE VISUAL FUNCT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G0916	SATISFY WITH CARE	PRXOVR	DEF					NA	NA	NA	N
G0916	SATISFY WITH CARE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G0917	CARE SURVEY NOT COMPLETE	PRXOVR	DEF					NA	NA	NA	N
G0917	CARE SURVEY NOT COMPLETE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G0918	NO SATISFY WITH CARE	PRXOVR	DEF					NA	NA	NA	N
G0918	NO SATISFY WITH CARE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G2011	ALCOHOL/SUB MISUSE ASSESS	PRXOVR	DEF					NA	NA	NA	S
G2011	ALCOHOL/SUB MISUSE ASSESS	MAXFEE	DEF					13.27	1/1/2019	12/31/2299	S
G8395	LVEF>=40% DOC NORMAL OR MILD	PRXOVR	DEF					NA	NA	NA	N
G8395	LVEF>=40% DOC NORMAL OR MILD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8396	LVEF NOT PERFORMED	PRXOVR	DEF					NA	NA	NA	N
G8396	LVEF NOT PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8397	DIL MACULA/FUNDUS EXAM/W DOC	PRXOVR	DEF					NA	NA	NA	N
G8397	DIL MACULA/FUNDUS EXAM/W DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8398	DIL MACULAR/FUNDUS NOT PERFO	PRXOVR	DEF					NA	NA	NA	N
G8398	DIL MACULAR/FUNDUS NOT PERFO	MAXFEE	DEF					NA			N
G8399	PT W/DXA RESULTS DOCUMENT	PRXOVR	DEF					NA	NA	NA	N
G8399	PT W/DXA RESULTS DOCUMENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8400	PT W/DXA NO RESULTS DOC	PRXOVR	DEF					NA	NA	NA	N
G8400	PT W/DXA NO RESULTS DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8404	LOW EXTEMITY NEUR EXAM DOCUM	PRXOVR	DEF					NA	NA	NA	N
G8404	LOW EXTEMITY NEUR EXAM DOCUM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8405	LOW EXTEMITY NEUR NOT PERFOR	PRXOVR	DEF					NA	NA	NA	N
G8405	LOW EXTEMITY NEUR NOT PERFOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8410	EVAL ON FOOT DOCUMENTED	PRXOVR	DEF					NA	NA	NA	N
G8410	EVAL ON FOOT DOCUMENTED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8415	EVAL ON FOOT NOT PERFORMED	PRXOVR	DEF					NA	NA	NA	N
G8415	EVAL ON FOOT NOT PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8416	PT INELIG FOOTWEAR EVALUATIO	PRXOVR	DEF					NA	NA	NA	N
G8416	PT INELIG FOOTWEAR EVALUATIO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8417	CALC BMI ABV UP PARAM F/U	PRXOVR	DEF					NA	NA	NA	N
G8417	CALC BMI ABV UP PARAM F/U	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8418	CALC BMI BLW LOW PARAM F/U	PRXOVR	DEF					NA	NA	NA	N
G8418	CALC BMI BLW LOW PARAM F/U	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8419	CALC BMI OUT NRM PARAM NOF/U	PRXOVR	DEF					NA	NA	NA	N
G8419	CALC BMI OUT NRM PARAM NOF/U	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8420	CALC BMI NORM PARAMETERS	PRXOVR	DEF					NA	NA	NA	N
G8420	CALC BMI NORM PARAMETERS	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8421	BMI NOT CALCULATED	PRXOVR	DEF					NA	NA	NA	N
G8421	BMI NOT CALCULATED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8422	PT INELIG BMI CALCULATION	PRXOVR	DEF					NA	NA	NA	N
G8422	PT INELIG BMI CALCULATION	MAXFEE	DEF					NA			N
G8427	DOCREV CUR MEDS BY ELIG CLIN	PRXOVR	DEF					NA	NA	NA	N
G8427	DOCREV CUR MEDS BY ELIG CLIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8428	CUR MEDS NOT DOCUMENT	PRXOVR	DEF					NA	NA	NA	N
G8428	CUR MEDS NOT DOCUMENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8430	DOC MED RSN NO MEDREC	PRXOVR	DEF					NA	NA	NA	N
G8430	DOC MED RSN NO MEDREC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8431	POS CLIN DEPRES SCRN F/U DOC	PRXOVR	DEF					NA	NA	NA	N
G8431	POS CLIN DEPRES SCRN F/U DOC	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8432	DEP SCR NOT DOC; RNG	PRXOVR	DEF					NA	NA	NA	N
G8432	DEP SCR NOT DOC; RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8433	SCR FOR DEP NOT CPT DOC RSN	PRXOVR	DEF					NA	NA	NA	N
G8433	SCR FOR DEP NOT CPT DOC RSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8442	DOC PAIN AS NT PERF; NOT ELG	PRXOVR	DEF					NA	NA	NA	N
G8442	DOC PAIN AS NT PERF; NOT ELG	MAXFEE	DEF					NA			N
G8450	BETA-BLOC RX PT W/ABN LVEF	PRXOVR	DEF					NA	NA	NA	N
G8450	BETA-BLOC RX PT W/ABN LVEF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8451	PT W/ABN LVEF INELIG B-BLOC	PRXOVR	DEF					NA	NA	NA	N
G8451	PT W/ABN LVEF INELIG B-BLOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8452	PT W/ABN LVEF B-BLOC NO RX	PRXOVR	DEF					NA	NA	NA	N
G8452	PT W/ABN LVEF B-BLOC NO RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8465	HIGH RISK RECURRENCE PRO CA	PRXOVR	DEF					NA	NA	NA	N
G8465	HIGH RISK RECURRENCE PRO CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8473	ACE/ARB THXPY RX'D	PRXOVR	DEF					NA	NA	NA	N
G8473	ACE/ARB THXPY RX'D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8474	ACE/ARB NOT RX'D; DOC REAS	PRXOVR	DEF					NA	NA	NA	N
G8474	ACE/ARB NOT RX'D; DOC REAS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8475	ACE/ARB THXPY NOT RX'D	PRXOVR	DEF					NA	NA	NA	N
G8475	ACE/ARB THXPY NOT RX'D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8476	BP SYS <140 AND DIAS <90	PRXOVR	DEF					NA	NA	NA	N
G8476	BP SYS <140 AND DIAS <90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8477	BP SYS>=140 AND/OR DIAS >=90	PRXOVR	DEF					NA	NA	NA	N
G8477	BP SYS>=140 AND/OR DIAS >=90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8478	BP NOT PERFORMED/DOC	PRXOVR	DEF					NA	NA	NA	N
G8478	BP NOT PERFORMED/DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8482	FLU IMMUNIZE ORDER/ADMIN	PRXOVR	DEF					NA	NA	NA	N
G8482	FLU IMMUNIZE ORDER/ADMIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8483	FLU IMM NO ADMIN DOC REA	PRXOVR	DEF					NA	NA	NA	N
G8483	FLU IMM NO ADMIN DOC REA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8484	FLU IMMUNIZE NO ADMIN	PRXOVR	DEF					NA	NA	NA	N
G8484	FLU IMMUNIZE NO ADMIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8506	PT REC ACE/ARB	PRXOVR	DEF					NA	NA	NA	N
G8506	PT REC ACE/ARB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8509	POS PAIN ASSESS NO F/U DOC	PRXOVR	DEF					NA	NA	NA	N
G8509	POS PAIN ASSESS NO F/U DOC	MAXFEE	DEF					NA			N
G8510	SCR DEP NEG; NO PLAN REQD	PRXOVR	DEF					NA	NA	NA	N
G8510	SCR DEP NEG; NO PLAN REQD	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8511	SCR DEP POS; NO PLAN DOC RNG	PRXOVR	DEF					NA	NA	NA	N
G8511	SCR DEP POS; NO PLAN DOC RNG	MAXFEE	DEF					0	10/1/2012	12/31/2299	N
G8535	ELD MALTREATMENT NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G8535	ELD MALTREATMENT NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8536	NO DOC ELDER MAL SCRN	PRXOVR	DEF					NA	NA	NA	N
G8536	NO DOC ELDER MAL SCRN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8539	DOC FUNCT AND CARE PLAN	PRXOVR	DEF					NA	NA	NA	N
G8539	DOC FUNCT AND CARE PLAN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8540	FOA NOT DOC AS BEING PERF	PRXOVR	DEF					NA	NA	NA	N
G8540	FOA NOT DOC AS BEING PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8541	NO DOC CUR FUNCT ASSESS	PRXOVR	DEF					NA	NA	NA	N
G8541	NO DOC CUR FUNCT ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8542	DOC FUNCT NO DEFICIENCIES	PRXOVR	DEF					NA	NA	NA	N
G8542	DOC FUNCT NO DEFICIENCIES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8543	CUR FUNCT ASSES; NO CARE PLN	PRXOVR	DEF					NA	NA	NA	N
G8543	CUR FUNCT ASSES; NO CARE PLN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8569	PROL INTUBATION REQ	PRXOVR	DEF					NA	NA	NA	N
G8569	PROL INTUBATION REQ	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8570	NO PROL INTUB REQ	PRXOVR	DEF					NA	NA	NA	N
G8570	NO PROL INTUB REQ	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8571	STER WD IFX 30 D POSTOP	PRXOVR	DEF					NA	NA	NA	N
G8571	STER WD IFX 30 D POSTOP	MAXFEE	DEF					NA			N
G8572	NO STER WD IFX	PRXOVR	DEF					NA	NA	NA	N
G8572	NO STER WD IFX	MAXFEE	DEF					NA			N
G8573	STK CABG	PRXOVR	DEF					NA	NA	NA	N
G8573	STK CABG	MAXFEE	DEF					NA			N
G8574	NO STRK CABG	PRXOVR	DEF					NA	NA	NA	N
G8574	NO STRK CABG	MAXFEE	DEF					NA			N
G8575	POSTOP REN FAIL	PRXOVR	DEF					NA	NA	NA	N
G8575	POSTOP REN FAIL	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8576	NO POSTOP REN FAIL	PRXOVR	DEF					NA	NA	NA	N
G8576	NO POSTOP REN FAIL	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8577	REOP REQ BLD GRFT OTH	PRXOVR	DEF					NA	NA	NA	N
G8577	REOP REQ BLD GRFT OTH	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8578	NO REOP REQ BLD GRFT OTH	PRXOVR	DEF					NA	NA	NA	N
G8578	NO REOP REQ BLD GRFT OTH	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8598	ASA/ANTIPLAT THER USED	PRXOVR	DEF					NA	NA	NA	N
G8598	ASA/ANTIPLAT THER USED	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8599	NO ASA/ANTIPLAT THER USE RNG	PRXOVR	DEF					NA	NA	NA	N
G8599	NO ASA/ANTIPLAT THER USE RNG	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8600	TPA INITI W/IN 4.5 HR	PRXOVR	DEF					NA	NA	NA	N
G8600	TPA INITI W/IN 4.5 HR	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8601	NO ELIG TPA INIT W/IN 4.5 HR	PRXOVR	DEF					NA	NA	NA	N
G8601	NO ELIG TPA INIT W/IN 4.5 HR	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8602	NO TPA INIT W/IN 4.5 HR	PRXOVR	DEF					NA	NA	NA	N
G8602	NO TPA INIT W/IN 4.5 HR	MAXFEE	DEF					0	1/1/2010	12/31/2299	N
G8627	SURG PROC W/IN 30 DAYS	PRXOVR	DEF					NA	NA	NA	N
G8627	SURG PROC W/IN 30 DAYS	MAXFEE	DEF					NA			N
G8628	NO SURG PROC W/IN 30 DAYS	PRXOVR	DEF					NA	NA	NA	N
G8628	NO SURG PROC W/IN 30 DAYS	MAXFEE	DEF					NA			N
G8633	PHARM THER OSTEO RX	PRXOVR	DEF					NA	NA	NA	N
G8633	PHARM THER OSTEO RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8635	NO PHARM THER OSTEO RX	PRXOVR	DEF					NA	NA	NA	N
G8635	NO PHARM THER OSTEO RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8647	RAFSCRS KI SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8647	RAFSCRS KI SCOR >= 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8648	RAFSCRS KI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8648	RAFSCRS KI SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8649	RAFSCRS KI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8649	RAFSCRS KI NO SCOR	MAXFEE	DEF					NA			N
G8650	RAFS CRS KI NO SCOR NO RSN	PRXOVR	DEF					NA	NA	NA	N
G8650	RAFS CRS KI NO SCOR NO RSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8651	RAFSCRS HI SCOR >=0	PRXOVR	DEF					NA	NA	NA	N
G8651	RAFSCRS HI SCOR >=0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8652	RAFSCRS HI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8652	RAFSCRS HI SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8653	RAFSCRS HI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8653	RAFSCRS HI NO SCOR	MAXFEE	DEF					NA			N
G8654	RAFS CRS HI NO SCOR NO SURV	PRXOVR	DEF					NA	NA	NA	N
G8654	RAFS CRS HI NO SCOR NO SURV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8655	RAFSCRS LLFAI SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8655	RAFSCRS LLFAI SCOR >= 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8656	RAFSCRS LLFAI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8656	RAFSCRS LLFAI SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8657	RAFSCRS LLFAI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8657	RAFSCRS LLFAI NO SCOR	MAXFEE	DEF					NA			N
G8658	RAFSCRS LLFAI NO SCOR + SURV	PRXOVR	DEF					NA	NA	NA	N
G8658	RAFSCRS LLFAI NO SCOR + SURV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8659	RAFSCRS LBI SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8659	RAFSCRS LBI SCOR >= 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8660	RAFSCRS LBI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8660	RAFSCRS LBI SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8661	RAFSCRS LBI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8661	RAFSCRS LBI NO SCOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8662	RAFS CRS LBI NO SCOR NO SURV	PRXOVR	DEF					NA	NA	NA	N
G8662	RAFS CRS LBI NO SCOR NO SURV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8663	RAFSCRS SI SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8663	RAFSCRS SI SCOR >= 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8664	RAFSCRS SI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8664	RAFSCRS SI SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8665	RAFSCRS SI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8665	RAFSCRS SI NO SCOR	MAXFEE	DEF					NA			N
G8666	RAFS CRS SI NO SCOR NO SURV	PRXOVR	DEF					NA	NA	NA	N
G8666	RAFS CRS SI NO SCOR NO SURV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8667	RAFSCRS EWH SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8667	RAFSCRS EWH SCOR >= 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8668	RAFSCRS EWH SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8668	RAFSCRS EWH SCOR < 0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8669	RAFSCRS	PRXOVR	DEF					NA	NA	NA	N
G8669	RAFSCRS	MAXFEE	DEF					NA			N
G8670	RAFS CRS EWH NO SCOR NO SURV	PRXOVR	DEF					NA	NA	NA	N
G8670	RAFS CRS EWH NO SCOR NO SURV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8671	RAFSCRS GOI SCOR >= 0	PRXOVR	DEF					NA	NA	NA	N
G8671	RAFSCRS GOI SCOR >= 0	MAXFEE	DEF					NA			N
G8672	RAFSCRS GOI SCOR < 0	PRXOVR	DEF					NA	NA	NA	N
G8672	RAFSCRS GOI SCOR < 0	MAXFEE	DEF					NA			N
G8673	RAFSCRS GOI NO SCOR	PRXOVR	DEF					NA	NA	NA	N
G8673	RAFSCRS GOI NO SCOR	MAXFEE	DEF					NA			N
G8674	RAFSCRS NECK; NO MSR/NO FOTO	PRXOVR	DEF					NA	NA	NA	N
G8674	RAFSCRS NECK; NO MSR/NO FOTO	MAXFEE	DEF					NA			N
G8694	LVEF <=40%	PRXOVR	DEF					NA	NA	NA	N
G8694	LVEF <=40%	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8708	ANTIBIOTIC NOT PRES	PRXOVR	DEF					NA	NA	NA	N
G8708	ANTIBIOTIC NOT PRES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8709	URI EP COMPETE DIAG	PRXOVR	DEF					NA	NA	NA	N
G8709	URI EP COMPETE DIAG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8710	PT PRES ANTIBIOTIC	PRXOVR	DEF					NA	NA	NA	N
G8710	PT PRES ANTIBIOTIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8711	PRES ANTIBX ON/WITHIN 3 DAY	PRXOVR	DEF					NA	NA	NA	N
G8711	PRES ANTIBX ON/WITHIN 3 DAY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8712	NOT PRES ANTIBIOTIC	PRXOVR	DEF					NA	NA	NA	N
G8712	NOT PRES ANTIBIOTIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8721	PT; PN; HIST GRADE DOC	PRXOVR	DEF					NA	NA	NA	N
G8721	PT; PN; HIST GRADE DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8722	MED REAS PT; PN; NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G8722	MED REAS PT; PN; NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8723	SPEC SIT NOT PRIM TUMOR	PRXOVR	DEF					NA	NA	NA	N
