Procedure Code	Procedure Description	Pricing Indicator	Rate Type	Mod1	Mod2	Mod3	Mod4	Max Fee	Max Fee Eff. Date	Max Fee End Date	PA
29125	APPLY FOREARM SPLINT	PRXOVR	DEF					NA	NA	NA	S
29125	APPLY FOREARM SPLINT	MAXFEE	FAC					31.44	12/31/2014	12/31/2299	S
29125	APPLY FOREARM SPLINT	MAXFEE	NFF					58.61	1/1/2016	12/31/2299	S
29425	APPLY SHORT LEG CAST	PRXOVR	DEF					NA	NA	NA	S
29425	APPLY SHORT LEG CAST	MAXFEE	FAC					45.18	12/31/2014	12/31/2299	S
29425	APPLY SHORT LEG CAST	MAXFEE	NFF					72.33	1/1/2016	12/31/2299	S
92502	EAR AND THROAT EXAMINATION	PRXOVR	DEF					NA	NA	NA	S
92502	EAR AND THROAT EXAMINATION	MAXFEE	DEF					68.86	1/1/2010	12/31/2299	S
92504	EAR MICROSCOPY EXAMINATION	PRXOVR	DEF					NA	NA	NA	S
92504	EAR MICROSCOPY EXAMINATION	MAXFEE	FAC					3.56	1/1/2014	12/31/2299	S
92504	EAR MICROSCOPY EXAMINATION	MAXFEE	NFF					14.41	1/1/2014	12/31/2299	S
92506	SPEECH/HEARING EVALUATION	PRXOVR	DEF					NA	NA	NA	S
92506	SPEECH/HEARING EVALUATION	MAXFEE	DEF					NA			S
92507	SPEECH/HEARING THERAPY	PRXOVR	DEF					NA	NA	NA	S
92507	SPEECH/HEARING THERAPY	MAXFEE	DEF					37.03	1/1/2010	12/31/2299	S
92508	SPEECH/HEARING THERAPY	PRXOVR	DEF					NA	NA	NA	S
92508	SPEECH/HEARING THERAPY	MAXFEE	DEF					18.15	9/1/2013	12/31/2299	S
92510	REHAB FOR EAR IMPLANT	PRXOVR	DEF					NA	NA	NA	N
92510	REHAB FOR EAR IMPLANT	MAXFEE	DEF					NA			N
92511	NASOPHARYNGOSCOPY	PRXOVR	DEF					NA	NA	NA	S
92511	NASOPHARYNGOSCOPY	MAXFEE	FAC					21.41	1/1/2014	12/31/2299	S
92511	NASOPHARYNGOSCOPY	MAXFEE	NFF					73.79	1/1/2014	12/31/2299	S
92512	NASAL FUNCTION STUDIES	PRXOVR	DEF					NA	NA	NA	S
92512	NASAL FUNCTION STUDIES	MAXFEE	FAC					9.75	1/1/2014	12/31/2299	S
92512	NASAL FUNCTION STUDIES	MAXFEE	NFF					24.90	1/1/2014	12/31/2299	S
92516	FACIAL NERVE FUNCTION TEST	PRXOVR	DEF					NA	NA	NA	S
92516	FACIAL NERVE FUNCTION TEST	MAXFEE	FAC					17.12	1/1/2014	12/31/2299	S
92516	FACIAL NERVE FUNCTION TEST	MAXFEE	NFF					30.86	1/1/2014	12/31/2299	S
92517	VEMP TEST I&R CERVICAL	PRXOVR	DEF					NA	NA	NA	S
92517	VEMP TEST I&R CERVICAL	MAXFEE	FAC					31.18	1/1/2021	12/31/2299	S
92517	VEMP TEST I&R CERVICAL	MAXFEE	NFF					61.01	1/1/2021	12/31/2299	S
92518	VEMP TEST I&R OCULAR	PRXOVR	DEF					NA	NA	NA	S
92518	VEMP TEST I&R OCULAR	MAXFEE	FAC					31.18	1/1/2021	12/31/2299	S
92518	VEMP TEST I&R OCULAR	MAXFEE	NFF					56.75	1/1/2021	12/31/2299	S
92519	VEMP TST I&R CERVICAL&OCULAR	PRXOVR	DEF					NA	NA	NA	S
92519	VEMP TST I&R CERVICAL&OCULAR	MAXFEE	FAC					46.68	1/1/2021	12/31/2299	S
92519	VEMP TST I&R CERVICAL&OCULAR	MAXFEE	NFF					94.97	1/1/2021	12/31/2299	S
92520	LARYNGEAL FUNCTION STUDIES	PRXOVR	DEF					NA	NA	NA	S
92520	LARYNGEAL FUNCTION STUDIES	MAXFEE	FAC					15.93	1/1/2014	12/31/2299	S
92520	LARYNGEAL FUNCTION STUDIES	MAXFEE	NFF					33.62	1/1/2014	12/31/2299	S
92521	EVALUATION OF SPEECH FLUENCY	PRXOVR	DEF					NA	NA	NA	S
92521	EVALUATION OF SPEECH FLUENCY	MAXFEE	DEF					77.67	1/1/2014	12/31/2299	S
92522	EVALUATE SPEECH PRODUCTION	PRXOVR	DEF					NA	NA	NA	S
92522	EVALUATE SPEECH PRODUCTION	MAXFEE	DEF					63.20	1/1/2014	12/31/2299	S
92523	SPEECH SOUND LANG COMPREHEN	PRXOVR	DEF					NA	NA	NA	S
92523	SPEECH SOUND LANG COMPREHEN	MAXFEE	DEF					131.09	1/1/2014	12/31/2299	S
92524	BEHAVRAL QUALIT ANALYS VOICE	PRXOVR	DEF					NA	NA	NA	S
92524	BEHAVRAL QUALIT ANALYS VOICE	MAXFEE	DEF					66	1/1/2014	12/31/2299	S
92526	ORAL FUNCTION THERAPY	PRXOVR	DEF					NA	NA	NA	S
92526	ORAL FUNCTION THERAPY	MAXFEE	DEF					39.94	7/23/2010	12/31/2299	S
92537	CALORIC VSTBLR TEST W/REC	PRXOVR	DEF					NA	NA	NA	S
92537	CALORIC VSTBLR TEST W/REC	MAXFEE	DEF					31.47	1/1/2016	12/31/2299	S
92537	CALORIC VSTBLR TEST W/REC	MAXFEE	DEF	26				25.18	1/1/2016	12/31/2299	S
92537	CALORIC VSTBLR TEST W/REC	MAXFEE	DEF	TC				6.29	1/1/2016	12/31/2299	S
92538	CALORIC VSTBLR TEST W/REC	PRXOVR	DEF					NA	NA	NA	S
92538	CALORIC VSTBLR TEST W/REC	MAXFEE	DEF					16.01	1/1/2016	12/31/2299	S
92538	CALORIC VSTBLR TEST W/REC	MAXFEE	DEF	26				12.81	1/1/2016	12/31/2299	S
92538	CALORIC VSTBLR TEST W/REC	MAXFEE	DEF	TC				3.20	1/1/2016	12/31/2299	S
