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 SX ONSET>=3HR PRXOVR DEF         NA NA NA N
1066F ISCHM STROKE SX ONSET>=3HR 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 INTRVWD ON/BEFORE DX MDD PRXOVR DEF         NA NA NA N
2060F PT INTRVWD ON/BEFORE DX 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 RED >=15% PRE-NTRV LVL PRXOVR DEF         NA NA NA N
3284F IOP RED >=15% PRE-NTRV 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 SCR PFRMD&INTERPD 6 MO PRXOVR DEF         NA NA NA N
3455F TB SCR PFRMD&INTERPD 6 MO 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         12.46 1/1/2024 12/31/2299 S
90791 PSYCH DIAGNOSTIC EVALUATION PRXOVR DEF         NA NA NA N
90791 PSYCH DIAGNOSTIC EVALUATION MAXFEE FAC         77.14 1/1/2024 12/31/2299 N
90791 PSYCH DIAGNOSTIC EVALUATION MAXFEE NFF         117.91 1/1/2024 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         35.58 1/1/2024 12/31/2299 N
90832 PSYTX W PT 30 MINUTES MAXFEE NFF         56.93 1/1/2024 12/31/2299 N
90834 PSYTX W PT 45 MINUTES PRXOVR DEF         NA NA NA N
90834 PSYTX W PT 45 MINUTES MAXFEE FAC         49.43 1/1/2024 12/31/2299 N
90834 PSYTX W PT 45 MINUTES MAXFEE NFF         74.01 1/1/2024 12/31/2299 N
90837 PSYTX W PT 60 MINUTES PRXOVR DEF         NA NA NA N
90837 PSYTX W PT 60 MINUTES MAXFEE FAC         75.77 1/1/2024 12/31/2299 N
90837 PSYTX W PT 60 MINUTES MAXFEE NFF         108.57 1/1/2024 12/31/2299 N
90839 PSYTX CRISIS INITIAL 60 MIN PRXOVR DEF         NA NA NA N
90839 PSYTX CRISIS INITIAL 60 MIN MAXFEE FAC         97.31 1/1/2024 12/31/2299 N
90839 PSYTX CRISIS INITIAL 60 MIN MAXFEE NFF         154.87 1/1/2024 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         46.85 1/1/2024 12/31/2299 N
90840 PSYTX CRISIS EA ADDL 30 MIN MAXFEE NFF         73.92 1/1/2024 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         57.66 1/1/2024 12/31/2299 N
90846 FAMILY PSYTX W/O PT 50 MIN MAXFEE NFF         92.26 1/1/2024 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         67.71 1/1/2024 12/31/2299 N
90847 FAMILY PSYTX W/PT 50 MIN MAXFEE NFF         90.85 1/1/2024 12/31/2299 N
90849 MULTIPLE FAMILY GROUP PSYTX PRXOVR DEF         NA NA NA N
90849 MULTIPLE FAMILY GROUP PSYTX MAXFEE FAC         22.92 1/1/2024 12/31/2299 N
90849 MULTIPLE FAMILY GROUP PSYTX MAXFEE NFF         36.67 1/1/2024 12/31/2299 N
90853 GROUP PSYCHOTHERAPY PRXOVR DEF         NA NA NA N
90853 GROUP PSYCHOTHERAPY MAXFEE DEF         29.85 1/1/2024 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         25.95 1/1/2024 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         50.01 1/1/2024 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         8.32 1/1/2024 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         63.85 1/1/2024 12/31/2299 S
96112 DEVEL TST PHYS/QHP 1ST HR MAXFEE NFF         64.54 1/1/2024 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         28.55 1/1/2024 12/31/2299 S
96113 DEVEL TST PHYS/QHP EA ADDL MAXFEE NFF         30.46 1/1/2024 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         54.66 1/1/2024 12/31/2299 S
96116 NUBHVL XM PHYS/QHP 1ST HR MAXFEE NFF         67.31 1/1/2024 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         50.30 1/1/2024 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         50.77 1/1/2024 12/31/2299 S
96130 PSYCL TST EVAL PHYS/QHP 1ST MAXFEE NFF         62.22 1/1/2024 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         50.77 1/1/2024 12/31/2299 S
96131 PSYCL TST EVAL PHYS/QHP EA MAXFEE NFF         62.22 1/1/2024 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         85.69 1/1/2024 12/31/2299 S
96132 NRPSYC TST EVAL PHYS/QHP 1ST MAXFEE NFF         102.24 1/1/2024 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         64.74 1/1/2024 12/31/2299 S
96133 NRPSYC TST EVAL PHYS/QHP EA MAXFEE NFF         83.13 1/1/2024 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         18.33 1/1/2024 12/31/2299 S
96136 PSYCL/NRPSYC TST PHY/QHP 1ST MAXFEE NFF         32.40 1/1/2024 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         16.86 1/1/2024 12/31/2299 S