G8723	SPEC SIT NOT PRIM TUMOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8724	PT; PN; HIST GRADE NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G8724	PT; PN; HIST GRADE NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8730	PAIN DOC POS AND PLAN	PRXOVR	DEF					NA	NA	NA	N
G8730	PAIN DOC POS AND PLAN	MAXFEE	DEF					NA			N
G8731	PAIN NEG NO PLAN	PRXOVR	DEF					NA	NA	NA	N
G8731	PAIN NEG NO PLAN	MAXFEE	DEF					NA			N
G8732	NO DOC OF PAIN	PRXOVR	DEF					NA	NA	NA	N
G8732	NO DOC OF PAIN	MAXFEE	DEF					NA			N
G8733	DOC POS ELDER MAL SCRN PLAN	PRXOVR	DEF					NA	NA	NA	N
G8733	DOC POS ELDER MAL SCRN PLAN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8734	DOC NEG ELD REQ	PRXOVR	DEF					NA	NA	NA	N
G8734	DOC NEG ELD REQ	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8735	ELD MAL SCRN POS NO PLAN	PRXOVR	DEF					NA	NA	NA	N
G8735	ELD MAL SCRN POS NO PLAN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8749	NO SIGNS MELANOMA	PRXOVR	DEF					NA	NA	NA	N
G8749	NO SIGNS MELANOMA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8752	SYS BP LESS 140	PRXOVR	DEF					NA	NA	NA	N
G8752	SYS BP LESS 140	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8753	SYS BP > OR = 140	PRXOVR	DEF					NA	NA	NA	N
G8753	SYS BP > OR = 140	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8754	DIAS BP LESS 90	PRXOVR	DEF					NA	NA	NA	N
G8754	DIAS BP LESS 90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8755	DIAS BP > OR = 90	PRXOVR	DEF					NA	NA	NA	N
G8755	DIAS BP > OR = 90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8756	NO BP MEASURE DOC	PRXOVR	DEF					NA	NA	NA	N
G8756	NO BP MEASURE DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8783	BP SCRN PERF REC INTERVAL	PRXOVR	DEF					NA	NA	NA	N
G8783	BP SCRN PERF REC INTERVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8785	BP SCRN NO PERF AT INTERVAL	PRXOVR	DEF					NA	NA	NA	N
G8785	BP SCRN NO PERF AT INTERVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8797	SPECIMEN SITE NOT ESOPHAGUS	PRXOVR	DEF					NA	NA	NA	N
G8797	SPECIMEN SITE NOT ESOPHAGUS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8798	SPECIMEN SITE NOT PROSTATE	PRXOVR	DEF					NA	NA	NA	N
G8798	SPECIMEN SITE NOT PROSTATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8806	PERF ULTRSND TO LCT PREG DOC	PRXOVR	DEF					NA	NA	NA	N
G8806	PERF ULTRSND TO LCT PREG DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8807	NO TA TV ULTRASND	PRXOVR	DEF					NA	NA	NA	N
G8807	NO TA TV ULTRASND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8808	ULTRASOUND NOT PERF; RNG	PRXOVR	DEF					NA	NA	NA	N
G8808	ULTRASOUND NOT PERF; RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8809	RH-IMMUNOGLOBULIN ORDER	PRXOVR	DEF					NA	NA	NA	N
G8809	RH-IMMUNOGLOBULIN ORDER	MAXFEE	DEF					NA			N
G8810	DOC REAS NO RH-IMMUNO	PRXOVR	DEF					NA	NA	NA	N
G8810	DOC REAS NO RH-IMMUNO	MAXFEE	DEF					NA			N
G8811	NO RH-IMMUNOGLOBULIN ORDER	PRXOVR	DEF					NA	NA	NA	N
G8811	NO RH-IMMUNOGLOBULIN ORDER	MAXFEE	DEF					NA			N
G8815	DOC REAS NO STATIN THERAPY	PRXOVR	DEF					NA	NA	NA	N
G8815	DOC REAS NO STATIN THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8816	STATIN MED PRES AT DISCH	PRXOVR	DEF					NA	NA	NA	N
G8816	STATIN MED PRES AT DISCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8817	DOC REAS NO STATIN MED DISCH	PRXOVR	DEF					NA	NA	NA	N
G8817	DOC REAS NO STATIN MED DISCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8818	PT DISCH TO HOME BY DAY#7	PRXOVR	DEF					NA	NA	NA	N
G8818	PT DISCH TO HOME BY DAY#7	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8825	PT NOT DISCH TO HOME DAY#7	PRXOVR	DEF					NA	NA	NA	N
G8825	PT NOT DISCH TO HOME DAY#7	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8826	PT DISCH HOME DAY #2 EVAR	PRXOVR	DEF					NA	NA	NA	N
G8826	PT DISCH HOME DAY #2 EVAR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8833	PT NOT DISCH HOME DAY#2 EVAR	PRXOVR	DEF					NA	NA	NA	N
G8833	PT NOT DISCH HOME DAY#2 EVAR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8834	PT DISCH HOME DAY #2 CEA	PRXOVR	DEF					NA	NA	NA	N
G8834	PT DISCH HOME DAY #2 CEA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8838	NOT DISCH HOME BY DAY #2	PRXOVR	DEF					NA	NA	NA	N
G8838	NOT DISCH HOME BY DAY #2	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8839	SLEEP APNEA ASSESS	PRXOVR	DEF					NA	NA	NA	N
G8839	SLEEP APNEA ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8840	DOC REAS NO SLEEP APNEA	PRXOVR	DEF					NA	NA	NA	N
G8840	DOC REAS NO SLEEP APNEA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8841	NO SLEEP APNEA ASSESS	PRXOVR	DEF					NA	NA	NA	N
G8841	NO SLEEP APNEA ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8842	AHI OR RDI INITIAL DX	PRXOVR	DEF					NA	NA	NA	N
G8842	AHI OR RDI INITIAL DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8843	DOC REAS NO AHI OR RDI	PRXOVR	DEF					NA	NA	NA	N
G8843	DOC REAS NO AHI OR RDI	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8844	NO AHI OR RDI INITIAL DX	PRXOVR	DEF					NA	NA	NA	N
G8844	NO AHI OR RDI INITIAL DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8845	POS AIRWAY PRESS PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
G8845	POS AIRWAY PRESS PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8846	MOD OR SEVERE OSA	PRXOVR	DEF					NA	NA	NA	N
G8846	MOD OR SEVERE OSA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8849	DOC REAS NO POS AIR PRESS	PRXOVR	DEF					NA	NA	NA	N
G8849	DOC REAS NO POS AIR PRESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8850	NO PAP PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
G8850	NO PAP PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8851	ADHERE POS AIR PRESS THERAPY	PRXOVR	DEF					NA	NA	NA	N
G8851	ADHERE POS AIR PRESS THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8852	POS AIR PRESS PRESCRIBE	PRXOVR	DEF					NA	NA	NA	N
G8852	POS AIR PRESS PRESCRIBE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8854	REAS NO ADHERE POS AIR PRES	PRXOVR	DEF					NA	NA	NA	N
G8854	REAS NO ADHERE POS AIR PRES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8855	POS AIR PRESS ADHERE NO PERF	PRXOVR	DEF					NA	NA	NA	N
G8855	POS AIR PRESS ADHERE NO PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8856	REF FOR OTO EVAL	PRXOVR	DEF					NA	NA	NA	N
G8856	REF FOR OTO EVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8857	NO ELIG REF FOR OTO EVAL	PRXOVR	DEF					NA	NA	NA	N
G8857	NO ELIG REF FOR OTO EVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8858	NOT REF FOR OTO EVAL	PRXOVR	DEF					NA	NA	NA	N
G8858	NOT REF FOR OTO EVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8861	DXA ORDERED FOR OSTEO	PRXOVR	DEF					NA	NA	NA	N
G8861	DXA ORDERED FOR OSTEO	MAXFEE	DEF					NA			N
G8863	NO ASSESS BONE LOSS	PRXOVR	DEF					NA	NA	NA	N
G8863	NO ASSESS BONE LOSS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8864	PNEUMOCOCCAL VACCINE ADMIN	PRXOVR	DEF					NA	NA	NA	N
G8864	PNEUMOCOCCAL VACCINE ADMIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8865	DOC MED REAS NO PNEUMOCOCCAL	PRXOVR	DEF					NA	NA	NA	N
G8865	DOC MED REAS NO PNEUMOCOCCAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8866	DOC PT REAS NO PNEUMOCOCCAL	PRXOVR	DEF					NA	NA	NA	N
G8866	DOC PT REAS NO PNEUMOCOCCAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8867	NO PNEUMOCOCCAL ADMIN	PRXOVR	DEF					NA	NA	NA	N
G8867	NO PNEUMOCOCCAL ADMIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8869	DOC IMMUNE HEP B ANTITNF	PRXOVR	DEF					NA	NA	NA	N
G8869	DOC IMMUNE HEP B ANTITNF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8872	INTRAOP IMAGE CONFIRM EXCISE	PRXOVR	DEF					NA	NA	NA	N
G8872	INTRAOP IMAGE CONFIRM EXCISE	MAXFEE	DEF					NA			N
G8873	SPECIMEN NOT INTRAOP IMAGE	PRXOVR	DEF					NA	NA	NA	N
G8873	SPECIMEN NOT INTRAOP IMAGE	MAXFEE	DEF					NA			N
G8874	TISSUE NOT IMAGE INTRAOP	PRXOVR	DEF					NA	NA	NA	N
G8874	TISSUE NOT IMAGE INTRAOP	MAXFEE	DEF					NA			N
G8875	BREAST CANCER DX MIN INVSIVE	PRXOVR	DEF					NA	NA	NA	N
G8875	BREAST CANCER DX MIN INVSIVE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8876	DOC REAS NO MIN INV DX	PRXOVR	DEF					NA	NA	NA	N
G8876	DOC REAS NO MIN INV DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8877	NO BRST CNCR DX MIN INVASIVE	PRXOVR	DEF					NA	NA	NA	N
G8877	NO BRST CNCR DX MIN INVASIVE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8878	SENT LYMPH NODE BIOPSY	PRXOVR	DEF					NA	NA	NA	N
G8878	SENT LYMPH NODE BIOPSY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8880	SEN LYM P NODE BIOP NOT PERF	PRXOVR	DEF					NA	NA	NA	N
G8880	SEN LYM P NODE BIOP NOT PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8881	BRST CNCR STAGE > T1N0M0	PRXOVR	DEF					NA	NA	NA	N
G8881	BRST CNCR STAGE > T1N0M0	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8882	NO SENT LYMPH NODE BIOPSY	PRXOVR	DEF					NA	NA	NA	N
G8882	NO SENT LYMPH NODE BIOPSY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8883	REV; COMM; TRACK; DOC BIOPSY	PRXOVR	DEF					NA	NA	NA	N
G8883	REV; COMM; TRACK; DOC BIOPSY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8884	DOC REAS BIOPSY NOT REVIEW	PRXOVR	DEF					NA	NA	NA	N
G8884	DOC REAS BIOPSY NOT REVIEW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8885	NO REV; COMM; TRACK BIOPSY	PRXOVR	DEF					NA	NA	NA	N
G8885	NO REV; COMM; TRACK BIOPSY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8923	LVEF <= 40% OR LVSD	PRXOVR	DEF					NA	NA	NA	N
G8923	LVEF <= 40% OR LVSD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8924	SPIR FEV1/FVC<70%;FEV<60%	PRXOVR	DEF					NA	NA	NA	N
G8924	SPIR FEV1/FVC<70%;FEV<60%	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8925	SPIR FEV1/FVC>=60% & NO COPD	PRXOVR	DEF					NA	NA	NA	N
G8925	SPIR FEV1/FVC>=60% & NO COPD	MAXFEE	DEF					NA			N
G8926	SPIRO NO PERF OR DOC	PRXOVR	DEF					NA	NA	NA	N
G8926	SPIRO NO PERF OR DOC	MAXFEE	DEF					NA			N
G8934	LVEF <=40% OR DEP LV SYS FCN	PRXOVR	DEF					NA	NA	NA	N
G8934	LVEF <=40% OR DEP LV SYS FCN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8935	RX ACE OR ARB THERAPY	PRXOVR	DEF					NA	NA	NA	N
G8935	RX ACE OR ARB THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8936	PT NOT ELIGIBLE ACE/ARB	PRXOVR	DEF					NA	NA	NA	N
G8936	PT NOT ELIGIBLE ACE/ARB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8937	NO RX ACE/ARB THERAPY	PRXOVR	DEF					NA	NA	NA	N
G8937	NO RX ACE/ARB THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8938	BMI DOC ONL FUP NT DOC	PRXOVR	DEF					NA	NA	NA	N
G8938	BMI DOC ONL FUP NT DOC	MAXFEE	DEF					NA			N
G8939	PAIN AS DOC POSITIVE; NO F/U	PRXOVR	DEF					NA	NA	NA	N
G8939	PAIN AS DOC POSITIVE; NO F/U	MAXFEE	DEF					NA			N
G8941	ELD MALTREATMENT DOC AS POS	PRXOVR	DEF					NA	NA	NA	N
G8941	ELD MALTREATMENT DOC AS POS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8942	DOC FCN/CARE PLAN W/30 DAYS	PRXOVR	DEF					NA	NA	NA	N
G8942	DOC FCN/CARE PLAN W/30 DAYS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8944	AJCC MEL CNR STG 0 - IIC	PRXOVR	DEF					NA	NA	NA	N
G8944	AJCC MEL CNR STG 0 - IIC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8946	MIBM BUT NO DX OF BREAST CA	PRXOVR	DEF					NA	NA	NA	N
G8946	MIBM BUT NO DX OF BREAST CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8950	PRE-HTN OR HTN DOC; F/U INDC	PRXOVR	DEF					NA	NA	NA	N
G8950	PRE-HTN OR HTN DOC; F/U INDC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8952	PRE-HTN/HTN; NO F/U; NOT GVN	PRXOVR	DEF					NA	NA	NA	N
G8952	PRE-HTN/HTN; NO F/U; NOT GVN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8955	MOST RECENT ASSESS VOL MGMT	PRXOVR	DEF					NA	NA	NA	N
G8955	MOST RECENT ASSESS VOL MGMT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8956	PT RCV HEDIA OUTPT DYLS FAC	PRXOVR	DEF					NA	NA	NA	N
G8956	PT RCV HEDIA OUTPT DYLS FAC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8958	ASSESS VOL MGMT NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G8958	ASSESS VOL MGMT NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8959	CLIN TX MDD COMM TO TX CLIN	PRXOVR	DEF					NA	NA	NA	N
G8959	CLIN TX MDD COMM TO TX CLIN	MAXFEE	DEF					NA			N
G8960	CLIN TX MDD NOT COMM	PRXOVR	DEF					NA	NA	NA	N
G8960	CLIN TX MDD NOT COMM	MAXFEE	DEF					NA			N
G8961	CSIT LOWRISK SURG PTS PREOP	PRXOVR	DEF					NA	NA	NA	N
G8961	CSIT LOWRISK SURG PTS PREOP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8962	CSIT ON PT ANY REAS 30 DAYS	PRXOVR	DEF					NA	NA	NA	N
G8962	CSIT ON PT ANY REAS 30 DAYS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8963	CSI PER ASX PT W/PCI 2 YRS	PRXOVR	DEF					NA	NA	NA	N
G8963	CSI PER ASX PT W/PCI 2 YRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8964	CSI ANY OTHER THAN PCI 2 YR	PRXOVR	DEF					NA	NA	NA	N
G8964	CSI ANY OTHER THAN PCI 2 YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8965	CSIT PERF ON LOW CHD RSK	PRXOVR	DEF					NA	NA	NA	N
G8965	CSIT PERF ON LOW CHD RSK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8966	CSIT PERF SX OR HIGH CHD RSK	PRXOVR	DEF					NA	NA	NA	N
G8966	CSIT PERF SX OR HIGH CHD RSK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8967	WARF OR OTHER FDA DRUG PRESC	PRXOVR	DEF					NA	NA	NA	N
G8967	WARF OR OTHER FDA DRUG PRESC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8968	DOC MED NOT PRESB	PRXOVR	DEF					NA	NA	NA	N
G8968	DOC MED NOT PRESB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8969	DOC PT RSN NO PRESC WARF/FDA	PRXOVR	DEF					NA	NA	NA	N
G8969	DOC PT RSN NO PRESC WARF/FDA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8970	NO RSK FAC OR 1 MOD RISK TE	PRXOVR	DEF					NA	NA	NA	N
G8970	NO RSK FAC OR 1 MOD RISK TE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G8973	MST RCNT HBB < 10G/DL	PRXOVR	DEF					NA	NA	NA	N
G8973	MST RCNT HBB < 10G/DL	MAXFEE	DEF					NA			N
G8974	HGB NOT DOC RNS NOT GVN	PRXOVR	DEF					NA	NA	NA	N
G8974	HGB NOT DOC RNS NOT GVN	MAXFEE	DEF					NA			N
G8975	HGB <10G/DL; MED RSN	PRXOVR	DEF					NA	NA	NA	N
G8975	HGB <10G/DL; MED RSN	MAXFEE	DEF					NA			N
G8976	HGB >= 10 G/DL	PRXOVR	DEF					NA	NA	NA	N
G8976	HGB >= 10 G/DL	MAXFEE	DEF					NA			N
G9063	ONC DX NSCLC STGI NO PROGRES	PRXOVR	DEF					NA	NA	NA	N
G9063	ONC DX NSCLC STGI NO PROGRES	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9064	ONC DX NSCLC STG2 NO PROGRES	PRXOVR	DEF					NA	NA	NA	N
G9064	ONC DX NSCLC STG2 NO PROGRES	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9065	ONC DX NSCLC STG3A NO PROGRE	PRXOVR	DEF					NA	NA	NA	N
G9065	ONC DX NSCLC STG3A NO PROGRE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9066	ONC DX NSCLC STG3B-4 METASTA	PRXOVR	DEF					NA	NA	NA	N
G9066	ONC DX NSCLC STG3B-4 METASTA	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9067	ONC DX NSCLC DX UNKNOWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9067	ONC DX NSCLC DX UNKNOWN NOS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9068	ONC DX SCLC/NSCLC LIMITED	PRXOVR	DEF					NA	NA	NA	N