92540	BASIC VESTIBULAR EVALUATION	PRXOVR	DEF					NA	NA	NA	S
92540	BASIC VESTIBULAR EVALUATION	MAXFEE	DEF					54.32	1/1/2010	12/31/2299	S
92540	BASIC VESTIBULAR EVALUATION	MAXFEE	DEF	TC				10.86	1/1/2010	12/31/2299	S
92540	BASIC VESTIBULAR EVALUATION	MAXFEE	DEF	26				43.46	1/1/2010	12/31/2299	S
92541	SPONTANEOUS NYSTAGMUS TEST	PRXOVR	DEF					NA	NA	NA	S
92541	SPONTANEOUS NYSTAGMUS TEST	MAXFEE	DEF					20.81	1/1/2016	12/31/2299	S
92541	SPONTANEOUS NYSTAGMUS TEST	MAXFEE	DEF	26				8.32	1/1/2016	12/31/2299	S
92541	SPONTANEOUS NYSTAGMUS TEST	MAXFEE	DEF	TC				14.49	1/1/2016	12/31/2299	S
92542	POSITIONAL NYSTAGMUS TEST	PRXOVR	DEF					NA	NA	NA	S
92542	POSITIONAL NYSTAGMUS TEST	MAXFEE	DEF					22.97	12/31/2014	12/31/2299	S
92542	POSITIONAL NYSTAGMUS TEST	MAXFEE	DEF	TC				16.08	12/31/2014	12/31/2299	S
92542	POSITIONAL NYSTAGMUS TEST	MAXFEE	DEF	26				6.89	12/31/2014	12/31/2299	S
92543	CALORIC VESTIBULAR TEST	PRXOVR	DEF					NA	NA	NA	S
92543	CALORIC VESTIBULAR TEST	MAXFEE	DEF					NA			S
92544	OPTOKINETIC NYSTAGMUS TEST	PRXOVR	DEF					NA	NA	NA	S
92544	OPTOKINETIC NYSTAGMUS TEST	MAXFEE	DEF					14.53	1/1/2016	12/31/2299	S
92544	OPTOKINETIC NYSTAGMUS TEST	MAXFEE	DEF	26				4.36	1/1/2016	12/31/2299	S
92544	OPTOKINETIC NYSTAGMUS TEST	MAXFEE	DEF	TC				10.17	1/1/2016	12/31/2299	S
92545	OSCILLATING TRACKING TEST	PRXOVR	DEF					NA	NA	NA	S
92545	OSCILLATING TRACKING TEST	MAXFEE	DEF					13.53	1/1/2016	12/31/2299	S
92545	OSCILLATING TRACKING TEST	MAXFEE	DEF	26				4.06	1/1/2016	12/31/2299	S
92545	OSCILLATING TRACKING TEST	MAXFEE	DEF	TC				9.47	1/1/2016	12/31/2299	S
92546	SINUSOIDAL ROTATIONAL TEST	PRXOVR	DEF					NA	NA	NA	S
92546	SINUSOIDAL ROTATIONAL TEST	MAXFEE	DEF					40.92	1/1/2010	12/31/2299	S
92546	SINUSOIDAL ROTATIONAL TEST	MAXFEE	DEF	TC				32.74	1/1/2010	12/31/2299	S
92546	SINUSOIDAL ROTATIONAL TEST	MAXFEE	DEF	26				8.18	1/1/2010	12/31/2299	S
92547	SUPPLEMENTAL ELECTRICAL TEST	PRXOVR	DEF					NA	NA	NA	S
92547	SUPPLEMENTAL ELECTRICAL TEST	MAXFEE	DEF					3.69	1/1/2010	12/31/2299	S
92548	CDP-SOT 6 COND W/I&R	PRXOVR	DEF					NA	NA	NA	S
92548	CDP-SOT 6 COND W/I&R	MAXFEE	DEF					63.02	1/1/2010	12/31/2299	S
92548	CDP-SOT 6 COND W/I&R	MAXFEE	DEF	TC				44.11	1/1/2010	12/31/2299	S
92548	CDP-SOT 6 COND W/I&R	MAXFEE	DEF	26				18.91	1/1/2010	12/31/2299	S
92549	CDP-SOT 6 COND W/I&R MCT&ADT	PRXOVR	DEF					NA	NA	NA	S
92549	CDP-SOT 6 COND W/I&R MCT&ADT	MAXFEE	DEF					49.59	1/1/2020	12/31/2299	S
92549	CDP-SOT 6 COND W/I&R MCT&ADT	MAXFEE	DEF	TC				13.77	1/1/2020	12/31/2299	S
92549	CDP-SOT 6 COND W/I&R MCT&ADT	MAXFEE	DEF	26				35.82	1/1/2020	12/31/2299	S
92550	TYMPANOMETRY & REFLEX THRESH	PRXOVR	DEF					NA	NA	NA	S
92550	TYMPANOMETRY & REFLEX THRESH	MAXFEE	DEF					11.82	1/1/2010	12/31/2299	S
92551	PURE TONE HEARING TEST AIR	PRXOVR	DEF					NA	NA	NA	S
92551	PURE TONE HEARING TEST AIR	MAXFEE	DEF					6.08	1/1/2010	12/31/2299	S
92552	PURE TONE AUDIOMETRY AIR	PRXOVR	DEF					NA	NA	NA	S
92552	PURE TONE AUDIOMETRY AIR	MAXFEE	DEF					11.67	1/1/2010	12/31/2299	S
92553	AUDIOMETRY AIR & BONE	PRXOVR	DEF					NA	NA	NA	S
92553	AUDIOMETRY AIR & BONE	MAXFEE	DEF					17.55	1/1/2010	12/31/2299	S
92555	SPEECH THRESHOLD AUDIOMETRY	PRXOVR	DEF					NA	NA	NA	S
92555	SPEECH THRESHOLD AUDIOMETRY	MAXFEE	DEF					10.07	1/1/2010	12/31/2299	S
92556	SPEECH AUDIOMETRY COMPLETE	PRXOVR	DEF					NA	NA	NA	S
92556	SPEECH AUDIOMETRY COMPLETE	MAXFEE	DEF					15.36	1/1/2010	12/31/2299	S
92557	COMPREHENSIVE HEARING TEST	PRXOVR	DEF					NA	NA	NA	S
92557	COMPREHENSIVE HEARING TEST	MAXFEE	FAC					24.22	1/1/2014	12/31/2299	S
92557	COMPREHENSIVE HEARING TEST	MAXFEE	NFF					31.89	1/1/2014	12/31/2299	S
92558	EVOKED AUDITORY TEST QUAL	PRXOVR	DEF					NA	NA	NA	S
92558	EVOKED AUDITORY TEST QUAL	MAXFEE	DEF					16.20	1/1/2012	12/31/2299	S
92559	GROUP AUDIOMETRIC TESTING	PRXOVR	DEF					NA	NA	NA	S
92559	GROUP AUDIOMETRIC TESTING	MAXFEE	DEF					NA			S
92560	BEKESY AUDIOMETRY SCREEN	PRXOVR	DEF					NA	NA	NA	S
92560	BEKESY AUDIOMETRY SCREEN	MAXFEE	DEF					NA			S