96137 PSYCL/NRPSYC TST PHY/QHP EA MAXFEE NFF         31.23 1/1/2024 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         2.47 1/1/2024 12/31/2299 N
96161 CAREGIVER HEALTH RISK ASSMT PRXOVR DEF         NA NA NA N
96161 CAREGIVER HEALTH RISK ASSMT MAXFEE DEF         2.47 1/1/2024 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         7.72 1/1/2024 12/31/2299 S
99406 BEHAV CHNG SMOKING 3-10 MIN MAXFEE NFF         10 1/1/2024 12/31/2299 S
99407 BEHAV CHNG SMOKING > 10 MIN PRXOVR DEF         NA NA NA S
99407 BEHAV CHNG SMOKING > 10 MIN MAXFEE FAC         29.48 1/1/2024 12/31/2299 S
99407 BEHAV CHNG SMOKING > 10 MIN MAXFEE NFF         29.48 1/1/2024 12/31/2299 S
G0396 ALCOHOL/SUBS INTERV 15-30MN PRXOVR DEF         NA NA NA S
G0396 ALCOHOL/SUBS INTERV 15-30MN MAXFEE DEF         26.30 1/1/2024 12/31/2299 S
G0397 ALCOHOL/SUBS INTERV >30 MIN PRXOVR DEF         NA NA NA S
G0397 ALCOHOL/SUBS INTERV >30 MIN MAXFEE DEF         50.06 1/1/2024 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         NA     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         NA     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         NA     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 TX ASSESS AT LST ANN PRXOVR DEF         NA NA NA N
G8851 ADHERE TX ASSESS AT LST ANN 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         NA     N
G8854 REAS NO ADHERE THERAPY PRXOVR DEF         NA NA NA N
G8854 REAS NO ADHERE THERAPY MAXFEE DEF         0 1/1/2016 12/31/2299 N
G8855 THER NOT ASSESSED ANNUALLY PRXOVR DEF         NA NA NA N
G8855 THER NOT ASSESSED ANNUALLY 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         NA     N
G8884 DOC REAS BIOPSY NOT REVIEW PRXOVR DEF         NA NA NA N
G8884 DOC REAS BIOPSY NOT REVIEW MAXFEE DEF         NA     N
G8885 NO REV; COMM; TRACK BIOPSY PRXOVR DEF         NA NA NA N
G8885 NO REV; COMM; TRACK BIOPSY MAXFEE DEF         NA     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 RES DOC FEV1/FVC<70% PRXOVR DEF         NA NA NA N
G8924 SPIR RES DOC FEV1/FVC<70% 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         NA     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         NA     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         NA     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         NA     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         NA     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         NA     N
G9452 DOC MED REAS NO HCV TEST PRXOVR DEF         NA NA NA N
G9452 DOC MED REAS NO HCV TEST 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         NA     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         NA     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         NA     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         NA     N
G9613 DOC POST SURG ANATOMY PRXOVR DEF         NA NA NA N
G9613 DOC POST SURG ANATOMY MAXFEE DEF         NA     N
G9614 PHOTODOC < 2 CEC LNDMK PRXOVR DEF         NA NA NA N
G9614 PHOTODOC < 2 CEC LNDMK MAXFEE DEF         NA     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         NA     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         NA     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 BIPOL PRXOVR DEF         NA NA NA N
G9717 DOC PT DX 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         NA     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         NA     N
G9853 ICU STAY LAST 30D LIFE PRXOVR DEF         NA NA NA N
G9853 ICU STAY LAST 30D LIFE MAXFEE DEF         NA     N
G9854 NO ICU STAY LAST 30D LIFE PRXOVR DEF         NA NA NA N
G9854 NO ICU STAY LAST 30D LIFE MAXFEE DEF         NA     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 INITIATED ANTI-TNF AGENT PRXOVR DEF         NA NA NA N
G9914 PT INITIATED 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         NA     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         226.07 1/1/2024 12/31/2299 N
T1015 CLINIC SERVICE PRXOVR DEF         NA NA NA N
T1015 CLINIC SERVICE UCCENC UC3         NA NA NA N