G9068	ONC DX SCLC/NSCLC LIMITED	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9069	ONC DX SCLC/NSCLC EXT AT DX	PRXOVR	DEF					NA	NA	NA	N
G9069	ONC DX SCLC/NSCLC EXT AT DX	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9070	ONC DX SCLC/NSCLC EXT UNKNWN	PRXOVR	DEF					NA	NA	NA	N
G9070	ONC DX SCLC/NSCLC EXT UNKNWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9071	ONC DX BRST STG1-2B HR;NOPRO	PRXOVR	DEF					NA	NA	NA	N
G9071	ONC DX BRST STG1-2B HR;NOPRO	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9072	ONC DX BRST STG1-2 NOPROGRES	PRXOVR	DEF					NA	NA	NA	N
G9072	ONC DX BRST STG1-2 NOPROGRES	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9073	ONC DX BRST STG3-HR; NO PRO	PRXOVR	DEF					NA	NA	NA	N
G9073	ONC DX BRST STG3-HR; NO PRO	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9074	ONC DX BRST STG3-NOPROGRESS	PRXOVR	DEF					NA	NA	NA	N
G9074	ONC DX BRST STG3-NOPROGRESS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9075	ONC DX BRST METASTIC/ RECUR	PRXOVR	DEF					NA	NA	NA	N
G9075	ONC DX BRST METASTIC/ RECUR	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9077	ONC DX PROSTATE T1NO PROGRES	PRXOVR	DEF					NA	NA	NA	N
G9077	ONC DX PROSTATE T1NO PROGRES	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9078	ONC DX PROSTATE T2NO PROGRES	PRXOVR	DEF					NA	NA	NA	N
G9078	ONC DX PROSTATE T2NO PROGRES	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9079	ONC DX PROSTATE T3B-T4NOPROG	PRXOVR	DEF					NA	NA	NA	N
G9079	ONC DX PROSTATE T3B-T4NOPROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9080	ONC DX PROSTATE W/RISE PSA	PRXOVR	DEF					NA	NA	NA	N
G9080	ONC DX PROSTATE W/RISE PSA	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9083	ONC DX PROSTATE UNKNWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9083	ONC DX PROSTATE UNKNWN NOS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9084	ONC DX COLON T1-3;N1-2;NO PR	PRXOVR	DEF					NA	NA	NA	N
G9084	ONC DX COLON T1-3;N1-2;NO PR	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9085	ONC DX COLON T4; N0 W/O PROG	PRXOVR	DEF					NA	NA	NA	N
G9085	ONC DX COLON T4; N0 W/O PROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9086	ONC DX COLON T1-4 NO DX PROG	PRXOVR	DEF					NA	NA	NA	N
G9086	ONC DX COLON T1-4 NO DX PROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9087	ONC DX COLON METAS EVID DX	PRXOVR	DEF					NA	NA	NA	N
G9087	ONC DX COLON METAS EVID DX	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9088	ONC DX COLON METAS NOEVID DX	PRXOVR	DEF					NA	NA	NA	N
G9088	ONC DX COLON METAS NOEVID DX	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9089	ONC DX COLON EXTENT UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9089	ONC DX COLON EXTENT UNKNOWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9090	ONC DX RECTAL T1-2 NO PROGR	PRXOVR	DEF					NA	NA	NA	N
G9090	ONC DX RECTAL T1-2 NO PROGR	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9091	ONC DX RECTAL T3 N0 NO PROG	PRXOVR	DEF					NA	NA	NA	N
G9091	ONC DX RECTAL T3 N0 NO PROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9092	ONC DX RECTAL T1-3;N1-2NOPRG	PRXOVR	DEF					NA	NA	NA	N
G9092	ONC DX RECTAL T1-3;N1-2NOPRG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9093	ONC DX RECTAL T4;N;M0 NO PRG	PRXOVR	DEF					NA	NA	NA	N
G9093	ONC DX RECTAL T4;N;M0 NO PRG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9094	ONC DX RECTAL M1 W/METS PROG	PRXOVR	DEF					NA	NA	NA	N
G9094	ONC DX RECTAL M1 W/METS PROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9095	ONC DX RECTAL EXTENT UNKNWN	PRXOVR	DEF					NA	NA	NA	N
G9095	ONC DX RECTAL EXTENT UNKNWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9096	ONC DX ESOPHAG T1-T3 NOPROG	PRXOVR	DEF					NA	NA	NA	N
G9096	ONC DX ESOPHAG T1-T3 NOPROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9097	ONC DX ESOPHAGEAL T4 NO PROG	PRXOVR	DEF					NA	NA	NA	N
G9097	ONC DX ESOPHAGEAL T4 NO PROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9098	ONC DX ESOPHAGEAL METS RECUR	PRXOVR	DEF					NA	NA	NA	N
G9098	ONC DX ESOPHAGEAL METS RECUR	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9099	ONC DX ESOPHAGEAL UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9099	ONC DX ESOPHAGEAL UNKNOWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9100	ONC DX GASTRIC NO RECURRENCE	PRXOVR	DEF					NA	NA	NA	N
G9100	ONC DX GASTRIC NO RECURRENCE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9101	ONC DX GASTRIC P R1-R2NOPROG	PRXOVR	DEF					NA	NA	NA	N
G9101	ONC DX GASTRIC P R1-R2NOPROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9102	ONC DX GASTRIC UNRESECTABLE	PRXOVR	DEF					NA	NA	NA	N
G9102	ONC DX GASTRIC UNRESECTABLE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9103	ONC DX GASTRIC RECURRENT	PRXOVR	DEF					NA	NA	NA	N
G9103	ONC DX GASTRIC RECURRENT	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9104	ONC DX GASTRIC UNKNOWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9104	ONC DX GASTRIC UNKNOWN NOS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9105	ONC DX PANCREATC P R0 RES NO	PRXOVR	DEF					NA	NA	NA	N
G9105	ONC DX PANCREATC P R0 RES NO	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9106	ONC DX PANCREATC P R1/R2 NO	PRXOVR	DEF					NA	NA	NA	N
G9106	ONC DX PANCREATC P R1/R2 NO	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9107	ONC DX PANCREATIC UNRESECTAB	PRXOVR	DEF					NA	NA	NA	N
G9107	ONC DX PANCREATIC UNRESECTAB	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9108	ONC DX PANCREATIC UNKNWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9108	ONC DX PANCREATIC UNKNWN NOS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9109	ONC DX HEAD/NECK T1-T2NO PRG	PRXOVR	DEF					NA	NA	NA	N
G9109	ONC DX HEAD/NECK T1-T2NO PRG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9110	ONC DX HEAD/NECK T3-4 NOPROG	PRXOVR	DEF					NA	NA	NA	N
G9110	ONC DX HEAD/NECK T3-4 NOPROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9111	ONC DX HEAD/NECK M1 METS REC	PRXOVR	DEF					NA	NA	NA	N
G9111	ONC DX HEAD/NECK M1 METS REC	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9112	ONC DX HEAD/NECK EXT UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9112	ONC DX HEAD/NECK EXT UNKNOWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9113	ONC DX OVARIAN STG1A-B NO PR	PRXOVR	DEF					NA	NA	NA	N
G9113	ONC DX OVARIAN STG1A-B NO PR	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9114	ONC DX OVARIAN STG1A-B OR 2	PRXOVR	DEF					NA	NA	NA	N
G9114	ONC DX OVARIAN STG1A-B OR 2	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9115	ONC DX OVARIAN STG3/4 NOPROG	PRXOVR	DEF					NA	NA	NA	N
G9115	ONC DX OVARIAN STG3/4 NOPROG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9116	ONC DX OVARIAN RECURRENCE	PRXOVR	DEF					NA	NA	NA	N
G9116	ONC DX OVARIAN RECURRENCE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9117	ONC DX OVARIAN UNKNOWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9117	ONC DX OVARIAN UNKNOWN NOS	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9123	ONC DX CML CHRONIC PHASE	PRXOVR	DEF					NA	NA	NA	N
G9123	ONC DX CML CHRONIC PHASE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9124	ONC DX CML ACCELER PHASE	PRXOVR	DEF					NA	NA	NA	N
G9124	ONC DX CML ACCELER PHASE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9125	ONC DX CML BLAST PHASE	PRXOVR	DEF					NA	NA	NA	N
G9125	ONC DX CML BLAST PHASE	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9126	ONC DX CML REMISSION	PRXOVR	DEF					NA	NA	NA	N
G9126	ONC DX CML REMISSION	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9128	ONC DX MULTI MYELOMA STAGE I	PRXOVR	DEF					NA	NA	NA	N
G9128	ONC DX MULTI MYELOMA STAGE I	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9129	ONC DX MULT MYELOMA STG2 HIG	PRXOVR	DEF					NA	NA	NA	N
G9129	ONC DX MULT MYELOMA STG2 HIG	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9130	ONC DX MULTI MYELOMA UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9130	ONC DX MULTI MYELOMA UNKNOWN	MAXFEE	DEF					0	4/1/2006	12/31/2299	N
G9131	ONC DX BRST UNKNOWN NOS	PRXOVR	DEF					NA	NA	NA	N
G9131	ONC DX BRST UNKNOWN NOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9132	ONC DX PROSTATE METS NO CAST	PRXOVR	DEF					NA	NA	NA	N
G9132	ONC DX PROSTATE METS NO CAST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9133	ONC DX PROSTATE CLINICAL MET	PRXOVR	DEF					NA	NA	NA	N
G9133	ONC DX PROSTATE CLINICAL MET	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9134	ONC NHLSTG 1-2 NO RELAP NO	PRXOVR	DEF					NA	NA	NA	N
G9134	ONC NHLSTG 1-2 NO RELAP NO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9135	ONC DX NHL STG 3-4 NOT RELAP	PRXOVR	DEF					NA	NA	NA	N
G9135	ONC DX NHL STG 3-4 NOT RELAP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9136	ONC DX NHL TRANS TO LG BCELL	PRXOVR	DEF					NA	NA	NA	N
G9136	ONC DX NHL TRANS TO LG BCELL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9137	ONC DX NHL RELAPSE/REFRACTOR	PRXOVR	DEF					NA	NA	NA	N
G9137	ONC DX NHL RELAPSE/REFRACTOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9138	ONC DX NHL STG UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9138	ONC DX NHL STG UNKNOWN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9139	ONC DX CML DX STATUS UNKNOWN	PRXOVR	DEF					NA	NA	NA	N
G9139	ONC DX CML DX STATUS UNKNOWN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9188	BETA NOT GIVEN NO REASON	PRXOVR	DEF					NA	NA	NA	N
G9188	BETA NOT GIVEN NO REASON	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9189	BETA PRES OR ALREADY TAKING	PRXOVR	DEF					NA	NA	NA	N
G9189	BETA PRES OR ALREADY TAKING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9190	MEDICAL REASON FOR NO BETA	PRXOVR	DEF					NA	NA	NA	N
G9190	MEDICAL REASON FOR NO BETA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9191	PT REASON FOR NO BETA	PRXOVR	DEF					NA	NA	NA	N
G9191	PT REASON FOR NO BETA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9192	SYSTEM REASON FOR NO BETA	PRXOVR	DEF					NA	NA	NA	N
G9192	SYSTEM REASON FOR NO BETA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9196	MED REASON FOR NO CEPH	PRXOVR	DEF					NA	NA	NA	N
G9196	MED REASON FOR NO CEPH	MAXFEE	DEF					NA			N
G9197	ORDER FOR CEPH	PRXOVR	DEF					NA	NA	NA	N
G9197	ORDER FOR CEPH	MAXFEE	DEF					NA			N
G9198	NO ORDER FOR CEPH NO REASON	PRXOVR	DEF					NA	NA	NA	N
G9198	NO ORDER FOR CEPH NO REASON	MAXFEE	DEF					NA			N
G9212	DOC OF DSM-IV INIT EVAL	PRXOVR	DEF					NA	NA	NA	N
G9212	DOC OF DSM-IV INIT EVAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9213	NO DOC OF DSM-IV	PRXOVR	DEF					NA	NA	NA	N
G9213	NO DOC OF DSM-IV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9223	PJP PROPH ORDERED CD4 LOW	PRXOVR	DEF					NA	NA	NA	N
G9223	PJP PROPH ORDERED CD4 LOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9225	NORSN NO FOOT EXAM	PRXOVR	DEF					NA	NA	NA	N
G9225	NORSN NO FOOT EXAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9226	3 COMP FOOT EXAM COMPLETED	PRXOVR	DEF					NA	NA	NA	N
G9226	3 COMP FOOT EXAM COMPLETED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9227	FOA DOC; CARE PLAN NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G9227	FOA DOC; CARE PLAN NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9228	GC CHL SYP DOCUMENTED	PRXOVR	DEF					NA	NA	NA	N
G9228	GC CHL SYP DOCUMENTED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9229	PTRSN NO GC CHL SYP TEST	PRXOVR	DEF					NA	NA	NA	N
G9229	PTRSN NO GC CHL SYP TEST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9230	NORSN FOR GC CHL SYP TEST	PRXOVR	DEF					NA	NA	NA	N
G9230	NORSN FOR GC CHL SYP TEST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9231	DOC ESRD DIA TRANS PREG	PRXOVR	DEF					NA	NA	NA	N
G9231	DOC ESRD DIA TRANS PREG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9232	PTRSN NO COMM COMORBID	PRXOVR	DEF					NA	NA	NA	N
G9232	PTRSN NO COMM COMORBID	MAXFEE	DEF					NA			N
G9239	DOC RSN HEMOD & CATH ACC	PRXOVR	DEF					NA	NA	NA	N
G9239	DOC RSN HEMOD & CATH ACC	MAXFEE	DEF					NA			N
G9240	DOC PT W CATH MAINT DIA	PRXOVR	DEF					NA	NA	NA	N
G9240	DOC PT W CATH MAINT DIA	MAXFEE	DEF					NA			N
G9241	DOC PT W OUT CATH MAINT DIA	PRXOVR	DEF					NA	NA	NA	N
G9241	DOC PT W OUT CATH MAINT DIA	MAXFEE	DEF					NA			N
G9242	DOC VIRAL LOAD >=200	PRXOVR	DEF					NA	NA	NA	N
G9242	DOC VIRAL LOAD >=200	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9243	DOC VIRAL LOAD <200	PRXOVR	DEF					NA	NA	NA	N
G9243	DOC VIRAL LOAD <200	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9246	NO MED VISIT IN 24MO	PRXOVR	DEF					NA	NA	NA	N
G9246	NO MED VISIT IN 24MO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9247	1 MED VISIT IN 24MO	PRXOVR	DEF					NA	NA	NA	N
G9247	1 MED VISIT IN 24MO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9250	DOC OF PAIN COMFORT 48HR	PRXOVR	DEF					NA	NA	NA	N
G9250	DOC OF PAIN COMFORT 48HR	MAXFEE	DEF					NA			N
G9251	DOC NO PAIN COMFORT 48HR	PRXOVR	DEF					NA	NA	NA	N
G9251	DOC NO PAIN COMFORT 48HR	MAXFEE	DEF					NA			N
G9254	DOC PT DISCHG >2D	PRXOVR	DEF					NA	NA	NA	N
G9254	DOC PT DISCHG >2D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9255	DOC PT DISCHG <=2D	PRXOVR	DEF					NA	NA	NA	N
G9255	DOC PT DISCHG <=2D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9256	DOC OF PAT DEATH AFTER CAS	PRXOVR	DEF					NA	NA	NA	N
G9256	DOC OF PAT DEATH AFTER CAS	MAXFEE	DEF					NA			N
G9257	DOC OF PAT STROKE AFTER CAS	PRXOVR	DEF					NA	NA	NA	N
G9257	DOC OF PAT STROKE AFTER CAS	MAXFEE	DEF					NA			N
G9258	DOC OF PAT STROKE AFTER CEA	PRXOVR	DEF					NA	NA	NA	N
G9258	DOC OF PAT STROKE AFTER CEA	MAXFEE	DEF					NA			N
G9259	SURVIVE/NO STROKE POST CAS	PRXOVR	DEF					NA	NA	NA	N
G9259	SURVIVE/NO STROKE POST CAS	MAXFEE	DEF					NA			N
G9260	DOC OF PAT DEATH AFTER CEA	PRXOVR	DEF					NA	NA	NA	N
G9260	DOC OF PAT DEATH AFTER CEA	MAXFEE	DEF					NA			N
G9261	SURVIVE/NO STROKE POST CEA	PRXOVR	DEF					NA	NA	NA	N
G9261	SURVIVE/NO STROKE POST CEA	MAXFEE	DEF					NA			N
G9262	DOC OF DEATH POST-AAA REPAIR	PRXOVR	DEF					NA	NA	NA	N
G9262	DOC OF DEATH POST-AAA REPAIR	MAXFEE	DEF					NA			N
G9263	DOC OF DISCH POST-AAA REPAIR	PRXOVR	DEF					NA	NA	NA	N
G9263	DOC OF DISCH POST-AAA REPAIR	MAXFEE	DEF					NA			N
G9264	DOC RSN HEMOD W/CATH >=90D	PRXOVR	DEF					NA	NA	NA	N
G9264	DOC RSN HEMOD W/CATH >=90D	MAXFEE	DEF					NA			N
G9265	DOC CATH >90D FOR MAINT DIA	PRXOVR	DEF					NA	NA	NA	N
G9265	DOC CATH >90D FOR MAINT DIA	MAXFEE	DEF					NA			N
G9266	NORSN PT CATH >=90D	PRXOVR	DEF					NA	NA	NA	N
G9266	NORSN PT CATH >=90D	MAXFEE	DEF					NA			N