92561	BEKESY AUDIOMETRY DIAGNOSIS	PRXOVR	DEF					NA	NA	NA	S
92561	BEKESY AUDIOMETRY DIAGNOSIS	MAXFEE	DEF					NA			S
92562	LOUDNESS BALANCE TEST	PRXOVR	DEF					NA	NA	NA	S
92562	LOUDNESS BALANCE TEST	MAXFEE	DEF					10.83	1/1/2010	12/31/2299	S
92563	TONE DECAY HEARING TEST	PRXOVR	DEF					NA	NA	NA	S
92563	TONE DECAY HEARING TEST	MAXFEE	DEF					10.07	1/1/2010	12/31/2299	S
92564	SISI HEARING TEST	PRXOVR	DEF					NA	NA	NA	S
92564	SISI HEARING TEST	MAXFEE	DEF					NA			S
92565	STENGER TEST PURE TONE	PRXOVR	DEF					NA	NA	NA	S
92565	STENGER TEST PURE TONE	MAXFEE	DEF					10.54	1/1/2010	12/31/2299	S
92567	TYMPANOMETRY	PRXOVR	DEF					NA	NA	NA	S
92567	TYMPANOMETRY	MAXFEE	FAC					8.30	1/1/2014	12/31/2299	S
92567	TYMPANOMETRY	MAXFEE	NFF					12.47	1/1/2014	12/31/2299	S
92568	ACOUSTIC REFL THRESHOLD TST	PRXOVR	DEF					NA	NA	NA	S
92568	ACOUSTIC REFL THRESHOLD TST	MAXFEE	DEF					10.07	1/1/2010	12/31/2299	S
92569	ACOUSTIC REFLEX DECAY TEST	PRXOVR	DEF					NA	NA	NA	N
92569	ACOUSTIC REFLEX DECAY TEST	MAXFEE	DEF					NA			N
92570	ACOUSTIC IMMITANCE TESTING	PRXOVR	DEF					NA	NA	NA	S
92570	ACOUSTIC IMMITANCE TESTING	MAXFEE	FAC					14.27	1/1/2014	12/31/2299	S
92570	ACOUSTIC IMMITANCE TESTING	MAXFEE	NFF					17.09	1/1/2014	12/31/2299	S
92571	FILTERED SPEECH HEARING TEST	PRXOVR	DEF					NA	NA	NA	S
92571	FILTERED SPEECH HEARING TEST	MAXFEE	DEF					10.30	1/1/2010	12/31/2299	S
92572	STAGGERED SPONDAIC WORD TEST	PRXOVR	DEF					NA	NA	NA	S
92572	STAGGERED SPONDAIC WORD TEST	MAXFEE	DEF					4.19	1/1/2010	12/31/2299	S
92573	LOMBARD TEST	PRXOVR	DEF					NA	NA	NA	N
92573	LOMBARD TEST	MAXFEE	DEF					NA			N
92575	SENSORINEURAL ACUITY TEST	PRXOVR	DEF					NA	NA	NA	S
92575	SENSORINEURAL ACUITY TEST	MAXFEE	DEF					9.48	1/1/2010	12/31/2299	S
92576	SYNTHETIC SENTENCE TEST	PRXOVR	DEF					NA	NA	NA	S
92576	SYNTHETIC SENTENCE TEST	MAXFEE	DEF					11.94	1/1/2010	12/31/2299	S
92577	STENGER TEST SPEECH	PRXOVR	DEF					NA	NA	NA	S
92577	STENGER TEST SPEECH	MAXFEE	DEF					14.06	1/1/2016	12/31/2299	S
92579	VISUAL AUDIOMETRY (VRA)	PRXOVR	DEF					NA	NA	NA	S
92579	VISUAL AUDIOMETRY (VRA)	MAXFEE	FAC					14.45	1/1/2014	12/31/2299	S
92579	VISUAL AUDIOMETRY (VRA)	MAXFEE	NFF					19.09	1/1/2014	12/31/2299	S
92582	CONDITIONING PLAY AUDIOMETRY	PRXOVR	DEF					NA	NA	NA	S
92582	CONDITIONING PLAY AUDIOMETRY	MAXFEE	DEF					19.03	1/1/2010	12/31/2299	S
92583	SELECT PICTURE AUDIOMETRY	PRXOVR	DEF					NA	NA	NA	S
92583	SELECT PICTURE AUDIOMETRY	MAXFEE	DEF					23.78	1/1/2010	12/31/2299	S
92584	ELECTROCOCHLEOGRAPHY	PRXOVR	DEF					NA	NA	NA	S
92584	ELECTROCOCHLEOGRAPHY	MAXFEE	DEF					64.05	1/1/2012	12/31/2299	S
92585	AUDITOR EVOKE POTENT COMPRE	PRXOVR	DEF					NA	NA	NA	S
92585	AUDITOR EVOKE POTENT COMPRE	MAXFEE	DEF					NA			S
92586	AUDITOR EVOKE POTENT LIMIT	PRXOVR	DEF					NA	NA	NA	S
92586	AUDITOR EVOKE POTENT LIMIT	MAXFEE	DEF					NA			S
92587	EVOKED AUDITORY TEST LIMITED	PRXOVR	DEF					NA	NA	NA	S
92587	EVOKED AUDITORY TEST LIMITED	MAXFEE	DEF					19.33	9/1/2013	12/31/2299	S
92587	EVOKED AUDITORY TEST LIMITED	MAXFEE	DEF	TC				1.93	9/1/2013	12/31/2299	S
92587	EVOKED AUDITORY TEST LIMITED	MAXFEE	DEF	26				17.40	9/1/2013	12/31/2299	S
92588	EVOKED AUDITORY TST COMPLETE	PRXOVR	DEF					NA	NA	NA	S
92588	EVOKED AUDITORY TST COMPLETE	MAXFEE	DEF					29.05	9/1/2013	12/31/2299	S
92588	EVOKED AUDITORY TST COMPLETE	MAXFEE	DEF	TC				2.91	9/1/2013	12/31/2299	S
92588	EVOKED AUDITORY TST COMPLETE	MAXFEE	DEF	26				26.15	9/1/2013	12/31/2299	S
92589	AUDITORY FUNCTION TEST(S)	PRXOVR	DEF					NA	NA	NA	N
92589	AUDITORY FUNCTION TEST(S)	MAXFEE	DEF					NA			N
92597	ORAL SPEECH DEVICE EVAL	PRXOVR	DEF					NA	NA	NA	S
92597	ORAL SPEECH DEVICE EVAL	MAXFEE	DEF					64.03	1/1/2010	12/31/2299	S
92601	COCHLEAR IMPLT F/UP EXAM <7	PRXOVR	DEF					NA	NA	NA	S
92601	COCHLEAR IMPLT F/UP EXAM <7	MAXFEE	FAC					65.09	1/1/2014	12/31/2299	S
92601	COCHLEAR IMPLT F/UP EXAM <7	MAXFEE	NFF					84.55	1/1/2014	12/31/2299	S
92602	REPROGRAM COCHLEAR IMPLT <7	PRXOVR	DEF					NA	NA	NA	S
92602	REPROGRAM COCHLEAR IMPLT <7	MAXFEE	FAC					40.52	1/1/2014	12/31/2299	S
92602	REPROGRAM COCHLEAR IMPLT <7	MAXFEE	NFF					59.39	1/1/2014	12/31/2299	S
92603	COCHLEAR IMPLT F/UP EXAM 7/>	PRXOVR	DEF					NA	NA	NA	S
92603	COCHLEAR IMPLT F/UP EXAM 7/>	MAXFEE	FAC					41.55	1/1/2014	12/31/2299	S
92603	COCHLEAR IMPLT F/UP EXAM 7/>	MAXFEE	NFF					57.12	1/1/2014	12/31/2299	S
92604	REPROGRAM COCHLEAR IMPLT 7/>	PRXOVR	DEF					NA	NA	NA	S
92604	REPROGRAM COCHLEAR IMPLT 7/>	MAXFEE	FAC					25.53	1/1/2014	12/31/2299	S
92604	REPROGRAM COCHLEAR IMPLT 7/>	MAXFEE	NFF					39	1/1/2014	12/31/2299	S
92606	NON-SPEECH DEVICE SERVICE	PRXOVR	DEF					NA	NA	NA	S
92606	NON-SPEECH DEVICE SERVICE	MAXFEE	DEF					35	1/1/2020	12/31/2299	S
92607	EX FOR SPEECH DEVICE RX 1HR	PRXOVR	DEF					NA	NA	NA	S
92607	EX FOR SPEECH DEVICE RX 1HR	MAXFEE	DEF					70.46	1/1/2010	12/31/2299	S
92608	EX FOR SPEECH DEVICE RX ADDL	PRXOVR	DEF					NA	NA	NA	S
92608	EX FOR SPEECH DEVICE RX ADDL	MAXFEE	DEF					14.09	1/1/2010	12/31/2299	S
92609	USE OF SPEECH DEVICE SERVICE	PRXOVR	DEF					NA	NA	NA	S
92609	USE OF SPEECH DEVICE SERVICE	MAXFEE	DEF					38.25	7/23/2010	12/31/2299	S
92610	EVALUATE SWALLOWING FUNCTION	PRXOVR	DEF					NA	NA	NA	S
92610	EVALUATE SWALLOWING FUNCTION	MAXFEE	FAC					43.63	1/1/2014	12/31/2299	S
92610	EVALUATE SWALLOWING FUNCTION	MAXFEE	NFF					55.73	1/1/2014	12/31/2299	S
92611	MOTION FLUOROSCOPY/SWALLOW	PRXOVR	DEF					NA	NA	NA	S
92611	MOTION FLUOROSCOPY/SWALLOW	MAXFEE	DEF					56.82	1/1/2010	12/31/2299	S
92612	ENDOSCOPY SWALLOW (FEES) VID	PRXOVR	DEF					NA	NA	NA	S
92612	ENDOSCOPY SWALLOW (FEES) VID	MAXFEE	FAC					38.59	1/1/2014	12/31/2299	S
92612	ENDOSCOPY SWALLOW (FEES) VID	MAXFEE	NFF					113	1/1/2014	12/31/2299	S
92614	LARYNGOSCOPIC SENSORY VID	PRXOVR	DEF					NA	NA	NA	S
92614	LARYNGOSCOPIC SENSORY VID	MAXFEE	FAC					34.34	1/1/2014	12/31/2299	S
92614	LARYNGOSCOPIC SENSORY VID	MAXFEE	NFF					87.58	1/1/2014	12/31/2299	S
92616	FEES W/LARYNGEAL SENSE TEST	PRXOVR	DEF					NA	NA	NA	S
92616	FEES W/LARYNGEAL SENSE TEST	MAXFEE	FAC					50.54	1/1/2014	12/31/2299	S
92616	FEES W/LARYNGEAL SENSE TEST	MAXFEE	NFF					120.29	1/1/2014	12/31/2299	S
92620	AUDITORY FUNCTION 60 MIN	PRXOVR	DEF					NA	NA	NA	S
92620	AUDITORY FUNCTION 60 MIN	MAXFEE	FAC					31.16	1/1/2014	12/31/2299	S
92620	AUDITORY FUNCTION 60 MIN	MAXFEE	NFF					37.92	1/1/2014	12/31/2299	S
92621	AUDITORY FUNCTION + 15 MIN	PRXOVR	DEF					NA	NA	NA	S
92621	AUDITORY FUNCTION + 15 MIN	MAXFEE	FAC					7.99	1/1/2014	12/31/2299	S
92621	AUDITORY FUNCTION + 15 MIN	MAXFEE	NFF					9.04	1/1/2014	12/31/2299	S
92625	TINNITUS ASSESSMENT	PRXOVR	DEF					NA	NA	NA	S
92625	TINNITUS ASSESSMENT	MAXFEE	FAC					23.46	1/1/2014	12/31/2299	S
92625	TINNITUS ASSESSMENT	MAXFEE	NFF					30.60	1/1/2014	12/31/2299	S
92626	EVAL AUD FUNCJ 1ST HOUR	PRXOVR	DEF					NA	NA	NA	S
92626	EVAL AUD FUNCJ 1ST HOUR	MAXFEE	FAC					25.98	1/1/2014	12/31/2299	S
92626	EVAL AUD FUNCJ 1ST HOUR	MAXFEE	NFF					39.52	1/1/2014	12/31/2299	S
92627	EVAL AUD FUNCJ EA ADDL 15	PRXOVR	DEF					NA	NA	NA	S
92627	EVAL AUD FUNCJ EA ADDL 15	MAXFEE	FAC					11.06	1/1/2014	12/31/2299	S
92627	EVAL AUD FUNCJ EA ADDL 15	MAXFEE	NFF					15.01	1/1/2014	12/31/2299	S
92630	AUD REHAB PRE-LING HEAR LOSS	PRXOVR	DEF					NA	NA	NA	S
92630	AUD REHAB PRE-LING HEAR LOSS	MAXFEE	DEF					22.75	12/7/2010	12/31/2299	S
92633	AUD REHAB POSTLING HEAR LOSS	PRXOVR	DEF					NA	NA	NA	S
92633	AUD REHAB POSTLING HEAR LOSS	MANUAL	DEF					NA	NA	NA	S
92640	AUD BRAINSTEM IMPLT PROGRAMG	PRXOVR	DEF					NA	NA	NA	S
92640	AUD BRAINSTEM IMPLT PROGRAMG	MAXFEE	FAC					30.87	1/1/2014	12/31/2299	S
92640	AUD BRAINSTEM IMPLT PROGRAMG	MAXFEE	NFF					42.87	1/1/2014	12/31/2299	S
92650	AEP SCR AUDITORY POTENTIAL	PRXOVR	DEF					NA	NA	NA	S
92650	AEP SCR AUDITORY POTENTIAL	MAXFEE	DEF					20.67	1/1/2021	12/31/2299	S
92651	AEP HEARING STATUS DETER I&R	PRXOVR	DEF					NA	NA	NA	S
92651	AEP HEARING STATUS DETER I&R	MAXFEE	DEF					64.54	1/1/2021	12/31/2299	S
92652	AEP THRSHLD EST MLT FREQ I&R	PRXOVR	DEF					NA	NA	NA	S
92652	AEP THRSHLD EST MLT FREQ I&R	MAXFEE	DEF					85.76	1/1/2021	12/31/2299	S
92653	AEP NEURODIAGNOSTIC I&R	PRXOVR	DEF					NA	NA	NA	S