G9267	DOC COMP OR MORT W IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9267	DOC COMP OR MORT W IN 30D	MAXFEE	DEF					NA			N
G9268	DOC COMP OR MORT W IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9268	DOC COMP OR MORT W IN 90D	MAXFEE	DEF					NA			N
G9269	DOC NO COMP OR MORT W IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9269	DOC NO COMP OR MORT W IN 30D	MAXFEE	DEF					NA			N
G9270	DOC NO COMP OR MORT W IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9270	DOC NO COMP OR MORT W IN 90D	MAXFEE	DEF					NA			N
G9273	SYS<140 AND DIA<90	PRXOVR	DEF					NA	NA	NA	N
G9273	SYS<140 AND DIA<90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9274	BP OUT OF NRML LIMITS	PRXOVR	DEF					NA	NA	NA	N
G9274	BP OUT OF NRML LIMITS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9275	DOC OF NON TOBACCO USER	PRXOVR	DEF					NA	NA	NA	N
G9275	DOC OF NON TOBACCO USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9276	DOC OF TOBACCO USER	PRXOVR	DEF					NA	NA	NA	N
G9276	DOC OF TOBACCO USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9277	DOC DAILY ASPIRIN OR CONTRA	PRXOVR	DEF					NA	NA	NA	N
G9277	DOC DAILY ASPIRIN OR CONTRA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9278	DOC NO DAILY ASPIRIN	PRXOVR	DEF					NA	NA	NA	N
G9278	DOC NO DAILY ASPIRIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9279	PNE SCRN DONE DOC VAC DONE	PRXOVR	DEF					NA	NA	NA	N
G9279	PNE SCRN DONE DOC VAC DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9280	PNE NOT GIVEN NORSN	PRXOVR	DEF					NA	NA	NA	N
G9280	PNE NOT GIVEN NORSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9281	PNE SCRN DONE DOC NOT IND	PRXOVR	DEF					NA	NA	NA	N
G9281	PNE SCRN DONE DOC NOT IND	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9282	DOC MEDRSN NO HISTO TYPE	PRXOVR	DEF					NA	NA	NA	N
G9282	DOC MEDRSN NO HISTO TYPE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9283	HIST TYPE DOC ON REPORT	PRXOVR	DEF					NA	NA	NA	N
G9283	HIST TYPE DOC ON REPORT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9284	NO HIST TYPE DOC ON REPORT	PRXOVR	DEF					NA	NA	NA	N
G9284	NO HIST TYPE DOC ON REPORT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9285	SITE NOT SMALL CELL LUNG CA	PRXOVR	DEF					NA	NA	NA	N
G9285	SITE NOT SMALL CELL LUNG CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9286	ANTIBIO RX W IN 10D OF SYMPT	PRXOVR	DEF					NA	NA	NA	N
G9286	ANTIBIO RX W IN 10D OF SYMPT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9287	NO ANTIBIO W IN 10D OF SYMPT	PRXOVR	DEF					NA	NA	NA	N
G9287	NO ANTIBIO W IN 10D OF SYMPT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9288	DOC MEDRSN NO HIST TYPE RPT	PRXOVR	DEF					NA	NA	NA	N
G9288	DOC MEDRSN NO HIST TYPE RPT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9289	DOC TYPE NSM LUNG CA	PRXOVR	DEF					NA	NA	NA	N
G9289	DOC TYPE NSM LUNG CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9290	NO DOC TYPE NSM LUNG CA	PRXOVR	DEF					NA	NA	NA	N
G9290	NO DOC TYPE NSM LUNG CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9291	NOT NSM LUNG CA	PRXOVR	DEF					NA	NA	NA	N
G9291	NOT NSM LUNG CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9292	MEDRSN NO PT CATEGORY	PRXOVR	DEF					NA	NA	NA	N
G9292	MEDRSN NO PT CATEGORY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9293	NO PT CATEGORY ON REPORT	PRXOVR	DEF					NA	NA	NA	N
G9293	NO PT CATEGORY ON REPORT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9294	PT CAT AND THCK ON REPORT	PRXOVR	DEF					NA	NA	NA	N
G9294	PT CAT AND THCK ON REPORT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9295	NON CUTANEOUS LOC	PRXOVR	DEF					NA	NA	NA	N
G9295	NON CUTANEOUS LOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9296	DOC SHARE DEC PRIOR PROC	PRXOVR	DEF					NA	NA	NA	N
G9296	DOC SHARE DEC PRIOR PROC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9297	NO DOC SHARE DEC PRIOR PROC	PRXOVR	DEF					NA	NA	NA	N
G9297	NO DOC SHARE DEC PRIOR PROC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9298	EVAL RISK VTE CARD 30D PRIOR	PRXOVR	DEF					NA	NA	NA	N
G9298	EVAL RISK VTE CARD 30D PRIOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9299	NO EVAL RISK VTE CARD PRIOR	PRXOVR	DEF					NA	NA	NA	N
G9299	NO EVAL RISK VTE CARD PRIOR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9300	DOC MEDRSN NO COMPL ANTIBIO	PRXOVR	DEF					NA	NA	NA	N
G9300	DOC MEDRSN NO COMPL ANTIBIO	MAXFEE	DEF					NA			N
G9301	DOC COMPL INF ANTIBIO	PRXOVR	DEF					NA	NA	NA	N
G9301	DOC COMPL INF ANTIBIO	MAXFEE	DEF					NA			N
G9302	NORSN INCOMP INF ANTIBIO	PRXOVR	DEF					NA	NA	NA	N
G9302	NORSN INCOMP INF ANTIBIO	MAXFEE	DEF					NA			N
G9303	NORSN NO PROS INFO OP RPT	PRXOVR	DEF					NA	NA	NA	N
G9303	NORSN NO PROS INFO OP RPT	MAXFEE	DEF					NA			N
G9304	PROS INFO OP RPT	PRXOVR	DEF					NA	NA	NA	N
G9304	PROS INFO OP RPT	MAXFEE	DEF					NA			N
G9305	NO INTERV REQ FOR LEAK	PRXOVR	DEF					NA	NA	NA	N
G9305	NO INTERV REQ FOR LEAK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9306	INTERV REQ FOR LEAK	PRXOVR	DEF					NA	NA	NA	N
G9306	INTERV REQ FOR LEAK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9307	NO RET FOR SURG W IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9307	NO RET FOR SURG W IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9308	UNPL RET OR W/COMPL W/IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9308	UNPL RET OR W/COMPL W/IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9309	NO UNPLND HOSP READM IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9309	NO UNPLND HOSP READM IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9310	UNPLND HOSP READM IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9310	UNPLND HOSP READM IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9311	NO SURG SITE INFECTION	PRXOVR	DEF					NA	NA	NA	N
G9311	NO SURG SITE INFECTION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9312	SURGICAL SITE INFECTION	PRXOVR	DEF					NA	NA	NA	N
G9312	SURGICAL SITE INFECTION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9313	AMOXIC NOT PRESC AS 1ST LINE	PRXOVR	DEF					NA	NA	NA	N
G9313	AMOXIC NOT PRESC AS 1ST LINE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9314	NORSN NOT FIRST LINE AMOX	PRXOVR	DEF					NA	NA	NA	N
G9314	NORSN NOT FIRST LINE AMOX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9315	AMOX W/WO CLAV RX	PRXOVR	DEF					NA	NA	NA	N
G9315	AMOX W/WO CLAV RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9316	DOC COMM RISK CALC	PRXOVR	DEF					NA	NA	NA	N
G9316	DOC COMM RISK CALC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9317	NO DOC COMM RISK CALC	PRXOVR	DEF					NA	NA	NA	N
G9317	NO DOC COMM RISK CALC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9318	IMAGE STD NOMENCLATURE	PRXOVR	DEF					NA	NA	NA	N
G9318	IMAGE STD NOMENCLATURE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9319	IMAGE NOT STD NOMENCLATURE	PRXOVR	DEF					NA	NA	NA	N
G9319	IMAGE NOT STD NOMENCLATURE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9321	DOC COUNT OF CT IN 12MO	PRXOVR	DEF					NA	NA	NA	N
G9321	DOC COUNT OF CT IN 12MO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9322	NO DOC COUNT OF CT IN 12MO	PRXOVR	DEF					NA	NA	NA	N
G9322	NO DOC COUNT OF CT IN 12MO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9326	CT DONE NO RAD DS INDEX; NRG	PRXOVR	DEF					NA	NA	NA	N
G9326	CT DONE NO RAD DS INDEX; NRG	MAXFEE	DEF					NA			N
G9327	CT DONE RAD DS INDEX	PRXOVR	DEF					NA	NA	NA	N
G9327	CT DONE RAD DS INDEX	MAXFEE	DEF					NA			N
G9329	NORSN NO DICOM FORMAT DOC	PRXOVR	DEF					NA	NA	NA	N
G9329	NORSN NO DICOM FORMAT DOC	MAXFEE	DEF					NA			N
G9340	DICOM FORMAT DOC ON RPT	PRXOVR	DEF					NA	NA	NA	N
G9340	DICOM FORMAT DOC ON RPT	MAXFEE	DEF					NA			N
G9341	SRCH FOR CT W IN 12 MOS	PRXOVR	DEF					NA	NA	NA	N
G9341	SRCH FOR CT W IN 12 MOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9342	NO SRCH FOR CT IN 12MO NORSN	PRXOVR	DEF					NA	NA	NA	N
G9342	NO SRCH FOR CT IN 12MO NORSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9344	SYSRSN NO DICOM SRCH	PRXOVR	DEF					NA	NA	NA	N
G9344	SYSRSN NO DICOM SRCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9345	FOLLOW UP PULM NOD	PRXOVR	DEF					NA	NA	NA	N
G9345	FOLLOW UP PULM NOD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9347	NO FOLLOW UP PULM NOD NORSN	PRXOVR	DEF					NA	NA	NA	N
G9347	NO FOLLOW UP PULM NOD NORSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9348	DOC RSN FOR ORD CT SCAN	PRXOVR	DEF					NA	NA	NA	N
G9348	DOC RSN FOR ORD CT SCAN	MAXFEE	DEF					NA			N
G9349	CT WITHIN 28 DAYS	PRXOVR	DEF					NA	NA	NA	N
G9349	CT WITHIN 28 DAYS	MAXFEE	DEF					NA			N
G9350	NO DOC SINUS CT 28D OR DX	PRXOVR	DEF					NA	NA	NA	N
G9350	NO DOC SINUS CT 28D OR DX	MAXFEE	DEF					NA			N
G9351	DOC >1 SINUS CT W 90D DX	PRXOVR	DEF					NA	NA	NA	N
G9351	DOC >1 SINUS CT W 90D DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9352	NOT >1 SINUS CT W 90D DX	PRXOVR	DEF					NA	NA	NA	N
G9352	NOT >1 SINUS CT W 90D DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9353	MEDRSN >1 SINUS CT W 90D DX	PRXOVR	DEF					NA	NA	NA	N
G9353	MEDRSN >1 SINUS CT W 90D DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9354	1 OR NO CT SINUS W/IN 90D DX	PRXOVR	DEF					NA	NA	NA	N
G9354	1 OR NO CT SINUS W/IN 90D DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9355	NO EARLY IND/DELIVERY	PRXOVR	DEF					NA	NA	NA	N
G9355	NO EARLY IND/DELIVERY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9356	EARLY IND/DELIVERY	PRXOVR	DEF					NA	NA	NA	N
G9356	EARLY IND/DELIVERY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9357	PP EVAL/EDU PERF	PRXOVR	DEF					NA	NA	NA	N
G9357	PP EVAL/EDU PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9358	PP EVAL/EDU NOT PERF	PRXOVR	DEF					NA	NA	NA	N
G9358	PP EVAL/EDU NOT PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9359	NEG MGD POS TB NOTACT	PRXOVR	DEF					NA	NA	NA	N
G9359	NEG MGD POS TB NOTACT	MAXFEE	DEF					NA			N
G9360	NO DOC OF NEG OR MAN POS TB	PRXOVR	DEF					NA	NA	NA	N
G9360	NO DOC OF NEG OR MAN POS TB	MAXFEE	DEF					NA			N
G9361	DOC RSN ELECT C-SEC/INDUCT	PRXOVR	DEF					NA	NA	NA	N
G9361	DOC RSN ELECT C-SEC/INDUCT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9364	SINUS CAUS BAC INX	PRXOVR	DEF					NA	NA	NA	N
G9364	SINUS CAUS BAC INX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9365	1HIGH RISK MED ORD	PRXOVR	DEF					NA	NA	NA	N
G9365	1HIGH RISK MED ORD	MAXFEE	DEF					NA			N
G9366	1HIGH RISK NO ORD	PRXOVR	DEF					NA	NA	NA	N
G9366	1HIGH RISK NO ORD	MAXFEE	DEF					NA			N
G9367	>= 2 SAME HI-RSK MED ORD	PRXOVR	DEF					NA	NA	NA	N
G9367	>= 2 SAME HI-RSK MED ORD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9368	>= 2 SAME HI-RSK MED NOT ORD	PRXOVR	DEF					NA	NA	NA	N
G9368	>= 2 SAME HI-RSK MED NOT ORD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9380	OFF ASSIS EOL ISS	PRXOVR	DEF					NA	NA	NA	N
G9380	OFF ASSIS EOL ISS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9382	NO OFF ASSIS EOL	PRXOVR	DEF					NA	NA	NA	N
G9382	NO OFF ASSIS EOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9383	RECD SCRN HCV INFEC	PRXOVR	DEF					NA	NA	NA	N
G9383	RECD SCRN HCV INFEC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9384	DOC MED RSN NO HCV SCRN	PRXOVR	DEF					NA	NA	NA	N
G9384	DOC MED RSN NO HCV SCRN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9385	DOC PT REAS NOT REC HCV SRN	PRXOVR	DEF					NA	NA	NA	N
G9385	DOC PT REAS NOT REC HCV SRN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9386	SCRN HCV INFEC NOT RECD	PRXOVR	DEF					NA	NA	NA	N
G9386	SCRN HCV INFEC NOT RECD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9389	UNPLN RUP POST CAP	PRXOVR	DEF					NA	NA	NA	N
G9389	UNPLN RUP POST CAP	MAXFEE	DEF					NA			N
G9390	NO UNPLN RUP POST CAP	PRXOVR	DEF					NA	NA	NA	N
G9390	NO UNPLN RUP POST CAP	MAXFEE	DEF					NA			N
G9393	INI PHQ9 >9 REMISS <5	PRXOVR	DEF					NA	NA	NA	N
G9393	INI PHQ9 >9 REMISS <5	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9394	DX BIPOL; DEATH; NHRES; HOSP	PRXOVR	DEF					NA	NA	NA	N
G9394	DX BIPOL; DEATH; NHRES; HOSP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9395	INI PHQ9 >9 NO REMISS >=5	PRXOVR	DEF					NA	NA	NA	N
G9395	INI PHQ9 >9 NO REMISS >=5	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9396	INI PHQ9 >9 NOT ASSESS	PRXOVR	DEF					NA	NA	NA	N
G9396	INI PHQ9 >9 NOT ASSESS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9399	DOC DISC TX CHOICES	PRXOVR	DEF					NA	NA	NA	N
G9399	DOC DISC TX CHOICES	MAXFEE	DEF					NA			N
G9400	DOC REAS NO DISC TX OPT	PRXOVR	DEF					NA	NA	NA	N
G9400	DOC REAS NO DISC TX OPT	MAXFEE	DEF					NA			N
G9401	NO DISC TX CHOICES	PRXOVR	DEF					NA	NA	NA	N
G9401	NO DISC TX CHOICES	MAXFEE	DEF					NA			N
G9402	RECD F/U W/IN 30D DISCH	PRXOVR	DEF					NA	NA	NA	N
G9402	RECD F/U W/IN 30D DISCH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9403	DOC REAS NO 30 DAY F/U	PRXOVR	DEF					NA	NA	NA	N
G9403	DOC REAS NO 30 DAY F/U	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9404	NO 30 DAY F/U	PRXOVR	DEF					NA	NA	NA	N
G9404	NO 30 DAY F/U	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9405	RECD F/U W/IN 7D DC	PRXOVR	DEF					NA	NA	NA	N
G9405	RECD F/U W/IN 7D DC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9406	DOC REAS NO 7D F/U	PRXOVR	DEF					NA	NA	NA	N
G9406	DOC REAS NO 7D F/U	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9407	NO 7D F/U	PRXOVR	DEF					NA	NA	NA	N
G9407	NO 7D F/U	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9408	CARD TAMP W/IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9408	CARD TAMP W/IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9409	NO CARD TAMP E/IN 30D	PRXOVR	DEF					NA	NA	NA	N
G9409	NO CARD TAMP E/IN 30D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9410	ADMIT W/IN 180D REQ REMOV	PRXOVR	DEF					NA	NA	NA	N
G9410	ADMIT W/IN 180D REQ REMOV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9411	NO ADMIT W/IN 180D REQ REMOV	PRXOVR	DEF					NA	NA	NA	N
G9411	NO ADMIT W/IN 180D REQ REMOV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9412	ADMIT W/IN 180D REQ SURG REV	PRXOVR	DEF					NA	NA	NA	N
G9412	ADMIT W/IN 180D REQ SURG REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9413	NO ADMIT REQ SURG REV	PRXOVR	DEF					NA	NA	NA	N
G9413	NO ADMIT REQ SURG REV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9414	1DOSE MENIG VAC BTWN 11 & 13	PRXOVR	DEF					NA	NA	NA	N
G9414	1DOSE MENIG VAC BTWN 11 & 13	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9415	NO 1DOSE MENI VAC BTWN 11&13	PRXOVR	DEF					NA	NA	NA	N
G9415	NO 1DOSE MENI VAC BTWN 11&13	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9416	PT 1 TDAP BETW 10-13 YRS	PRXOVR	DEF					NA	NA	NA	N