92653	AEP NEURODIAGNOSTIC I&R	MAXFEE	DEF					63.07	1/1/2021	12/31/2299	S
92700	UNLISTED ORL SERVICE/PX	PRXOVR	DEF					NA	NA	NA	S
92700	UNLISTED ORL SERVICE/PX	MANUAL	DEF					NA	NA	NA	S
96110	DEVELOPMENTAL SCREEN W/SCORE	PRXOVR	DEF					NA	NA	NA	S
96110	DEVELOPMENTAL SCREEN W/SCORE	MAXFEE	DEF					7.92	1/1/2012	12/31/2299	S
96111	DEVELOPMENTAL TEST EXTEND	PRXOVR	DEF					NA	NA	NA	S
96111	DEVELOPMENTAL TEST EXTEND	MAXFEE	DEF					NA			S
96112	DEVEL TST PHYS/QHP 1ST HR	PRXOVR	DEF					NA	NA	NA	S
96112	DEVEL TST PHYS/QHP 1ST HR	MAXFEE	FAC					41.71	1/1/2019	12/31/2299	S
96112	DEVEL TST PHYS/QHP 1ST HR	MAXFEE	NFF					56.11	1/1/2019	12/31/2299	S
96113	DEVEL TST PHYS/QHP EA ADDL	PRXOVR	DEF					NA	NA	NA	S
96113	DEVEL TST PHYS/QHP EA ADDL	MAXFEE	FAC					20.86	1/1/2019	12/31/2299	S
96113	DEVEL TST PHYS/QHP EA ADDL	MAXFEE	NFF					28.06	1/1/2019	12/31/2299	S
96125	COGNITIVE TEST BY HC PRO	PRXOVR	DEF					NA	NA	NA	S
96125	COGNITIVE TEST BY HC PRO	MAXFEE	DEF					53	4/1/2022	12/31/2299	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
97001	PT EVALUATION	PRXOVR	DEF					NA	NA	NA	S
97001	PT EVALUATION	MAXFEE	DEF					NA			S
97002	PT RE-EVALUATION	PRXOVR	DEF					NA	NA	NA	S
97002	PT RE-EVALUATION	MAXFEE	DEF					NA			S
97003	OT EVALUATION	PRXOVR	DEF					NA	NA	NA	S
97003	OT EVALUATION	MAXFEE	DEF					NA			S
97004	OT RE-EVALUATION	PRXOVR	DEF					NA	NA	NA	S
97004	OT RE-EVALUATION	MAXFEE	DEF					NA			S
97012	MECHANICAL TRACTION THERAPY	PRXOVR	DEF					NA	NA	NA	S
97012	MECHANICAL TRACTION THERAPY	MAXFEE	DEF					12.13	1/1/2010	12/31/2299	S
97016	VASOPNEUMATIC DEVICE THERAPY	PRXOVR	DEF					NA	NA	NA	S
97016	VASOPNEUMATIC DEVICE THERAPY	MAXFEE	DEF					11.22	1/1/2010	12/31/2299	S
97018	PARAFFIN BATH THERAPY	PRXOVR	DEF					NA	NA	NA	S
97018	PARAFFIN BATH THERAPY	MAXFEE	DEF					4.81	1/1/2010	12/31/2299	S
97022	WHIRLPOOL THERAPY	PRXOVR	DEF					NA	NA	NA	S
97022	WHIRLPOOL THERAPY	MAXFEE	DEF					9.92	1/1/2010	12/31/2299	S
97024	DIATHERMY EG MICROWAVE	PRXOVR	DEF					NA	NA	NA	S
97024	DIATHERMY EG MICROWAVE	MAXFEE	DEF					4.07	1/1/2010	12/31/2299	S
97032	ELECTRICAL STIMULATION	PRXOVR	DEF					NA	NA	NA	S
97032	ELECTRICAL STIMULATION	MAXFEE	DEF					10.69	1/1/2010	12/31/2299	S
97034	CONTRAST BATH THERAPY	PRXOVR	DEF					NA	NA	NA	S
97034	CONTRAST BATH THERAPY	MAXFEE	DEF					8.87	1/1/2010	12/31/2299	S
97035	ULTRASOUND THERAPY	PRXOVR	DEF					NA	NA	NA	S
97035	ULTRASOUND THERAPY	MAXFEE	DEF					9.06	1/1/2010	12/31/2299	S
97036	HYDROTHERAPY	PRXOVR	DEF					NA	NA	NA	S
97036	HYDROTHERAPY	MAXFEE	DEF					14.02	1/1/2010	12/31/2299	S
97110	THERAPEUTIC EXERCISES	PRXOVR	DEF					NA	NA	NA	S
97110	THERAPEUTIC EXERCISES	MAXFEE	DEF					16.44	1/1/2010	12/31/2299	S
97112	NEUROMUSCULAR REEDUCATION	PRXOVR	DEF					NA	NA	NA	S
97112	NEUROMUSCULAR REEDUCATION	MAXFEE	DEF					16.93	1/1/2010	12/31/2299	S
97113	AQUATIC THERAPY/EXERCISES	PRXOVR	DEF					NA	NA	NA	S
97113	AQUATIC THERAPY/EXERCISES	MAXFEE	DEF					19.38	1/1/2010	12/31/2299	S
97116	GAIT TRAINING THERAPY	PRXOVR	DEF					NA	NA	NA	S
97116	GAIT TRAINING THERAPY	MAXFEE	DEF					14.41	1/1/2010	12/31/2299	S
97124	MASSAGE THERAPY	PRXOVR	DEF					NA	NA	NA	S
97124	MASSAGE THERAPY	MAXFEE	DEF					13	1/1/2010	12/31/2299	S
97127	THER IVNTJ W/FOCUS COG FUNCJ	PRXOVR	DEF					NA	NA	NA	S
97127	THER IVNTJ W/FOCUS COG FUNCJ	MAXFEE	DEF					NA			S
97129	THER IVNTJ 1ST 15 MIN	PRXOVR	DEF					NA	NA	NA	S
97129	THER IVNTJ 1ST 15 MIN	MAXFEE	FAC					18.88	1/1/2020	12/31/2299	S
97129	THER IVNTJ 1ST 15 MIN	MAXFEE	NFF					19.15	1/1/2020	12/31/2299	S
97130	THER IVNTJ EA ADDL 15 MIN	PRXOVR	DEF					NA	NA	NA	S
97130	THER IVNTJ EA ADDL 15 MIN	MAXFEE	DEF					18.31	1/1/2020	12/31/2299	S
97140	MANUAL THERAPY 1/> REGIONS	PRXOVR	DEF					NA	NA	NA	S
97140	MANUAL THERAPY 1/> REGIONS	MAXFEE	DEF					15.36	1/1/2010	12/31/2299	S
97150	GROUP THERAPEUTIC PROCEDURES	PRXOVR	DEF					NA	NA	NA	S
97150	GROUP THERAPEUTIC PROCEDURES	MAXFEE	DEF					12.84	1/1/2010	12/31/2299	S
97161	PT EVAL LOW COMPLEX 20 MIN	PRXOVR	DEF					NA	NA	NA	S
97161	PT EVAL LOW COMPLEX 20 MIN	MAXFEE	DEF					63.15	1/1/2017	12/31/2299	S
97162	PT EVAL MOD COMPLEX 30 MIN	PRXOVR	DEF					NA	NA	NA	S
97162	PT EVAL MOD COMPLEX 30 MIN	MAXFEE	DEF					63.15	1/1/2017	12/31/2299	S
97163	PT EVAL HIGH COMPLEX 45 MIN	PRXOVR	DEF					NA	NA	NA	S
97163	PT EVAL HIGH COMPLEX 45 MIN	MAXFEE	DEF					63.15	1/1/2017	12/31/2299	S
97164	PT RE-EVAL EST PLAN CARE	PRXOVR	DEF					NA	NA	NA	S
97164	PT RE-EVAL EST PLAN CARE	MAXFEE	DEF					42.78	1/1/2017	12/31/2299	S
97165	OT EVAL LOW COMPLEX 30 MIN	PRXOVR	DEF					NA	NA	NA	S
97165	OT EVAL LOW COMPLEX 30 MIN	MAXFEE	DEF					61.31	1/1/2017	12/31/2299	S
97166	OT EVAL MOD COMPLEX 45 MIN	PRXOVR	DEF					NA	NA	NA	S
97166	OT EVAL MOD COMPLEX 45 MIN	MAXFEE	DEF					61.31	1/1/2017	12/31/2299	S
97167	OT EVAL HIGH COMPLEX 60 MIN	PRXOVR	DEF					NA	NA	NA	S
97167	OT EVAL HIGH COMPLEX 60 MIN	MAXFEE	DEF					61.31	1/1/2017	12/31/2299	S
97168	OT RE-EVAL EST PLAN CARE	PRXOVR	DEF					NA	NA	NA	S
97168	OT RE-EVAL EST PLAN CARE	MAXFEE	DEF					40.39	1/1/2017	12/31/2299	S
97530	THERAPEUTIC ACTIVITIES	PRXOVR	DEF					NA	NA	NA	S
97530	THERAPEUTIC ACTIVITIES	MAXFEE	DEF					17.64	1/1/2010	12/31/2299	S
97532	COGNITIVE SKILLS DEVELOPMENT	PRXOVR	DEF					NA	NA	NA	S
97532	COGNITIVE SKILLS DEVELOPMENT	MAXFEE	DEF					NA			S
97533	SENSORY INTEGRATION	PRXOVR	DEF					NA	NA	NA	S
97533	SENSORY INTEGRATION	MAXFEE	DEF					21.38	1/1/2010	12/31/2299	S
97535	SELF CARE MNGMENT TRAINING	PRXOVR	DEF					NA	NA	NA	S
97535	SELF CARE MNGMENT TRAINING	MAXFEE	DEF					21.39	1/1/2010	12/31/2299	S
97537	COMMUNITY/WORK REINTEGRATION	PRXOVR	DEF					NA	NA	NA	S
97537	COMMUNITY/WORK REINTEGRATION	MAXFEE	DEF					19.46	1/1/2010	12/31/2299	S
97542	WHEELCHAIR MNGMENT TRAINING	PRXOVR	DEF					NA	NA	NA	S
97542	WHEELCHAIR MNGMENT TRAINING	MAXFEE	DEF					23.79	1/1/2017	12/31/2299	S
97597	RMVL DEVITAL TIS 20 CM/<	PRXOVR	DEF					NA	NA	NA	S
97597	RMVL DEVITAL TIS 20 CM/<	MAXFEE	FAC					9.90	1/1/2014	12/31/2299	S
97597	RMVL DEVITAL TIS 20 CM/<	MAXFEE	NFF					36.76	1/1/2014	12/31/2299	S
97598	RMVL DEVITAL TIS ADDL 20CM/<	PRXOVR	DEF					NA	NA	NA	S
97598	RMVL DEVITAL TIS ADDL 20CM/<	MAXFEE	FAC					10.19	1/1/2014	12/31/2299	S
97598	RMVL DEVITAL TIS ADDL 20CM/<	MAXFEE	NFF					23.77	1/1/2014	12/31/2299	S
97750	PHYSICAL PERFORMANCE TEST	PRXOVR	DEF					NA	NA	NA	S
97750	PHYSICAL PERFORMANCE TEST	MAXFEE	DEF					18.47	1/1/2010	12/31/2299	S
97755	ASSISTIVE TECHNOLOGY ASSESS	PRXOVR	DEF					NA	NA	NA	S
97755	ASSISTIVE TECHNOLOGY ASSESS	MAXFEE	DEF					24.81	1/1/2010	12/31/2299	S
97760	ORTHOTIC MGMT&TRAING 1ST ENC	PRXOVR	DEF					NA	NA	NA	S
97760	ORTHOTIC MGMT&TRAING 1ST ENC	MAXFEE	DEF					29.97	12/31/2014	12/31/2299	S
97761	PROSTHETIC TRAING 1ST ENC	PRXOVR	DEF					NA	NA	NA	S
97761	PROSTHETIC TRAING 1ST ENC	MAXFEE	DEF					20.50	1/1/2010	12/31/2299	S
97762	C/O FOR ORTHOTIC/PROSTH USE	PRXOVR	DEF					NA	NA	NA	S
97762	C/O FOR ORTHOTIC/PROSTH USE	MAXFEE	DEF					NA			S
97763	ORTHC/PROSTC MGMT SBSQ ENC	PRXOVR	DEF					NA	NA	NA	S
97763	ORTHC/PROSTC MGMT SBSQ ENC	MAXFEE	DEF					37.24	1/1/2018	12/31/2299	S
97810	ACUPUNCT W/O STIMUL 15 MIN	PRXOVR	DEF					NA	NA	NA	S
97810	ACUPUNCT W/O STIMUL 15 MIN	MAXFEE	DEF					25	1/1/2017	12/31/2299	S
97811	ACUPUNCT W/O STIMUL ADDL 15M	PRXOVR	DEF					NA	NA	NA	S
97811	ACUPUNCT W/O STIMUL ADDL 15M	MAXFEE	DEF					17.50	1/1/2017	12/31/2299	S
97813	ACUPUNCT W/STIMUL 15 MIN	PRXOVR	DEF					NA	NA	NA	S
97813	ACUPUNCT W/STIMUL 15 MIN	MAXFEE	DEF					31.15	1/1/2018	12/31/2299	S
97814	ACUPUNCT W/STIMUL ADDL 15M	PRXOVR	DEF					NA	NA	NA	S
97814	ACUPUNCT W/STIMUL ADDL 15M	MAXFEE	DEF					23.65	1/1/2018	12/31/2299	S
E1399	DURABLE MEDICAL EQUIPMENT MI	PRXOVR	DEF					NA	NA	NA	Y S
E1399	DURABLE MEDICAL EQUIPMENT MI	PADOLR	DEF					NA	NA	NA	Y S
E1399	DURABLE MEDICAL EQUIPMENT MI	REPAIR	DEF					NA	NA	NA	Y S
E2500	SGD DIGITIZED PRE-REC <=8MIN	PRXOVR	DEF					NA	NA	NA	N
E2500	SGD DIGITIZED PRE-REC <=8MIN	MAXFEE	DEF					266.75	1/1/2010	12/31/2299	N
E2502	SGD PREREC MSG >8MIN <=20MIN	PRXOVR	DEF					NA	NA	NA	N
E2502	SGD PREREC MSG >8MIN <=20MIN	MAXFEE	DEF					811.95	1/1/2010	12/31/2299	N