G9416	PT 1 TDAP BETW 10-13 YRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9417	PT NOT 1 TDAP BETW 10-13 YRS	PRXOVR	DEF					NA	NA	NA	N
G9417	PT NOT 1 TDAP BETW 10-13 YRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9418	LUNGCX BX RPT DOCS CLASS	PRXOVR	DEF					NA	NA	NA	N
G9418	LUNGCX BX RPT DOCS CLASS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9419	MED REAS NOT INCL HISTO TYPE	PRXOVR	DEF					NA	NA	NA	N
G9419	MED REAS NOT INCL HISTO TYPE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9420	SPEC SITE NO LUNG	PRXOVR	DEF					NA	NA	NA	N
G9420	SPEC SITE NO LUNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9421	LUNG CX BX RPT NO DOC CLASS	PRXOVR	DEF					NA	NA	NA	N
G9421	LUNG CX BX RPT NO DOC CLASS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9422	RPT DOC CLASS HISTO TYPE	PRXOVR	DEF					NA	NA	NA	N
G9422	RPT DOC CLASS HISTO TYPE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9423	MED REAS RPT NO HISTO TYPE	PRXOVR	DEF					NA	NA	NA	N
G9423	MED REAS RPT NO HISTO TYPE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9424	SITE NO LUNG OR LUNG CX	PRXOVR	DEF					NA	NA	NA	N
G9424	SITE NO LUNG OR LUNG CX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9425	SPEC RPT NO DOC CLASS HISTO	PRXOVR	DEF					NA	NA	NA	N
G9425	SPEC RPT NO DOC CLASS HISTO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9426	IMPR MED TIME EDARR PAIN MED	PRXOVR	DEF					NA	NA	NA	N
G9426	IMPR MED TIME EDARR PAIN MED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9427	NO IMPRO MED TIME PAIN MED	PRXOVR	DEF					NA	NA	NA	N
G9427	NO IMPRO MED TIME PAIN MED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9428	PATHO RPT INCL PT CTG	PRXOVR	DEF					NA	NA	NA	N
G9428	PATHO RPT INCL PT CTG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9429	DOC MED RSN NO PT CAT	PRXOVR	DEF					NA	NA	NA	N
G9429	DOC MED RSN NO PT CAT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9430	SPEC SITE NO CUTANEOUS	PRXOVR	DEF					NA	NA	NA	N
G9430	SPEC SITE NO CUTANEOUS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9431	PATHO RPT NO PT CTG	PRXOVR	DEF					NA	NA	NA	N
G9431	PATHO RPT NO PT CTG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9432	ASTH CONTROLLED	PRXOVR	DEF					NA	NA	NA	N
G9432	ASTH CONTROLLED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9434	ASTH NOT CONTROLLED	PRXOVR	DEF					NA	NA	NA	N
G9434	ASTH NOT CONTROLLED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9448	BORN 1945-1965	PRXOVR	DEF					NA	NA	NA	N
G9448	BORN 1945-1965	MAXFEE	DEF					NA			N
G9449	HX BLD TRANSF B/F 1992	PRXOVR	DEF					NA	NA	NA	N
G9449	HX BLD TRANSF B/F 1992	MAXFEE	DEF					NA			N
G9450	HX INJEC DRUG USE	PRXOVR	DEF					NA	NA	NA	N
G9450	HX INJEC DRUG USE	MAXFEE	DEF					NA			N
G9451	1X SCRN HCV INFECT	PRXOVR	DEF					NA	NA	NA	N
G9451	1X SCRN HCV INFECT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9452	DOC MED REAS NO SCRN HCV	PRXOVR	DEF					NA	NA	NA	N
G9452	DOC MED REAS NO SCRN HCV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9453	PT REAS NO HCV INFECT	PRXOVR	DEF					NA	NA	NA	N
G9453	PT REAS NO HCV INFECT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9454	NO SCR HCV INF 12 MTH RP	PRXOVR	DEF					NA	NA	NA	N
G9454	NO SCR HCV INF 12 MTH RP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9455	ABD IMAG W/US; CT OR MRI	PRXOVR	DEF					NA	NA	NA	N
G9455	ABD IMAG W/US; CT OR MRI	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9456	DOC MED PT REAS NO HCC SCRN	PRXOVR	DEF					NA	NA	NA	N
G9456	DOC MED PT REAS NO HCC SCRN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9457	PT NO ABD IMG NO DOC RSN	PRXOVR	DEF					NA	NA	NA	N
G9457	PT NO ABD IMG NO DOC RSN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9458	TOB USER RECD CESS INTERV	PRXOVR	DEF					NA	NA	NA	N
G9458	TOB USER RECD CESS INTERV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9459	TOB NON-USER	PRXOVR	DEF					NA	NA	NA	N
G9459	TOB NON-USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9460	NO TOB ASSESS OR CESS INTER	PRXOVR	DEF					NA	NA	NA	N
G9460	NO TOB ASSESS OR CESS INTER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9468	NO RECD CORTICO>=10MG/D >60D	PRXOVR	DEF					NA	NA	NA	N
G9468	NO RECD CORTICO>=10MG/D >60D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9469	REC CORTICO>90D OR 1RX 900MG	PRXOVR	DEF					NA	NA	NA	N
G9469	REC CORTICO>90D OR 1RX 900MG	MAXFEE	DEF					NA			N
G9470	NO REC CORTICO>60D 1RX 600MG	PRXOVR	DEF					NA	NA	NA	N
G9470	NO REC CORTICO>60D 1RX 600MG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9471	W/IN 2YR DXA NOT ORDER	PRXOVR	DEF					NA	NA	NA	N
G9471	W/IN 2YR DXA NOT ORDER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9472	NO DXA NO MED HX NO RV SX	PRXOVR	DEF					NA	NA	NA	N
G9472	NO DXA NO MED HX NO RV SX	MAXFEE	DEF					NA			N
G9497	REC INST NO SMOKE DAY SURG	PRXOVR	DEF					NA	NA	NA	N
G9497	REC INST NO SMOKE DAY SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9498	ABX REG PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
G9498	ABX REG PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9500	RAD EXPOS IND/EXP TM DOC	PRXOVR	DEF					NA	NA	NA	N
G9500	RAD EXPOS IND/EXP TM DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9501	RAD EXPOS IND/EXP TM NO DOC	PRXOVR	DEF					NA	NA	NA	N
G9501	RAD EXPOS IND/EXP TM NO DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9502	MED REAS NO PERF FOOT EXAM	PRXOVR	DEF					NA	NA	NA	N
G9502	MED REAS NO PERF FOOT EXAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9503	PT TK TAMS HCL	PRXOVR	DEF					NA	NA	NA	N
G9503	PT TK TAMS HCL	MAXFEE	DEF					NA			N
G9504	DOC RSN HEP B STAT NOT ASSES	PRXOVR	DEF					NA	NA	NA	N
G9504	DOC RSN HEP B STAT NOT ASSES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9505	ABX PRES W/IN 10 DYS OF SYMP	PRXOVR	DEF					NA	NA	NA	N
G9505	ABX PRES W/IN 10 DYS OF SYMP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9506	BIO IMM RESP MOD PRESC	PRXOVR	DEF					NA	NA	NA	N
G9506	BIO IMM RESP MOD PRESC	MAXFEE	DEF					NA			N
G9507	DOC REAS ON STATIN OR CONTRA	PRXOVR	DEF					NA	NA	NA	N
G9507	DOC REAS ON STATIN OR CONTRA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9508	DOC PT NOT ON STATIN	PRXOVR	DEF					NA	NA	NA	N
G9508	DOC PT NOT ON STATIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9509	ADIT MDD DYS REM 12 MNTHS	PRXOVR	DEF					NA	NA	NA	N
G9509	ADIT MDD DYS REM 12 MNTHS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9510	REMIS12M NOT PHQ-9 SCORE <5	PRXOVR	DEF					NA	NA	NA	N
G9510	REMIS12M NOT PHQ-9 SCORE <5	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9511	IDX EVT DTE PHQ>9 DOC 12 MO	PRXOVR	DEF					NA	NA	NA	N
G9511	IDX EVT DTE PHQ>9 DOC 12 MO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9512	INDIV PDC > 0.8	PRXOVR	DEF					NA	NA	NA	N
G9512	INDIV PDC > 0.8	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9513	INDIV PDC NOT > 0.8	PRXOVR	DEF					NA	NA	NA	N
G9513	INDIV PDC NOT > 0.8	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9514	REQ RET OR W/IN 90D OF SURG	PRXOVR	DEF					NA	NA	NA	N
G9514	REQ RET OR W/IN 90D OF SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9515	NO REAS; NO RET OR W/IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9515	NO REAS; NO RET OR W/IN 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9516	IMPR VIS ACUIT W/IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9516	IMPR VIS ACUIT W/IN 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9517	NO IMPR VIS ACUIT W/IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9517	NO IMPR VIS ACUIT W/IN 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9518	DOC ACTIVE INJ DRUG USE	PRXOVR	DEF					NA	NA	NA	N
G9518	DOC ACTIVE INJ DRUG USE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9519	FINAL REF +/- 1.0 W/IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9519	FINAL REF +/- 1.0 W/IN 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9520	REFRACT NOT +/- 1.0 W/IN 90D	PRXOVR	DEF					NA	NA	NA	N
G9520	REFRACT NOT +/- 1.0 W/IN 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9521	ER AND IP HOSP <2 IN 12 MOS	PRXOVR	DEF					NA	NA	NA	N
G9521	ER AND IP HOSP <2 IN 12 MOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9522	ER/IP HOSP =/>2 IN 12 MOS	PRXOVR	DEF					NA	NA	NA	N
G9522	ER/IP HOSP =/>2 IN 12 MOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9523	D/C HEMO OR PERIT DIALYSIS	PRXOVR	DEF					NA	NA	NA	N
G9523	D/C HEMO OR PERIT DIALYSIS	MAXFEE	DEF					NA			N
G9524	REFER TO HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9524	REFER TO HOSPICE	MAXFEE	DEF					NA			N
G9525	DOC PT REAS NO HOSPICE REFER	PRXOVR	DEF					NA	NA	NA	N
G9525	DOC PT REAS NO HOSPICE REFER	MAXFEE	DEF					NA			N
G9526	NO REASON; NO REFER HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9526	NO REASON; NO REFER HOSPICE	MAXFEE	DEF					NA			N
G9529	MINOR BLUNT TRAUMA W/HEAD CT	PRXOVR	DEF					NA	NA	NA	N
G9529	MINOR BLUNT TRAUMA W/HEAD CT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9530	PT MBHT HD CT ORD EC PROV	PRXOVR	DEF					NA	NA	NA	N
G9530	PT MBHT HD CT ORD EC PROV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9531	PT DOC	PRXOVR	DEF					NA	NA	NA	N
G9531	PT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9532	PT HD CT ORD	PRXOVR	DEF					NA	NA	NA	N
G9532	PT HD CT ORD	MAXFEE	DEF					NA			N
G9533	INDIC FOR HEAD CT NOT VALID	PRXOVR	DEF					NA	NA	NA	N
G9533	INDIC FOR HEAD CT NOT VALID	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9534	ADV BRAIN IMAGE NOT ORDERED	PRXOVR	DEF					NA	NA	NA	N
G9534	ADV BRAIN IMAGE NOT ORDERED	MAXFEE	DEF					NA			N
G9535	NORMAL NEURO EXAM	PRXOVR	DEF					NA	NA	NA	N
G9535	NORMAL NEURO EXAM	MAXFEE	DEF					NA			N
G9536	DOC MED REAS ADV BRAIN IMAGE	PRXOVR	DEF					NA	NA	NA	N
G9536	DOC MED REAS ADV BRAIN IMAGE	MAXFEE	DEF					NA			N
G9537	IMG HD CLIN TRIAL	PRXOVR	DEF					NA	NA	NA	N
G9537	IMG HD CLIN TRIAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9538	ADV BRAIN IMAGE ORDERED	PRXOVR	DEF					NA	NA	NA	N
G9538	ADV BRAIN IMAGE ORDERED	MAXFEE	DEF					NA			N
G9539	INTENT POT REMV TIME PLACEMT	PRXOVR	DEF					NA	NA	NA	N
G9539	INTENT POT REMV TIME PLACEMT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9540	PT ALIVE 3 MOS POST PROC	PRXOVR	DEF					NA	NA	NA	N
G9540	PT ALIVE 3 MOS POST PROC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9541	FILTER REM 3 MON PLMT	PRXOVR	DEF					NA	NA	NA	N
G9541	FILTER REM 3 MON PLMT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9542	DOC REASS APPR REMO FILT 3MS	PRXOVR	DEF					NA	NA	NA	N
G9542	DOC REASS APPR REMO FILT 3MS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9543	DOC 2X RE-ASSESS FILT REMOV	PRXOVR	DEF					NA	NA	NA	N
G9543	DOC 2X RE-ASSESS FILT REMOV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9544	NO FILT REMOV W/IN 3MOS PLCM	PRXOVR	DEF					NA	NA	NA	N
G9544	NO FILT REMOV W/IN 3MOS PLCM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9547	CYS REN LES OR ADREN	PRXOVR	DEF					NA	NA	NA	N
G9547	CYS REN LES OR ADREN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9548	NO F/U REC IMAGE STUDY	PRXOVR	DEF					NA	NA	NA	N
G9548	NO F/U REC IMAGE STUDY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9549	DOC MED RSN FOR F/U IMAG	PRXOVR	DEF					NA	NA	NA	N
G9549	DOC MED RSN FOR F/U IMAG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9550	IMAG REC	PRXOVR	DEF					NA	NA	NA	N
G9550	IMAG REC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9551	IMAG NO LES	PRXOVR	DEF					NA	NA	NA	N
G9551	IMAG NO LES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9552	INC THYR NODE <1.0 IN RPT	PRXOVR	DEF					NA	NA	NA	N
G9552	INC THYR NODE <1.0 IN RPT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9553	PRIOR THYROID DISE DX	PRXOVR	DEF					NA	NA	NA	N
G9553	PRIOR THYROID DISE DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9554	CT/CTA/MRI/A CHST FOLL REC	PRXOVR	DEF					NA	NA	NA	N
G9554	CT/CTA/MRI/A CHST FOLL REC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9555	DOC MED RSN FOR FOLLUP IMAGE	PRXOVR	DEF					NA	NA	NA	N
G9555	DOC MED RSN FOR FOLLUP IMAGE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9556	CT/CTA/MRI/A NO FOLLUP IMAG	PRXOVR	DEF					NA	NA	NA	N
G9556	CT/CTA/MRI/A NO FOLLUP IMAG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9557	CT/CTA/MRI/A NO THYR <1.0CM	PRXOVR	DEF					NA	NA	NA	N
G9557	CT/CTA/MRI/A NO THYR <1.0CM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9558	TX BETA-LACTAM ABX THERAPY	PRXOVR	DEF					NA	NA	NA	N
G9558	TX BETA-LACTAM ABX THERAPY	MAXFEE	DEF					NA			N
G9559	DOC MED REAS NO ABX THERAPY	PRXOVR	DEF					NA	NA	NA	N
G9559	DOC MED REAS NO ABX THERAPY	MAXFEE	DEF					NA			N
G9560	NO BETA-LACTAM ABX THER; RNG	PRXOVR	DEF					NA	NA	NA	N
G9560	NO BETA-LACTAM ABX THER; RNG	MAXFEE	DEF					NA			N
G9561	PRESC OPIATES >6 WKS	PRXOVR	DEF					NA	NA	NA	N
G9561	PRESC OPIATES >6 WKS	MAXFEE	DEF					NA			N
G9562	FOLL-UP EVAL Q3MO OPIOD TX	PRXOVR	DEF					NA	NA	NA	N
G9562	FOLL-UP EVAL Q3MO OPIOD TX	MAXFEE	DEF					NA			N
G9563	NO F/U EVAL Q3MO OPIOD TX	PRXOVR	DEF					NA	NA	NA	N
G9563	NO F/U EVAL Q3MO OPIOD TX	MAXFEE	DEF					NA			N
G9573	ADL PT MD OR DYS REM 6 MON	PRXOVR	DEF					NA	NA	NA	N
G9573	ADL PT MD OR DYS REM 6 MON	MAXFEE	DEF					NA			N
G9574	ADL PT MD DYS NO REM 6 MON	PRXOVR	DEF					NA	NA	NA	N
G9574	ADL PT MD DYS NO REM 6 MON	MAXFEE	DEF					NA			N
G9577	PRESC OPIATES >6 WKS	PRXOVR	DEF					NA	NA	NA	N
G9577	PRESC OPIATES >6 WKS	MAXFEE	DEF					NA			N
G9578	DOC OPIOID TX 1X DURING THER	PRXOVR	DEF					NA	NA	NA	N
G9578	DOC OPIOID TX 1X DURING THER	MAXFEE	DEF					NA			N
G9579	NO DOC OPIOID TX 1X AT THER	PRXOVR	DEF					NA	NA	NA	N
G9579	NO DOC OPIOID TX 1X AT THER	MAXFEE	DEF					NA			N
G9580	DOOR TO PUNC TIME <2HRS	PRXOVR	DEF					NA	NA	NA	N
G9580	DOOR TO PUNC TIME <2HRS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9582	DOOR TO PUNC TIME >2HR; NRG	PRXOVR	DEF					NA	NA	NA	N
G9582	DOOR TO PUNC TIME >2HR; NRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9583	PRESC OPIATES >6 WKS	PRXOVR	DEF					NA	NA	NA	N
G9583	PRESC OPIATES >6 WKS	MAXFEE	DEF					NA			N
G9584	EVAL OPIOID USE INSTR/PT INT	PRXOVR	DEF					NA	NA	NA	N
G9584	EVAL OPIOID USE INSTR/PT INT	MAXFEE	DEF					NA			N
G9585	NO EVAL OPI USE INSTR/INTV	PRXOVR	DEF					NA	NA	NA	N
G9585	NO EVAL OPI USE INSTR/INTV	MAXFEE	DEF					NA			N
G9593	LOW PECARN PED HEAD TRAUMA	PRXOVR	DEF					NA	NA	NA	N
G9593	LOW PECARN PED HEAD TRAUMA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9594	PT MBHT HD CT ORD EC PROV	PRXOVR	DEF					NA	NA	NA	N
G9594	PT MBHT HD CT ORD EC PROV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9595	DOC SHNT/TUM/COAG	PRXOVR	DEF					NA	NA	NA	N