E2504	SGD PREREC MSG>20MIN <=40MIN	PRXOVR	DEF					NA	NA	NA	Y
E2504	SGD PREREC MSG>20MIN <=40MIN	MAXFEE	DEF					1071.06	1/1/2010	12/31/2299	Y
E2506	SGD PREREC MSG > 40 MIN	PRXOVR	DEF					NA	NA	NA	Y
E2506	SGD PREREC MSG > 40 MIN	MAXFEE	DEF					2129.15	1/1/2010	12/31/2299	Y
E2508	SGD SPELLING PHYS CONTACT	PRXOVR	DEF					NA	NA	NA	Y
E2508	SGD SPELLING PHYS CONTACT	MAXFEE	DEF					3452.16	1/1/2010	12/31/2299	Y
E2510	SGD W MULTI METHODS MSG/ACCS	PRXOVR	DEF					NA	NA	NA	Y
E2510	SGD W MULTI METHODS MSG/ACCS	MAXFEE	DEF					6565.20	1/1/2010	12/31/2299	Y
E2511	SGD SFTWRE PRGRM FOR PC/PDA	PRXOVR	DEF					NA	NA	NA	Y
E2511	SGD SFTWRE PRGRM FOR PC/PDA	MAXFEE	DEF					645	7/1/2021	12/31/2299	Y
E2512	SGD ACCESSORY; MOUNTING SYS	PRXOVR	DEF					NA	NA	NA	Y
E2512	SGD ACCESSORY; MOUNTING SYS	MAXFEE	DEF					652.16	12/7/2010	12/31/2299	Y
E2599	SGD ACCESSORY NOC	PRXOVR	DEF					NA	NA	NA	Y
E2599	SGD ACCESSORY NOC	PADOLR	DEF					NA	NA	NA	Y
G0515	COGNITIVE SKILLS DEVELOPMENT	PRXOVR	DEF					NA	NA	NA	S
G0515	COGNITIVE SKILLS DEVELOPMENT	MAXFEE	DEF					NA			S
K0739	REPAIR/SVC DME NON-OXYGEN EQ	PRXOVR	DEF					NA	NA	NA	S
K0739	REPAIR/SVC DME NON-OXYGEN EQ	MAXFEE	DEF					12.17	1/1/2017	12/31/2299	S
L3208	SURGICAL BOOT EACH INFANT	PRXOVR	DEF					NA	NA	NA	N
L3208	SURGICAL BOOT EACH INFANT	MAXFEE	DEF					26.91	1/1/2010	12/31/2299	N
L3209	SURGICAL BOOT EACH CHILD	PRXOVR	DEF					NA	NA	NA	N
L3209	SURGICAL BOOT EACH CHILD	MAXFEE	DEF					26.91	1/1/2010	12/31/2299	N
L3211	SURGICAL BOOT EACH JUNIOR	PRXOVR	DEF					NA	NA	NA	N
L3211	SURGICAL BOOT EACH JUNIOR	MAXFEE	DEF					26.91	1/1/2010	12/31/2299	N
L7368	LITHIUM ION BATTERY CHARGER	PRXOVR	DEF					NA	NA	NA	Y
L7368	LITHIUM ION BATTERY CHARGER	MAXFEE	DEF					366.30	9/1/2011	12/31/2299	Y
L8621	REPL ZINC AIR BATTERY	PRXOVR	DEF					NA	NA	NA	S
L8621	REPL ZINC AIR BATTERY	MAXFEE	DEF					0.45	9/1/2011	12/31/2299	S
L8622	REPL ALKALINE BATTERY	PRXOVR	DEF					NA	NA	NA	S
L8622	REPL ALKALINE BATTERY	MAXFEE	DEF					0.24	9/1/2011	12/31/2299	S
L8623	LITH ION BATT CID;NON-EARLVL	PRXOVR	DEF					NA	NA	NA	S
L8623	LITH ION BATT CID;NON-EARLVL	MAXFEE	DEF					46.94	9/1/2011	12/31/2299	S
L8624	LITH ION BATT CID; EAR LEVEL	PRXOVR	DEF					NA	NA	NA	S
L8624	LITH ION BATT CID; EAR LEVEL	MAXFEE	DEF					117.04	9/1/2011	12/31/2299	S
Q4038	CAST SUP SHRT LEG FIBERGLASS	PRXOVR	DEF					NA	NA	NA	N
Q4038	CAST SUP SHRT LEG FIBERGLASS	MAXFEE	DEF					15.27	10/1/2003	12/31/2299	N
Q4040	CAST SUP SHRT LEG PED FBRGLS	PRXOVR	DEF					NA	NA	NA	N
Q4040	CAST SUP SHRT LEG PED FBRGLS	MAXFEE	DEF					7.64	10/1/2003	12/31/2299	N
T1015	CLINIC SERVICE	PRXOVR	DEF					NA	NA	NA	N
T1015	CLINIC SERVICE	UCCENC	UC5					NA	NA	NA	N
T1015	CLINIC SERVICE	UCCENC	UC4					NA	NA	NA	N
V5014	HEARING AID REPAIR/MODIFYING	PRXOVR	DEF					NA	NA	NA	S
V5014	HEARING AID REPAIR/MODIFYING	REPAIR	DEF					NA	NA	NA	S
V5030	BODY-WORN HEARING AID AIR	PRXOVR	DEF					NA	NA	NA	Y
V5030	BODY-WORN HEARING AID AIR	MAXFEE	DEF					339.50	1/1/2010	12/31/2299	Y
V5040	BODY-WORN HEARING AID BONE	PRXOVR	DEF					NA	NA	NA	Y
V5040	BODY-WORN HEARING AID BONE	MAXFEE	DEF					339.50	1/1/2010	12/31/2299	Y
V5050	HEARING AID MONAURAL IN EAR	PRXOVR	DEF					NA	NA	NA	Y
V5050	HEARING AID MONAURAL IN EAR	MAXFEE	DEF					242.50	1/1/2010	12/31/2299	Y
V5060	BEHIND EAR HEARING AID	PRXOVR	DEF					NA	NA	NA	Y
V5060	BEHIND EAR HEARING AID	MAXFEE	DEF					242.50	1/1/2010	12/31/2299	Y
V5070	GLASSES AIR CONDUCTION	PRXOVR	DEF					NA	NA	NA	Y
V5070	GLASSES AIR CONDUCTION	MAXFEE	DEF					242.50	1/1/2010	12/31/2299	Y
V5080	GLASSES BONE CONDUCTION	PRXOVR	DEF					NA	NA	NA	Y
V5080	GLASSES BONE CONDUCTION	MAXFEE	DEF					242.50	1/1/2010	12/31/2299	Y
V5130	IN EAR BINAURAL HEARING AID	PRXOVR	DEF					NA	NA	NA	Y
V5130	IN EAR BINAURAL HEARING AID	MAXFEE	DEF					485	1/1/2010	12/31/2299	Y
V5140	BEHIND EAR BINAUR HEARING AI	PRXOVR	DEF					NA	NA	NA	Y
V5140	BEHIND EAR BINAUR HEARING AI	MAXFEE	DEF					485	1/1/2010	12/31/2299	Y
V5150	GLASSES BINAURAL HEARING AID	PRXOVR	DEF					NA	NA	NA	Y
V5150	GLASSES BINAURAL HEARING AID	MAXFEE	DEF					485	1/1/2010	12/31/2299	Y
V5160	DISPENSING FEE BINAURAL	PRXOVR	DEF					NA	NA	NA	Y
V5160	DISPENSING FEE BINAURAL	MAXFEE	DEF					291	1/1/2010	12/31/2299	Y
V5170	WITHIN EAR CROS HEARING AID	PRXOVR	DEF					NA	NA	NA	Y
V5170	WITHIN EAR CROS HEARING AID	MAXFEE	DEF					NA			Y
V5171	HEARING AID MONAURAL ITE	PRXOVR	DEF					NA	NA	NA	Y
V5171	HEARING AID MONAURAL ITE	MAXFEE	DEF					800	7/1/2021	12/31/2299	Y
V5172	HEARING AID MONAURAL ITC	PRXOVR	DEF					NA	NA	NA	Y
V5172	HEARING AID MONAURAL ITC	MAXFEE	DEF					800	7/1/2021	12/31/2299	Y
V5180	BEHIND EAR CROS HEARING AID	PRXOVR	DEF					NA	NA	NA	Y
V5180	BEHIND EAR CROS HEARING AID	MAXFEE	DEF					NA			Y
V5181	HEARING AID MONAURAL BTE	PRXOVR	DEF					NA	NA	NA	Y
V5181	HEARING AID MONAURAL BTE	MAXFEE	DEF					800	7/1/2021	12/31/2299	Y
V5190	HEARING AID MONAURAL GLASSES	PRXOVR	DEF					NA	NA	NA	Y
V5190	HEARING AID MONAURAL GLASSES	MAXFEE	DEF					242.50	1/1/2010	12/31/2299	Y
V5200	DISP FEE CONTRALATERAL MONAU	PRXOVR	DEF					NA	NA	NA	Y
V5200	DISP FEE CONTRALATERAL MONAU	MAXFEE	DEF					194	1/1/2010	12/31/2299	Y
V5210	IN EAR BICROS HEARING AID	PRXOVR	DEF					NA	NA	NA	Y
V5210	IN EAR BICROS HEARING AID	MAXFEE	DEF					NA			Y
V5211	HEARING AID BINAURAL ITE/ITE	PRXOVR	DEF					NA	NA	NA	Y
V5211	HEARING AID BINAURAL ITE/ITE	MAXFEE	DEF					1600	7/1/2021	12/31/2299	Y
V5212	HEARING AID BINAURAL ITE/ITC	PRXOVR	DEF					NA	NA	NA	Y
V5212	HEARING AID BINAURAL ITE/ITC	MAXFEE	DEF					1600	7/1/2021	12/31/2299	Y
V5213	HEARING AID BINAURAL ITE/BTE	PRXOVR	DEF					NA	NA	NA	Y
V5213	HEARING AID BINAURAL ITE/BTE	MAXFEE	DEF					1600	7/1/2021	12/31/2299	Y
V5214	HEARING AID BINAURAL ITC/ITC	PRXOVR	DEF					NA	NA	NA	Y
V5214	HEARING AID BINAURAL ITC/ITC	MAXFEE	DEF					1600	7/1/2021	12/31/2299	Y
V5215	HEARING AID BINAURAL ITC/BTE	PRXOVR	DEF					NA	NA	NA	Y
V5215	HEARING AID BINAURAL ITC/BTE	MAXFEE	DEF					1600	7/1/2021	12/31/2299	Y
V5220	BEHIND EAR BICROS HEARING AI	PRXOVR	DEF					NA	NA	NA	Y
V5220	BEHIND EAR BICROS HEARING AI	MAXFEE	DEF					NA			Y
V5221	HEARING AID BINAURAL BTE/BTE	PRXOVR	DEF					NA	NA	NA	Y
V5221	HEARING AID BINAURAL BTE/BTE	MAXFEE	DEF					1600	7/1/2021	12/31/2299	Y
V5230	HEARING AID BINAURAL GLASSES	PRXOVR	DEF					NA	NA	NA	Y
V5230	HEARING AID BINAURAL GLASSES	MAXFEE	DEF					242.50	1/1/2010	12/31/2299	Y
V5240	DISP FEE CONTRALATERAL BINAU	PRXOVR	DEF					NA	NA	NA	Y
V5240	DISP FEE CONTRALATERAL BINAU	MAXFEE	DEF					194	1/1/2010	12/31/2299	Y
V5241	DISPENSING FEE; MONAURAL	PRXOVR	DEF					NA	NA	NA	Y
V5241	DISPENSING FEE; MONAURAL	MAXFEE	DEF					194	1/1/2010	12/31/2299	Y
V5246	HEARING AID; PROG; MON; ITE	PRXOVR	DEF					NA	NA	NA	Y
V5246	HEARING AID; PROG; MON; ITE	MAXFEE	DEF					339.50	1/1/2010	12/31/2299	Y
V5247	HEARING AID; PROG; MON; BTE	PRXOVR	DEF					NA	NA	NA	Y
V5247	HEARING AID; PROG; MON; BTE	MAXFEE	DEF					339.50	1/1/2010	12/31/2299	Y
V5252	HEARING AID; PROG; BIN; ITE	PRXOVR	DEF					NA	NA	NA	Y
V5252	HEARING AID; PROG; BIN; ITE	MAXFEE	DEF					679	1/1/2010	12/31/2299	Y
V5253	HEARING AID; PROG; BIN; BTE	PRXOVR	DEF					NA	NA	NA	Y
V5253	HEARING AID; PROG; BIN; BTE	MAXFEE	DEF					679	1/1/2010	12/31/2299	Y
V5256	HEARING AID; DIGIT; MON; ITE	PRXOVR	DEF					NA	NA	NA	Y
V5256	HEARING AID; DIGIT; MON; ITE	MAXFEE	DEF					727.50	1/1/2010	12/31/2299	Y
V5257	HEARING AID; DIGIT; MON; BTE	PRXOVR	DEF					NA	NA	NA	Y
V5257	HEARING AID; DIGIT; MON; BTE	MAXFEE	DEF					727.50	1/1/2010	12/31/2299	Y
V5260	HEARING AID; DIGIT; BIN; ITE	PRXOVR	DEF					NA	NA	NA	Y
V5260	HEARING AID; DIGIT; BIN; ITE	MAXFEE	DEF					1455	1/1/2010	12/31/2299	Y
V5261	HEARING AID; DIGIT; BIN; BTE	PRXOVR	DEF					NA	NA	NA	Y
V5261	HEARING AID; DIGIT; BIN; BTE	MAXFEE	DEF					1455	1/1/2010	12/31/2299	Y
V5264	EAR MOLD/INSERT	PRXOVR	DEF					NA	NA	NA	S
V5264	EAR MOLD/INSERT	MAXFEE	DEF					24.25	1/1/2010	12/31/2299	S
V5266	BATTERY FOR HEARING DEVICE	PRXOVR	DEF					NA	NA	NA	N
V5266	BATTERY FOR HEARING DEVICE	MAXFEE	DEF					0.97	1/1/2010	12/31/2299	N
V5267	HEARING AID SUP/ACCESS/DEV	PRXOVR	DEF					NA	NA	NA	Y
V5267	HEARING AID SUP/ACCESS/DEV	PADOLR	DEF					NA	NA	NA	Y