G9595	DOC SHNT/TUM/COAG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9596	PED PT HD CT ORD	PRXOVR	DEF					NA	NA	NA	N
G9596	PED PT HD CT ORD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9597	NO LOW PECARN PED HEAD TRAUM	PRXOVR	DEF					NA	NA	NA	N
G9597	NO LOW PECARN PED HEAD TRAUM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9598	AOR ANE 5.5-5.9 CM MAX DIAM	PRXOVR	DEF					NA	NA	NA	N
G9598	AOR ANE 5.5-5.9 CM MAX DIAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9599	AOR ANE >=6.0 CM MAX DIAM	PRXOVR	DEF					NA	NA	NA	N
G9599	AOR ANE >=6.0 CM MAX DIAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9600	SYMP AAA URGENT REPAIR	PRXOVR	DEF					NA	NA	NA	N
G9600	SYMP AAA URGENT REPAIR	MAXFEE	DEF					NA			N
G9601	PT DCHG HOME POST OP DAY 7	PRXOVR	DEF					NA	NA	NA	N
G9601	PT DCHG HOME POST OP DAY 7	MAXFEE	DEF					NA			N
G9602	PT NO DCHG HOME POSTOP DAY 7	PRXOVR	DEF					NA	NA	NA	N
G9602	PT NO DCHG HOME POSTOP DAY 7	MAXFEE	DEF					NA			N
G9603	PT SURV IMPROV BSLINE TX	PRXOVR	DEF					NA	NA	NA	N
G9603	PT SURV IMPROV BSLINE TX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9604	PT SURV RESULTS NOT AVAIL	PRXOVR	DEF					NA	NA	NA	N
G9604	PT SURV RESULTS NOT AVAIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9605	SURV SCORE NO IMPROV W/TX	PRXOVR	DEF					NA	NA	NA	N
G9605	SURV SCORE NO IMPROV W/TX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9606	INTRAOP CYST EVAL TRAC INJ	PRXOVR	DEF					NA	NA	NA	N
G9606	INTRAOP CYST EVAL TRAC INJ	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9607	DOC MED RSN NOT PERF CYSTOSC	PRXOVR	DEF					NA	NA	NA	N
G9607	DOC MED RSN NOT PERF CYSTOSC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9608	INTRAOP CYST EVAL NOT DONE	PRXOVR	DEF					NA	NA	NA	N
G9608	INTRAOP CYST EVAL NOT DONE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9609	DOC ORDER ANTI-PLAT	PRXOVR	DEF					NA	NA	NA	N
G9609	DOC ORDER ANTI-PLAT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9610	DOC MD RSN NO ANTIPLA	PRXOVR	DEF					NA	NA	NA	N
G9610	DOC MD RSN NO ANTIPLA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9611	NO DOC ORDER ANTI-PLAT RNG	PRXOVR	DEF					NA	NA	NA	N
G9611	NO DOC ORDER ANTI-PLAT RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9612	PHODOC 2 MR CEC LNDMK	PRXOVR	DEF					NA	NA	NA	N
G9612	PHODOC 2 MR CEC LNDMK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9613	DOC POST SURG ANATOMY	PRXOVR	DEF					NA	NA	NA	N
G9613	DOC POST SURG ANATOMY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9614	PHOTODOC < 2 CEC LNDMK	PRXOVR	DEF					NA	NA	NA	N
G9614	PHOTODOC < 2 CEC LNDMK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9615	PRE-OP ASST DOC	PRXOVR	DEF					NA	NA	NA	N
G9615	PRE-OP ASST DOC	MAXFEE	DEF					NA			N
G9616	DOC RSN NO PREOP ASSMT	PRXOVR	DEF					NA	NA	NA	N
G9616	DOC RSN NO PREOP ASSMT	MAXFEE	DEF					NA			N
G9617	PRE-OP ASST NOT DOC; RNG	PRXOVR	DEF					NA	NA	NA	N
G9617	PRE-OP ASST NOT DOC; RNG	MAXFEE	DEF					NA			N
G9618	DOC SCR UTER MAL OR US/SAMP	PRXOVR	DEF					NA	NA	NA	N
G9618	DOC SCR UTER MAL OR US/SAMP	MAXFEE	DEF					NA			N
G9620	NO SCR UTR MALIG/US/SAMP RNG	PRXOVR	DEF					NA	NA	NA	N
G9620	NO SCR UTR MALIG/US/SAMP RNG	MAXFEE	DEF					NA			N
G9621	SCR UNHEAL ETOH W/COUNSEL	PRXOVR	DEF					NA	NA	NA	N
G9621	SCR UNHEAL ETOH W/COUNSEL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9622	NO UNHEAL ETOH USER	PRXOVR	DEF					NA	NA	NA	N
G9622	NO UNHEAL ETOH USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9623	DOC MED RSN NO SCR ETOH USE	PRXOVR	DEF					NA	NA	NA	N
G9623	DOC MED RSN NO SCR ETOH USE	MAXFEE	DEF					NA			N
G9624	PT NOT SCRN OR NO COUNSELING	PRXOVR	DEF					NA	NA	NA	N
G9624	PT NOT SCRN OR NO COUNSELING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9625	PT BL SRG 30 DAY PST SRG	PRXOVR	DEF					NA	NA	NA	N
G9625	PT BL SRG 30 DAY PST SRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9626	MED RSN NO RPT BLADDER INJ	PRXOVR	DEF					NA	NA	NA	N
G9626	MED RSN NO RPT BLADDER INJ	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9627	PT NO BL SRG 30 DAY PST SRG	PRXOVR	DEF					NA	NA	NA	N
G9627	PT NO BL SRG 30 DAY PST SRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9628	PT BWLI SRG 30 DAY PST SRG	PRXOVR	DEF					NA	NA	NA	N
G9628	PT BWLI SRG 30 DAY PST SRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9629	MED RSN NO RPT BOWEL INJ	PRXOVR	DEF					NA	NA	NA	N
G9629	MED RSN NO RPT BOWEL INJ	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9630	PT NO BWLI SRG 30 DAY SRG	PRXOVR	DEF					NA	NA	NA	N
G9630	PT NO BWLI SRG 30 DAY SRG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9631	PT UI SRG 30 DAY PST SRG	PRXOVR	DEF					NA	NA	NA	N
G9631	PT UI SRG 30 DAY PST SRG	MAXFEE	DEF					NA			N
G9632	MED RSN FOR NO RPT URET INJ	PRXOVR	DEF					NA	NA	NA	N
G9632	MED RSN FOR NO RPT URET INJ	MAXFEE	DEF					NA			N
G9633	PT NO UI SRG 30 DAY PST SRG	PRXOVR	DEF					NA	NA	NA	N
G9633	PT NO UI SRG 30 DAY PST SRG	MAXFEE	DEF					NA			N
G9634	QUAL LIFE TOOL 2X SAME/IMPR	PRXOVR	DEF					NA	NA	NA	N
G9634	QUAL LIFE TOOL 2X SAME/IMPR	MAXFEE	DEF					NA			N
G9635	NO DOC RSN DO QUAL LIFE ASSM	PRXOVR	DEF					NA	NA	NA	N
G9635	NO DOC RSN DO QUAL LIFE ASSM	MAXFEE	DEF					NA			N
G9636	NO LIFE ASST 2X SAME/DECR	PRXOVR	DEF					NA	NA	NA	N
G9636	NO LIFE ASST 2X SAME/DECR	MAXFEE	DEF					NA			N
G9637	DOC >1 DOSE REDUC TECH	PRXOVR	DEF					NA	NA	NA	N
G9637	DOC >1 DOSE REDUC TECH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9638	NO DOC >1 DOSE REDUC TECH	PRXOVR	DEF					NA	NA	NA	N
G9638	NO DOC >1 DOSE REDUC TECH	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9639	AMP NO REQD IN48H IELER PROC	PRXOVR	DEF					NA	NA	NA	N
G9639	AMP NO REQD IN48H IELER PROC	MAXFEE	DEF					NA			N
G9640	DOC PLAN HYBRID/STAGE PROC	PRXOVR	DEF					NA	NA	NA	N
G9640	DOC PLAN HYBRID/STAGE PROC	MAXFEE	DEF					NA			N
G9641	AMP REQD W/IN 48H IELER PROC	PRXOVR	DEF					NA	NA	NA	N
G9641	AMP REQD W/IN 48H IELER PROC	MAXFEE	DEF					NA			N
G9642	CURRENT SMOKER	PRXOVR	DEF					NA	NA	NA	N
G9642	CURRENT SMOKER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9643	ELECTIVE SURGERY	PRXOVR	DEF					NA	NA	NA	N
G9643	ELECTIVE SURGERY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9644	NO SMOK B/4 ANES DAY OF SURG	PRXOVR	DEF					NA	NA	NA	N
G9644	NO SMOK B/4 ANES DAY OF SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9645	HAD SMOKE B/4 ANES DAY SURG	PRXOVR	DEF					NA	NA	NA	N
G9645	HAD SMOKE B/4 ANES DAY SURG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9646	PT W/90D MRS 0-2	PRXOVR	DEF					NA	NA	NA	N
G9646	PT W/90D MRS 0-2	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9647	NO MRS SCORE IN 90D FOLLOWUP	PRXOVR	DEF					NA	NA	NA	N
G9647	NO MRS SCORE IN 90D FOLLOWUP	MAXFEE	DEF					NA			N
G9648	PT W/90D MRS >2	PRXOVR	DEF					NA	NA	NA	N
G9648	PT W/90D MRS >2	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9649	PSOR AS DOC SPC BM	PRXOVR	DEF					NA	NA	NA	N
G9649	PSOR AS DOC SPC BM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9651	PSOR AS DOC NO SPC BM	PRXOVR	DEF					NA	NA	NA	N
G9651	PSOR AS DOC NO SPC BM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9654	MON ANESTH CARE	PRXOVR	DEF					NA	NA	NA	N
G9654	MON ANESTH CARE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9655	TOC TOOL INCL KEY ELEM	PRXOVR	DEF					NA	NA	NA	N
G9655	TOC TOOL INCL KEY ELEM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9656	PT TRANS FROM ANEST TO PACU	PRXOVR	DEF					NA	NA	NA	N
G9656	PT TRANS FROM ANEST TO PACU	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9658	TOC TOOL INCL ELEM NOT USED	PRXOVR	DEF					NA	NA	NA	N
G9658	TOC TOOL INCL ELEM NOT USED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9659	>=86Y NO HX COLO CA/RSN SCOP	PRXOVR	DEF					NA	NA	NA	N
G9659	>=86Y NO HX COLO CA/RSN SCOP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9660	DOC MED RSN SCOPE PT >= 86Y	PRXOVR	DEF					NA	NA	NA	N
G9660	DOC MED RSN SCOPE PT >= 86Y	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9661	PT >= 86 W/ HI RISK	PRXOVR	DEF					NA	NA	NA	N
G9661	PT >= 86 W/ HI RISK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9662	PRIOR DX/ACTIVE CLIN ASCVD	PRXOVR	DEF					NA	NA	NA	N
G9662	PRIOR DX/ACTIVE CLIN ASCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9663	FAST/DIR LDL >= 190 MG/DL	PRXOVR	DEF					NA	NA	NA	N
G9663	FAST/DIR LDL >= 190 MG/DL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9664	TAKING STATIN OR REC'D ORDER	PRXOVR	DEF					NA	NA	NA	N
G9664	TAKING STATIN OR REC'D ORDER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9665	NO STATIN/NO ORDER STATIN	PRXOVR	DEF					NA	NA	NA	N
G9665	NO STATIN/NO ORDER STATIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9666	FAS/DIR LDL 70-189MG/DL MST	PRXOVR	DEF					NA	NA	NA	N
G9666	FAS/DIR LDL 70-189MG/DL MST	MAXFEE	DEF					NA			N
G9674	PT W/CLIN ASCVD DX	PRXOVR	DEF					NA	NA	NA	N
G9674	PT W/CLIN ASCVD DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9675	PT W/FAST/DIR LAB LDL-C >190	PRXOVR	DEF					NA	NA	NA	N
G9675	PT W/FAST/DIR LAB LDL-C >190	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9676	40-75Y W/TYPE 1/2 W/LDL-C RS	PRXOVR	DEF					NA	NA	NA	N
G9676	40-75Y W/TYPE 1/2 W/LDL-C RS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9687	HOSPICE ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9687	HOSPICE ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9688	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9688	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9689	INPT ELECT CAROTID INTERVENT	PRXOVR	DEF					NA	NA	NA	N
G9689	INPT ELECT CAROTID INTERVENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9690	PT IN HOS	PRXOVR	DEF					NA	NA	NA	N
G9690	PT IN HOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9691	PT HOSP DUR MSMT PERIOD	PRXOVR	DEF					NA	NA	NA	N
G9691	PT HOSP DUR MSMT PERIOD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9692	HOSP RECD BY PT DUR MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9692	HOSP RECD BY PT DUR MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9693	PT USE HOSP DURING MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9693	PT USE HOSP DURING MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9694	HOSP SRV USED PT IN MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9694	HOSP SRV USED PT IN MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9695	LONG ACT INHAL BRONCHDIL PRE	PRXOVR	DEF					NA	NA	NA	N
G9695	LONG ACT INHAL BRONCHDIL PRE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9696	MED RSN NO PRESC BRONCHDIL	PRXOVR	DEF					NA	NA	NA	N
G9696	MED RSN NO PRESC BRONCHDIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9697	PT RSN NO PRESC BRONCHDIL	PRXOVR	DEF					NA	NA	NA	N
G9697	PT RSN NO PRESC BRONCHDIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9698	SYS RSN NO PRESC BRONCHDIL	PRXOVR	DEF					NA	NA	NA	N
G9698	SYS RSN NO PRESC BRONCHDIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9699	LONG INHAL BRONCHDIL NO PRES	PRXOVR	DEF					NA	NA	NA	N
G9699	LONG INHAL BRONCHDIL NO PRES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9700	PT IS W/HOSP DURING MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9700	PT IS W/HOSP DURING MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9701	CHILD ANBX 30 PRIOR DX ESTAB	PRXOVR	DEF					NA	NA	NA	N
G9701	CHILD ANBX 30 PRIOR DX ESTAB	MAXFEE	DEF					NA			N
G9702	PT USE HOSP DURING MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9702	PT USE HOSP DURING MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9703	ANBX 30 PRIOR TO EPISODE	PRXOVR	DEF					NA	NA	NA	N
G9703	ANBX 30 PRIOR TO EPISODE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9704	AJCC BR CA STG I: T1 MIC/T1A	PRXOVR	DEF					NA	NA	NA	N
G9704	AJCC BR CA STG I: T1 MIC/T1A	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9705	AJCC BR CA STG IB	PRXOVR	DEF					NA	NA	NA	N
G9705	AJCC BR CA STG IB	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9706	LOW RECUR PROST CA	PRXOVR	DEF					NA	NA	NA	N
G9706	LOW RECUR PROST CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9707	PT HAD HOSP DUR MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9707	PT HAD HOSP DUR MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9708	BILAT MAST/HX BI /UNILAT MAS	PRXOVR	DEF					NA	NA	NA	N
G9708	BILAT MAST/HX BI /UNILAT MAS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9709	HOSP SRV USED PT IN MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9709	HOSP SRV USED PT IN MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9710	PT PROV HOSP SRV MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9710	PT PROV HOSP SRV MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9711	PT HX TOT COL OR COLON CA	PRXOVR	DEF					NA	NA	NA	N
G9711	PT HX TOT COL OR COLON CA	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9712	DOC MED RSN PRESC ANBX	PRXOVR	DEF					NA	NA	NA	N
G9712	DOC MED RSN PRESC ANBX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9713	PT USE HOSP DURING MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9713	PT USE HOSP DURING MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9714	PT IS W/HOSP DURING MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9714	PT IS W/HOSP DURING MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9715	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9715	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9716	BMI DOC ONL FUP NOT CMPLTD	PRXOVR	DEF					NA	NA	NA	N
G9716	BMI DOC ONL FUP NOT CMPLTD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9717	DOC PT DX DEP/BIPOL	PRXOVR	DEF					NA	NA	NA	N
G9717	DOC PT DX DEP/BIPOL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9718	HOSPICE ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9718	HOSPICE ANYTIME MSMT PER	MAXFEE	DEF					NA			N
G9719	PT NOT AMBUL/IMMOB/WC	PRXOVR	DEF					NA	NA	NA	N
G9719	PT NOT AMBUL/IMMOB/WC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9720	HOSPICE ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9720	HOSPICE ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9721	PT NOT AMBUL/IMMOB/WC	PRXOVR	DEF					NA	NA	NA	N
G9721	PT NOT AMBUL/IMMOB/WC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9722	DOC HX RENAL FAIL OR CR+ >=4	PRXOVR	DEF					NA	NA	NA	N
G9722	DOC HX RENAL FAIL OR CR+ >=4	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9723	HOSP RECD BY PT DUR MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9723	HOSP RECD BY PT DUR MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9724	PT W/DOC USE ANTICOAG MST YR	PRXOVR	DEF					NA	NA	NA	N
G9724	PT W/DOC USE ANTICOAG MST YR	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9725	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9725	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9726	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9726	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9727	PT UNABLE CMPLT LEPF PROM	PRXOVR	DEF					NA	NA	NA	N
G9727	PT UNABLE CMPLT LEPF PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9728	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9728	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9729	PT UNBL CMPLT LEPF PROM	PRXOVR	DEF					NA	NA	NA	N
G9729	PT UNBL CMPLT LEPF PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9730	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9730	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9731	PT UNBL CMPLT LEPF PROM	PRXOVR	DEF					NA	NA	NA	N
G9731	PT UNBL CMPLT LEPF PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9732	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9732	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9733	PT UNBL CMPLT LB FS PROM	PRXOVR	DEF					NA	NA	NA	N
G9733	PT UNBL CMPLT LB FS PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9734	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9734	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9735	PT UNBL CMPLT SHLD FS PROM	PRXOVR	DEF					NA	NA	NA	N
G9735	PT UNBL CMPLT SHLD FS PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9736	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9736	REFUSED TO PARTICIPATE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9737	PT UNBL CMPLT EWH FS PROM	PRXOVR	DEF					NA	NA	NA	N
G9737	PT UNBL CMPLT EWH FS PROM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9738	REFUSED TO PARTICIPATE	PRXOVR	DEF					NA	NA	NA	N
G9738	REFUSED TO PARTICIPATE	MAXFEE	DEF					NA			N
G9739	PT UNBL CMPLT GO FS PROM	PRXOVR	DEF					NA	NA	NA	N
G9739	PT UNBL CMPLT GO FS PROM	MAXFEE	DEF					NA			N
G9740	HOSP SRV TO PT DUR MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9740	HOSP SRV TO PT DUR MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9741	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9741	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9742	PSYCH SYMPT ASSESSED	PRXOVR	DEF					NA	NA	NA	N
G9742	PSYCH SYMPT ASSESSED	MAXFEE	DEF					NA			N
G9743	PSYCH SYMP NOT ASSESSED; RNS	PRXOVR	DEF					NA	NA	NA	N
G9743	PSYCH SYMP NOT ASSESSED; RNS	MAXFEE	DEF					NA			N
G9744	PT NOT ELI D/T ACT DIG HTN	PRXOVR	DEF					NA	NA	NA	N
G9744	PT NOT ELI D/T ACT DIG HTN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9745	DOC RSN NO HBP SCRN OR F/U	PRXOVR	DEF					NA	NA	NA	N
G9745	DOC RSN NO HBP SCRN OR F/U	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9746	MIT STEN; VALVE OR TRANS AF	PRXOVR	DEF					NA	NA	NA	N
G9746	MIT STEN; VALVE OR TRANS AF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9747	PALL DIALYSIS WITH CATHETER	PRXOVR	DEF					NA	NA	NA	N
G9747	PALL DIALYSIS WITH CATHETER	MAXFEE	DEF					NA			N
G9748	APP TRANSPL LVG KIDNEY DONOR	PRXOVR	DEF					NA	NA	NA	N
G9748	APP TRANSPL LVG KIDNEY DONOR	MAXFEE	DEF					NA			N
G9749	PALL DIALYSIS WITH CATHETER	PRXOVR	DEF					NA	NA	NA	N
G9749	PALL DIALYSIS WITH CATHETER	MAXFEE	DEF					NA			N
G9750	APP TRANSPL LVG KIDNEY DONOR	PRXOVR	DEF					NA	NA	NA	N
G9750	APP TRANSPL LVG KIDNEY DONOR	MAXFEE	DEF					NA			N
G9751	PT DIED W/IN 24 MOS RPT TIME	PRXOVR	DEF					NA	NA	NA	N
G9751	PT DIED W/IN 24 MOS RPT TIME	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9752	URGENT SURGERY	PRXOVR	DEF					NA	NA	NA	N
G9752	URGENT SURGERY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9753	DOC NO DICOM; CT OTHER FAC	PRXOVR	DEF					NA	NA	NA	N
G9753	DOC NO DICOM; CT OTHER FAC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9754	INCID PULM NODULE	PRXOVR	DEF					NA	NA	NA	N
G9754	INCID PULM NODULE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9755	DOC MED RSN NO FLLW UP	PRXOVR	DEF					NA	NA	NA	N
G9755	DOC MED RSN NO FLLW UP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9756	SURG PROC W/SILICONE OIL	PRXOVR	DEF					NA	NA	NA	N
G9756	SURG PROC W/SILICONE OIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9757	SURG PROC W/SILICONE OIL	PRXOVR	DEF					NA	NA	NA	N
G9757	SURG PROC W/SILICONE OIL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9758	PT IN HOS	PRXOVR	DEF					NA	NA	NA	N
G9758	PT IN HOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9759	HX PREOP POST CAP RUP	PRXOVR	DEF					NA	NA	NA	N
G9759	HX PREOP POST CAP RUP	MAXFEE	DEF					NA			N
G9760	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9760	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9761	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9761	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9762	PT HAD >= 2-3 HPV VACCINES	PRXOVR	DEF					NA	NA	NA	N
G9762	PT HAD >= 2-3 HPV VACCINES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9763	PT NOT HAVE 2-3 HPV VACCINES	PRXOVR	DEF					NA	NA	NA	N
G9763	PT NOT HAVE 2-3 HPV VACCINES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9764	PT TREATD W/ORAL SYST OR BIO	PRXOVR	DEF					NA	NA	NA	N
G9764	PT TREATD W/ORAL SYST OR BIO	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9765	DOC PAT DECLINED THERAPY	PRXOVR	DEF					NA	NA	NA	N
G9765	DOC PAT DECLINED THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9766	CVA STROKE DX TX TRANSF FAC	PRXOVR	DEF					NA	NA	NA	N
G9766	CVA STROKE DX TX TRANSF FAC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9767	HOSP NEW DX CVA CONSID EVST	PRXOVR	DEF					NA	NA	NA	N
G9767	HOSP NEW DX CVA CONSID EVST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9768	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9768	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9769	BN DEN 2YR/GOT OST MED/THER	PRXOVR	DEF					NA	NA	NA	N
G9769	BN DEN 2YR/GOT OST MED/THER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9770	PERIP NERVE BLOCK	PRXOVR	DEF					NA	NA	NA	N
G9770	PERIP NERVE BLOCK	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9771	ANES END; 1 TEMP >35.5(95.9)	PRXOVR	DEF					NA	NA	NA	N
G9771	ANES END; 1 TEMP >35.5(95.9)	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9772	DOC MED RSN NO TEMP >= 35.5	PRXOVR	DEF					NA	NA	NA	N
G9772	DOC MED RSN NO TEMP >= 35.5	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9773	1 BOD TEMP >=35.5	PRXOVR	DEF					NA	NA	NA	N
G9773	1 BOD TEMP >=35.5	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9774	PT HAD HYST	PRXOVR	DEF					NA	NA	NA	N
G9774	PT HAD HYST	MAXFEE	DEF					NA			N
G9775	RECD 2 ANTI-EMET PRE/INTRAOP	PRXOVR	DEF					NA	NA	NA	N
G9775	RECD 2 ANTI-EMET PRE/INTRAOP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9776	DOC MED RSN NO PROPH ANTIEM	PRXOVR	DEF					NA	NA	NA	N
G9776	DOC MED RSN NO PROPH ANTIEM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9777	PT NO ANTIEMET PRE/INTRAOP	PRXOVR	DEF					NA	NA	NA	N
G9777	PT NO ANTIEMET PRE/INTRAOP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9778	PTS DX W/PREGN	PRXOVR	DEF					NA	NA	NA	N
G9778	PTS DX W/PREGN	MAXFEE	DEF					NA			N
G9779	PTS BREASTFEEDING	PRXOVR	DEF					NA	NA	NA	N
G9779	PTS BREASTFEEDING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9780	PTS DX W/RHABDOMYOLYSIS	PRXOVR	DEF					NA	NA	NA	N
G9780	PTS DX W/RHABDOMYOLYSIS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9781	DOC RSN NO STATIN	PRXOVR	DEF					NA	NA	NA	N
G9781	DOC RSN NO STATIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9782	HX DX FAM/PURE HYPERCHOLES	PRXOVR	DEF					NA	NA	NA	N
G9782	HX DX FAM/PURE HYPERCHOLES	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9783	DOC DX DM; FAST <70; NO STAT	PRXOVR	DEF					NA	NA	NA	N
G9783	DOC DX DM; FAST <70; NO STAT	MAXFEE	DEF					NA			N
G9784	PATH/DERM PROV 2ND BIOP OPIN	PRXOVR	DEF					NA	NA	NA	N
G9784	PATH/DERM PROV 2ND BIOP OPIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9785	PATH REPORT SENT	PRXOVR	DEF					NA	NA	NA	N
G9785	PATH REPORT SENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9786	PATH REPORT NOT SENT	PRXOVR	DEF					NA	NA	NA	N
G9786	PATH REPORT NOT SENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9787	PT ALIVE	PRXOVR	DEF					NA	NA	NA	N
G9787	PT ALIVE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9788	MOST RCT BP </= 140/90	PRXOVR	DEF					NA	NA	NA	N
G9788	MOST RCT BP </= 140/90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9789	RECORD BP IP; ER; URG/SELF	PRXOVR	DEF					NA	NA	NA	N
G9789	RECORD BP IP; ER; URG/SELF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9790	MOST RCT BP >/= 140/90	PRXOVR	DEF					NA	NA	NA	N
G9790	MOST RCT BP >/= 140/90	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9791	MOST RCT TOB STAT FREE	PRXOVR	DEF					NA	NA	NA	N
G9791	MOST RCT TOB STAT FREE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9792	MOST RCT TOB STAT NOT FREE	PRXOVR	DEF					NA	NA	NA	N
G9792	MOST RCT TOB STAT NOT FREE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9793	PT ON DAILY ASA/ANTIPLAT	PRXOVR	DEF					NA	NA	NA	N
G9793	PT ON DAILY ASA/ANTIPLAT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9794	DOC MED RSN NO DAILY ASPIRIN	PRXOVR	DEF					NA	NA	NA	N
G9794	DOC MED RSN NO DAILY ASPIRIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9795	PT NO DAILY ASA/ANTIPLAT	PRXOVR	DEF					NA	NA	NA	N
G9795	PT NO DAILY ASA/ANTIPLAT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9796	PT NOT CURRENTLY ON STATIN	PRXOVR	DEF					NA	NA	NA	N
G9796	PT NOT CURRENTLY ON STATIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9797	PT CURRENTLY ON STATIN	PRXOVR	DEF					NA	NA	NA	N
G9797	PT CURRENTLY ON STATIN	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9798	D/C AMI BTW 7/1-6/30 MEAS PD	PRXOVR	DEF					NA	NA	NA	N
G9798	D/C AMI BTW 7/1-6/30 MEAS PD	MAXFEE	DEF					NA			N
G9799	MED DISP EVT INDIC HX ASTH	PRXOVR	DEF					NA	NA	NA	N
G9799	MED DISP EVT INDIC HX ASTH	MAXFEE	DEF					NA			N
G9800	PT ID INTOL/ALLEG BETA-BLOCK	PRXOVR	DEF					NA	NA	NA	N
G9800	PT ID INTOL/ALLEG BETA-BLOCK	MAXFEE	DEF					NA			N
G9801	NONACUT TRANSF FROM INPT	PRXOVR	DEF					NA	NA	NA	N
G9801	NONACUT TRANSF FROM INPT	MAXFEE	DEF					NA			N
G9802	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9802	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					NA			N
G9803	PT PRESC 135 DAY TRMT	PRXOVR	DEF					NA	NA	NA	N
G9803	PT PRESC 135 DAY TRMT	MAXFEE	DEF					NA			N
G9804	PT NOT PRESC 135 DAY TRMT	PRXOVR	DEF					NA	NA	NA	N
G9804	PT NOT PRESC 135 DAY TRMT	MAXFEE	DEF					NA			N
G9805	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9805	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9806	PT RECD CERV CYTO/HPV	PRXOVR	DEF					NA	NA	NA	N
G9806	PT RECD CERV CYTO/HPV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9807	PT NO RECD CERV CYTO/HPV	PRXOVR	DEF					NA	NA	NA	N
G9807	PT NO RECD CERV CYTO/HPV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9808	PT NO ASTHM CONT MED MST PER	PRXOVR	DEF					NA	NA	NA	N
G9808	PT NO ASTHM CONT MED MST PER	MAXFEE	DEF					NA			N
G9809	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9809	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					NA			N
G9810	PDC 75% W/ASTH CONT MED	PRXOVR	DEF					NA	NA	NA	N
G9810	PDC 75% W/ASTH CONT MED	MAXFEE	DEF					NA			N
G9811	NO PDC 75% W/ASTH CONT MED	PRXOVR	DEF					NA	NA	NA	N
G9811	NO PDC 75% W/ASTH CONT MED	MAXFEE	DEF					NA			N
G9812	PT DIED DURING INPT/30D AFT	PRXOVR	DEF					NA	NA	NA	N
G9812	PT DIED DURING INPT/30D AFT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9813	PT NOT DIED W/IN 30D OF PROC	PRXOVR	DEF					NA	NA	NA	N
G9813	PT NOT DIED W/IN 30D OF PROC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9814	DEATH DURING INDEX HOSP	PRXOVR	DEF					NA	NA	NA	N
G9814	DEATH DURING INDEX HOSP	MAXFEE	DEF					NA			N
G9815	DEATH NOT DURING INDEX HOSP	PRXOVR	DEF					NA	NA	NA	N
G9815	DEATH NOT DURING INDEX HOSP	MAXFEE	DEF					NA			N
G9816	DEATH <30 DAY POST DISCHARGE	PRXOVR	DEF					NA	NA	NA	N
G9816	DEATH <30 DAY POST DISCHARGE	MAXFEE	DEF					NA			N
G9817	NO DEATH 30-DAYS POST-DISCH	PRXOVR	DEF					NA	NA	NA	N
G9817	NO DEATH 30-DAYS POST-DISCH	MAXFEE	DEF					NA			N
G9818	DOC SEX ACTIVITY	PRXOVR	DEF					NA	NA	NA	N
G9818	DOC SEX ACTIVITY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9819	PT W/HOSP ANYTIME MSMT PER	PRXOVR	DEF					NA	NA	NA	N
G9819	PT W/HOSP ANYTIME MSMT PER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9820	DOC CHLAM SCR TEST W/FOLLOW	PRXOVR	DEF					NA	NA	NA	N
G9820	DOC CHLAM SCR TEST W/FOLLOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9821	NO DOC CHLAM SCR TS W/FOLLOW	PRXOVR	DEF					NA	NA	NA	N
G9821	NO DOC CHLAM SCR TS W/FOLLOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9822	ENDO ABL PROC YR PREV IND DT	PRXOVR	DEF					NA	NA	NA	N
G9822	ENDO ABL PROC YR PREV IND DT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9823	ENDO SMPL/HYST BX RES DOC	PRXOVR	DEF					NA	NA	NA	N
G9823	ENDO SMPL/HYST BX RES DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9824	ENDO SMPL/HYST BX RES NO DOC	PRXOVR	DEF					NA	NA	NA	N
G9824	ENDO SMPL/HYST BX RES NO DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9825	HER-2 NEG;UNDOC/UNKN	PRXOVR	DEF					NA	NA	NA	N
G9825	HER-2 NEG;UNDOC/UNKN	MAXFEE	DEF					NA			N
G9826	TRANSF PRACT AFT INIT CHEMO	PRXOVR	DEF					NA	NA	NA	N
G9826	TRANSF PRACT AFT INIT CHEMO	MAXFEE	DEF					NA			N
G9827	HER-2 TARG THER NO INIT TX	PRXOVR	DEF					NA	NA	NA	N
G9827	HER-2 TARG THER NO INIT TX	MAXFEE	DEF					NA			N
G9828	HER-2 TARG THER DUR INIT TX	PRXOVR	DEF					NA	NA	NA	N
G9828	HER-2 TARG THER DUR INIT TX	MAXFEE	DEF					NA			N
G9829	BREAST ADJ CHEMO ADMIN	PRXOVR	DEF					NA	NA	NA	N
G9829	BREAST ADJ CHEMO ADMIN	MAXFEE	DEF					NA			N
G9830	HER-2 POS	PRXOVR	DEF					NA	NA	NA	N
G9830	HER-2 POS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9831	AJCC STG BRT CA DX II OR III	PRXOVR	DEF					NA	NA	NA	N
G9831	AJCC STG BRT CA DX II OR III	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9832	BRT CA DX I; NO T1/T1A/T1B	PRXOVR	DEF					NA	NA	NA	N
G9832	BRT CA DX I; NO T1/T1A/T1B	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9833	TRANSF PRACT AFT INIT CHEMO	PRXOVR	DEF					NA	NA	NA	N
G9833	TRANSF PRACT AFT INIT CHEMO	MAXFEE	DEF					NA			N
G9834	PT MET DIS AT DX	PRXOVR	DEF					NA	NA	NA	N
G9834	PT MET DIS AT DX	MAXFEE	DEF					NA			N
G9835	TRASTUZ GIVEN W/IN 12 MOS DX	PRXOVR	DEF					NA	NA	NA	N
G9835	TRASTUZ GIVEN W/IN 12 MOS DX	MAXFEE	DEF					NA			N
G9836	RSN NO TRAST GIVEN DOC	PRXOVR	DEF					NA	NA	NA	N
G9836	RSN NO TRAST GIVEN DOC	MAXFEE	DEF					NA			N
G9837	TRASTUZ NOT IN 12 MOS DX	PRXOVR	DEF					NA	NA	NA	N
G9837	TRASTUZ NOT IN 12 MOS DX	MAXFEE	DEF					NA			N
G9838	PT MET DIS AT DX	PRXOVR	DEF					NA	NA	NA	N
G9838	PT MET DIS AT DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9839	ANTI-EGFR MON ANTI THER	PRXOVR	DEF					NA	NA	NA	N
G9839	ANTI-EGFR MON ANTI THER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9840	GENE TESTING PERFORMED	PRXOVR	DEF					NA	NA	NA	N
G9840	GENE TESTING PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9841	GENE TESTING NOT PERFORMED	PRXOVR	DEF					NA	NA	NA	N
G9841	GENE TESTING NOT PERFORMED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9842	PT MET DIS AT DX	PRXOVR	DEF					NA	NA	NA	N
G9842	PT MET DIS AT DX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9843	KRAS OR NRAS GENE MUTATION	PRXOVR	DEF					NA	NA	NA	N
G9843	KRAS OR NRAS GENE MUTATION	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9844	PT NO RECD ANTI-EGFR THER	PRXOVR	DEF					NA	NA	NA	N
G9844	PT NO RECD ANTI-EGFR THER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9845	PT RECD ANTI-EGFR THER	PRXOVR	DEF					NA	NA	NA	N
G9845	PT RECD ANTI-EGFR THER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9846	PT DIED FROM CANCER	PRXOVR	DEF					NA	NA	NA	N
G9846	PT DIED FROM CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9847	PT RECD CHEMO LAST 14D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9847	PT RECD CHEMO LAST 14D LIFE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9848	PT NO CHEMO LAST 14D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9848	PT NO CHEMO LAST 14D LIFE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9849	PT DIED FROM CANCER	PRXOVR	DEF					NA	NA	NA	N
G9849	PT DIED FROM CANCER	MAXFEE	DEF					NA			N
G9850	1/MORE ED LAST 30D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9850	1/MORE ED LAST 30D LIFE	MAXFEE	DEF					NA			N
G9851	1/NO ED VISIT LAST 30D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9851	1/NO ED VISIT LAST 30D LIFE	MAXFEE	DEF					NA			N
G9852	PT DIED FROM CANCER	PRXOVR	DEF					NA	NA	NA	N
G9852	PT DIED FROM CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9853	ICU STAY LAST 30D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9853	ICU STAY LAST 30D LIFE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9854	NO ICU STAY LAST 30D LIFE	PRXOVR	DEF					NA	NA	NA	N
G9854	NO ICU STAY LAST 30D LIFE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9855	PT DIED FROM CANCER	PRXOVR	DEF					NA	NA	NA	N
G9855	PT DIED FROM CANCER	MAXFEE	DEF					NA			N
G9856	PT NO HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9856	PT NO HOSPICE	MAXFEE	DEF					NA			N
G9857	PT ADMIT HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9857	PT ADMIT HOSPICE	MAXFEE	DEF					NA			N
G9858	PT ENROLL HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9858	PT ENROLL HOSPICE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9859	PT DIED FROM CANCER	PRXOVR	DEF					NA	NA	NA	N
G9859	PT DIED FROM CANCER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9860	PT LESS 3D HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9860	PT LESS 3D HOSPICE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9861	PT MORE THAN 3D HOSPICE	PRXOVR	DEF					NA	NA	NA	N
G9861	PT MORE THAN 3D HOSPICE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9862	DOC RSN NO 10 YR FOLLOW	PRXOVR	DEF					NA	NA	NA	N
G9862	DOC RSN NO 10 YR FOLLOW	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9890	EM BRIDGE PAYMENT	PRXOVR	DEF					NA	NA	NA	N
G9890	EM BRIDGE PAYMENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9891	EM SESSION REPORTING	PRXOVR	DEF					NA	NA	NA	N
G9891	EM SESSION REPORTING	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9892	DOC PT RSN NO DIL MAC EXAM	PRXOVR	DEF					NA	NA	NA	N
G9892	DOC PT RSN NO DIL MAC EXAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9893	NO MAC EXAM	PRXOVR	DEF					NA	NA	NA	N
G9893	NO MAC EXAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9894	ADR DEP THRPY PRESCRIBED	PRXOVR	DEF					NA	NA	NA	N
G9894	ADR DEP THRPY PRESCRIBED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9895	DOC MED RSN NO ADR DEP THRPY	PRXOVR	DEF					NA	NA	NA	N
G9895	DOC MED RSN NO ADR DEP THRPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9896	DOC PT RSN NO ADR DEP THRPY	PRXOVR	DEF					NA	NA	NA	N
G9896	DOC PT RSN NO ADR DEP THRPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9897	PT NT PRSC ADR DEP THRPY RNG	PRXOVR	DEF					NA	NA	NA	N
G9897	PT NT PRSC ADR DEP THRPY RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9898	PT 66+ SNP OR LTC POS > 90D	PRXOVR	DEF					NA	NA	NA	N
G9898	PT 66+ SNP OR LTC POS > 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9899	SCRN MAM PERF RSLTS DOC	PRXOVR	DEF					NA	NA	NA	N
G9899	SCRN MAM PERF RSLTS DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9900	SCRN MAM PERF RSLTS NOT DOC	PRXOVR	DEF					NA	NA	NA	N
G9900	SCRN MAM PERF RSLTS NOT DOC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9901	PT 66+ SNP OR LTC POS > 90D	PRXOVR	DEF					NA	NA	NA	N
G9901	PT 66+ SNP OR LTC POS > 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9902	PT SCRN TBCO AND ID AS USER	PRXOVR	DEF					NA	NA	NA	N
G9902	PT SCRN TBCO AND ID AS USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9903	PT SCRN TBCO ID AS NON USER	PRXOVR	DEF					NA	NA	NA	N
G9903	PT SCRN TBCO ID AS NON USER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9904	DOC MED RSN NO TBCO SCRN	PRXOVR	DEF					NA	NA	NA	N
G9904	DOC MED RSN NO TBCO SCRN	MAXFEE	DEF					NA			N
G9905	NO PT TBCO SCRN RNG	PRXOVR	DEF					NA	NA	NA	N
G9905	NO PT TBCO SCRN RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9906	PT RECV TBCO CESS INTERV	PRXOVR	DEF					NA	NA	NA	N
G9906	PT RECV TBCO CESS INTERV	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9907	DOC MED RSN NO TBCO INTERV	PRXOVR	DEF					NA	NA	NA	N
G9907	DOC MED RSN NO TBCO INTERV	MAXFEE	DEF					NA			N
G9908	NO PT TBCO CESS INTERV RNG	PRXOVR	DEF					NA	NA	NA	N
G9908	NO PT TBCO CESS INTERV RNG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9909	DOC MED RSN NO TBCO INTERV	PRXOVR	DEF					NA	NA	NA	N
G9909	DOC MED RSN NO TBCO INTERV	MAXFEE	DEF					NA			N
G9910	PT 66+ SNP OR LTC POS > 90D	PRXOVR	DEF					NA	NA	NA	N
G9910	PT 66+ SNP OR LTC POS > 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9911	NODE NEG PRE/POST SYST THER	PRXOVR	DEF					NA	NA	NA	N
G9911	NODE NEG PRE/POST SYST THER	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9912	HBV STATUS ASSESED AND INT	PRXOVR	DEF					NA	NA	NA	N
G9912	HBV STATUS ASSESED AND INT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9913	NO HBV STATUS ASSESD AND INT	PRXOVR	DEF					NA	NA	NA	N
G9913	NO HBV STATUS ASSESD AND INT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9914	PT RECEIVING ANTI-TNF AGENT	PRXOVR	DEF					NA	NA	NA	N
G9914	PT RECEIVING ANTI-TNF AGENT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9915	NO DOCUMNTD HBV RESULTS RCD	PRXOVR	DEF					NA	NA	NA	N
G9915	NO DOCUMNTD HBV RESULTS RCD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9916	FUNCT STATUS PAST 12 MONTHS	PRXOVR	DEF					NA	NA	NA	N
G9916	FUNCT STATUS PAST 12 MONTHS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9917	ADV DEM CRGVR LIMITED	PRXOVR	DEF					NA	NA	NA	N
G9917	ADV DEM CRGVR LIMITED	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9918	NO FUNCT STAT PERF; RSN NOS	PRXOVR	DEF					NA	NA	NA	N
G9918	NO FUNCT STAT PERF; RSN NOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9919	SCRN ND POS ND PROV OF REC	PRXOVR	DEF					NA	NA	NA	N
G9919	SCRN ND POS ND PROV OF REC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9920	SCRNING PERF AND NEGATIVE	PRXOVR	DEF					NA	NA	NA	N
G9920	SCRNING PERF AND NEGATIVE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9921	NO OR PART SCRN ND RNG OR OS	PRXOVR	DEF					NA	NA	NA	N
G9921	NO OR PART SCRN ND RNG OR OS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9922	SFTY CNCRNS SCRN ND MIT RECS	PRXOVR	DEF					NA	NA	NA	N
G9922	SFTY CNCRNS SCRN ND MIT RECS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9923	SAFTY CNCRNS SCRN AND NEG	PRXOVR	DEF					NA	NA	NA	N
G9923	SAFTY CNCRNS SCRN AND NEG	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9924	DOC MED RSN NO SCRN OR RECS	PRXOVR	DEF					NA	NA	NA	N
G9924	DOC MED RSN NO SCRN OR RECS	MAXFEE	DEF					NA			N
G9925	NO SCRN PROV RSN NOS	PRXOVR	DEF					NA	NA	NA	N
G9925	NO SCRN PROV RSN NOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9926	SFTY CNCRNS SCRN BUT NO RECS	PRXOVR	DEF					NA	NA	NA	N
G9926	SFTY CNCRNS SCRN BUT NO RECS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9927	DOC NO WARF /FDA PT TRIAL	PRXOVR	DEF					NA	NA	NA	N
G9927	DOC NO WARF /FDA PT TRIAL	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9928	NO WARF OR FDA DRUG PRESC	PRXOVR	DEF					NA	NA	NA	N
G9928	NO WARF OR FDA DRUG PRESC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9929	TRS/REV AF	PRXOVR	DEF					NA	NA	NA	N
G9929	TRS/REV AF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9930	COM CARE	PRXOVR	DEF					NA	NA	NA	N
G9930	COM CARE	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9931	NO CHAD OR CHAD SCR 0 OR 1	PRXOVR	DEF					NA	NA	NA	N
G9931	NO CHAD OR CHAD SCR 0 OR 1	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9932	DOC PT RSN NO TB SCRN RECRDS	PRXOVR	DEF					NA	NA	NA	N
G9932	DOC PT RSN NO TB SCRN RECRDS	MAXFEE	DEF					NA			N
G9933	CANC DETECTD DURING COL SCRN	PRXOVR	DEF					NA	NA	NA	N
G9933	CANC DETECTD DURING COL SCRN	MAXFEE	DEF					NA			N
G9934	DOC RSN NOT DETECTING CANCER	PRXOVR	DEF					NA	NA	NA	N
G9934	DOC RSN NOT DETECTING CANCER	MAXFEE	DEF					NA			N
G9935	CANC NOT DETECTD DURING SRCN	PRXOVR	DEF					NA	NA	NA	N
G9935	CANC NOT DETECTD DURING SRCN	MAXFEE	DEF					NA			N
G9936	PMH PLYP/NEO CO/RECT/JUN/ANS	PRXOVR	DEF					NA	NA	NA	N
G9936	PMH PLYP/NEO CO/RECT/JUN/ANS	MAXFEE	DEF					NA			N
G9937	DIG OR SURV COLSCO	PRXOVR	DEF					NA	NA	NA	N
G9937	DIG OR SURV COLSCO	MAXFEE	DEF					NA			N
G9938	PT 66+ SNP OR LTC POS > 90D	PRXOVR	DEF					NA	NA	NA	N
G9938	PT 66+ SNP OR LTC POS > 90D	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9939	SAME PATH/DERM PERF BIOPSY	PRXOVR	DEF					NA	NA	NA	N
G9939	SAME PATH/DERM PERF BIOPSY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9940	DOC REAS NO STATIN THERAPY	PRXOVR	DEF					NA	NA	NA	N
G9940	DOC REAS NO STATIN THERAPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9941	PRE AND POST VAS WTHN 3 MOS	PRXOVR	DEF					NA	NA	NA	N
G9941	PRE AND POST VAS WTHN 3 MOS	MAXFEE	DEF					NA			N
G9942	ADTL SPINE PROC ON SAME DATE	PRXOVR	DEF					NA	NA	NA	N
G9942	ADTL SPINE PROC ON SAME DATE	MAXFEE	DEF					NA			N
G9943	BK PN NT MSR VAS SCL PRE/PST	PRXOVR	DEF					NA	NA	NA	N
G9943	BK PN NT MSR VAS SCL PRE/PST	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9944	VAS 3 MON PRE AND 1 YR POST	PRXOVR	DEF					NA	NA	NA	N
G9944	VAS 3 MON PRE AND 1 YR POST	MAXFEE	DEF					NA			N
G9945	PT W/CANCER SCOLIOSIS	PRXOVR	DEF					NA	NA	NA	N
G9945	PT W/CANCER SCOLIOSIS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9946	BK PAIN NO VAS	PRXOVR	DEF					NA	NA	NA	N
G9946	BK PAIN NO VAS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9947	PRE AND POST VAS WTHN 3 MOS	PRXOVR	DEF					NA	NA	NA	N
G9947	PRE AND POST VAS WTHN 3 MOS	MAXFEE	DEF					NA			N
G9948	ADTL SPINE PROC ON SAME DATE	PRXOVR	DEF					NA	NA	NA	N
G9948	ADTL SPINE PROC ON SAME DATE	MAXFEE	DEF					NA			N
G9949	LEG PAIN NO VAS	PRXOVR	DEF					NA	NA	NA	N
G9949	LEG PAIN NO VAS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9954	PT >2 RSK FAC POST-OP VOMIT	PRXOVR	DEF					NA	NA	NA	N
G9954	PT >2 RSK FAC POST-OP VOMIT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9955	INHLNT ANESTH ONLY FOR INDUC	PRXOVR	DEF					NA	NA	NA	N
G9955	INHLNT ANESTH ONLY FOR INDUC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9956	COMBO THRPY OF >= 2 PROPHLY	PRXOVR	DEF					NA	NA	NA	N
G9956	COMBO THRPY OF >= 2 PROPHLY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9957	DOC MED RSN NO COMBO THRPY	PRXOVR	DEF					NA	NA	NA	N
G9957	DOC MED RSN NO COMBO THRPY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9958	NO COMBO PROHPYL THRP FOR PT	PRXOVR	DEF					NA	NA	NA	N
G9958	NO COMBO PROHPYL THRP FOR PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9959	SYSTEMIC ANTIMICRO NOT PRESC	PRXOVR	DEF					NA	NA	NA	N
G9959	SYSTEMIC ANTIMICRO NOT PRESC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9960	MED RSN SYS ANTIMI NT RX	PRXOVR	DEF					NA	NA	NA	N
G9960	MED RSN SYS ANTIMI NT RX	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9961	SYSTEMIC ANTIMICRO PRESC	PRXOVR	DEF					NA	NA	NA	N
G9961	SYSTEMIC ANTIMICRO PRESC	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9962	EMBOLIZATION DOC SEPARATLY	PRXOVR	DEF					NA	NA	NA	N
G9962	EMBOLIZATION DOC SEPARATLY	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9963	EMBOLIZATION NOT DOC SEPARAT	PRXOVR	DEF					NA	NA	NA	N
G9963	EMBOLIZATION NOT DOC SEPARAT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9964	PT RECV >=1 WELL-CHLD VISIT	PRXOVR	DEF					NA	NA	NA	N
G9964	PT RECV >=1 WELL-CHLD VISIT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9965	NO WELL-CHLD VIST RECV BY PT	PRXOVR	DEF					NA	NA	NA	N
G9965	NO WELL-CHLD VIST RECV BY PT	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9966	SCRN; INTER; REPORT CHILD	PRXOVR	DEF					NA	NA	NA	N
G9966	SCRN; INTER; REPORT CHILD	MAXFEE	DEF					NA			N
G9967	NO SCRN; INTER; REPRT CHILD	PRXOVR	DEF					NA	NA	NA	N
G9967	NO SCRN; INTER; REPRT CHILD	MAXFEE	DEF					NA			N
G9968	PT REFRD 2 PVDR/SPCLST IN PP	PRXOVR	DEF					NA	NA	NA	N
G9968	PT REFRD 2 PVDR/SPCLST IN PP	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9969	PVDR RFRD PT RPRT RCVD	PRXOVR	DEF					NA	NA	NA	N
G9969	PVDR RFRD PT RPRT RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9970	PVDR RFRD PT NO RPRT RCVD	PRXOVR	DEF					NA	NA	NA	N
G9970	PVDR RFRD PT NO RPRT RCVD	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9974	MAC EXAM PERF	PRXOVR	DEF					NA	NA	NA	N
G9974	MAC EXAM PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9975	DOC MED RSN NO DIL MAC EXAM	PRXOVR	DEF					NA	NA	NA	N
G9975	DOC MED RSN NO DIL MAC EXAM	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9976	DOC PAT RSN NO MAC EXM PERF	PRXOVR	DEF					NA	NA	NA	N
G9976	DOC PAT RSN NO MAC EXM PERF	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
G9977	DIL MAC EXAM NO PERF RSN NOS	PRXOVR	DEF					NA	NA	NA	N
G9977	DIL MAC EXAM NO PERF RSN NOS	MAXFEE	DEF					0	1/1/2016	12/31/2299	N
H2000	COMP MULTIDISIPLN EVALUATION	PRXOVR	DEF					NA	NA	NA	N
H2000	COMP MULTIDISIPLN EVALUATION	MAXFEE	DEF					200.51	1/1/2023	12/31/2299	N
T1015	CLINIC SERVICE	PRXOVR	DEF					NA	NA	NA	N
T1015	CLINIC SERVICE	UCCENC	UC3					NA	NA	NA	N