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         79.19 1/1/2024 12/31/2299 S
92504 EAR MICROSCOPY EXAMINATION PRXOVR DEF         NA NA NA S
92504 EAR MICROSCOPY EXAMINATION MAXFEE FAC         4.09 1/1/2024 12/31/2299 S
92504 EAR MICROSCOPY EXAMINATION MAXFEE NFF         16.57 1/1/2024 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         57.23 1/1/2024 12/31/2299 S
92508 SPEECH/HEARING THERAPY PRXOVR DEF         NA NA NA S
92508 SPEECH/HEARING THERAPY MAXFEE DEF         20.87 1/1/2024 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         24.62 1/1/2024 12/31/2299 S
92511 NASOPHARYNGOSCOPY MAXFEE NFF         84.86 1/1/2024 12/31/2299 S
92512 NASAL FUNCTION STUDIES PRXOVR DEF         NA NA NA S
92512 NASAL FUNCTION STUDIES MAXFEE FAC         14.02 1/1/2024 12/31/2299 S
92512 NASAL FUNCTION STUDIES MAXFEE NFF         31.84 1/1/2024 12/31/2299 S
92516 FACIAL NERVE FUNCTION TEST PRXOVR DEF         NA NA NA S
92516 FACIAL NERVE FUNCTION TEST MAXFEE FAC         19.69 1/1/2024 12/31/2299 S
92516 FACIAL NERVE FUNCTION TEST MAXFEE NFF         35.49 1/1/2024 12/31/2299 S
92517 VEMP TEST I&R CERVICAL PRXOVR DEF         NA NA NA S
92517 VEMP TEST I&R CERVICAL MAXFEE FAC         35.86 1/1/2024 12/31/2299 S
92517 VEMP TEST I&R CERVICAL MAXFEE NFF         70.16 1/1/2024 12/31/2299 S
92518 VEMP TEST I&R OCULAR PRXOVR DEF         NA NA NA S
92518 VEMP TEST I&R OCULAR MAXFEE FAC         35.86 1/1/2024 12/31/2299 S
92518 VEMP TEST I&R OCULAR MAXFEE NFF         65.26 1/1/2024 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         53.68 1/1/2024 12/31/2299 S
92519 VEMP TST I&R CERVICAL&OCULAR MAXFEE NFF         108.66 1/1/2024 12/31/2299 S
92520 LARYNGEAL FUNCTION STUDIES PRXOVR DEF         NA NA NA S
92520 LARYNGEAL FUNCTION STUDIES MAXFEE FAC         20.07 1/1/2024 12/31/2299 S
92520 LARYNGEAL FUNCTION STUDIES MAXFEE NFF         42.05 1/1/2024 12/31/2299 S
92521 EVALUATION OF SPEECH FLUENCY PRXOVR DEF         NA NA NA S
92521 EVALUATION OF SPEECH FLUENCY MAXFEE DEF         89.32 1/1/2024 12/31/2299 S
92522 EVALUATE SPEECH PRODUCTION PRXOVR DEF         NA NA NA S
92522 EVALUATE SPEECH PRODUCTION MAXFEE DEF         72.68 1/1/2024 12/31/2299 S
92523 SPEECH SOUND LANG COMPREHEN PRXOVR DEF         NA NA NA S
92523 SPEECH SOUND LANG COMPREHEN MAXFEE DEF         150.75 1/1/2024 12/31/2299 S
92524 BEHAVRAL QUALIT ANALYS VOICE PRXOVR DEF         NA NA NA S
92524 BEHAVRAL QUALIT ANALYS VOICE MAXFEE DEF         75.90 1/1/2024 12/31/2299 S
92526 ORAL FUNCTION THERAPY PRXOVR DEF         NA NA NA S
92526 ORAL FUNCTION THERAPY MAXFEE DEF         55.16 1/1/2024 12/31/2299 S
92537 CALORIC VSTBLR TEST W/REC PRXOVR DEF         NA NA NA S
92537 CALORIC VSTBLR TEST W/REC MAXFEE DEF         36.19 1/1/2024 12/31/2299 S
92537 CALORIC VSTBLR TEST W/REC MAXFEE DEF TC       7.24 1/1/2024 12/31/2299 S
92537 CALORIC VSTBLR TEST W/REC MAXFEE DEF 26       28.95 1/1/2024 12/31/2299 S
92538 CALORIC VSTBLR TEST W/REC PRXOVR DEF         NA NA NA S
92538 CALORIC VSTBLR TEST W/REC MAXFEE DEF         18.41 1/1/2024 12/31/2299 S
92538 CALORIC VSTBLR TEST W/REC MAXFEE DEF TC       3.68 1/1/2024 12/31/2299 S
92538 CALORIC VSTBLR TEST W/REC MAXFEE DEF 26       14.73 1/1/2024 12/31/2299 S
92540 BASIC VESTIBULAR EVALUATION PRXOVR DEF         NA NA NA S
92540 BASIC VESTIBULAR EVALUATION MAXFEE DEF         62.47 1/1/2024 12/31/2299 S
92540 BASIC VESTIBULAR EVALUATION MAXFEE DEF TC       12.49 1/1/2024 12/31/2299 S
92540 BASIC VESTIBULAR EVALUATION MAXFEE DEF 26       49.98 1/1/2024 12/31/2299 S
92541 SPONTANEOUS NYSTAGMUS TEST PRXOVR DEF         NA NA NA S
92541 SPONTANEOUS NYSTAGMUS TEST MAXFEE DEF         23.93 1/1/2024 12/31/2299 S
92541 SPONTANEOUS NYSTAGMUS TEST MAXFEE DEF TC       14.36 1/1/2024 12/31/2299 S
92541 SPONTANEOUS NYSTAGMUS TEST MAXFEE DEF 26       9.57 1/1/2024 12/31/2299 S
92542 POSITIONAL NYSTAGMUS TEST PRXOVR DEF         NA NA NA S
92542 POSITIONAL NYSTAGMUS TEST MAXFEE DEF         26.42 1/1/2024 12/31/2299 S
92542 POSITIONAL NYSTAGMUS TEST MAXFEE DEF TC       18.49 1/1/2024 12/31/2299 S
92542 POSITIONAL NYSTAGMUS TEST MAXFEE DEF 26       7.93 1/1/2024 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         16.71 1/1/2024 12/31/2299 S
92544 OPTOKINETIC NYSTAGMUS TEST MAXFEE DEF TC       11.70 1/1/2024 12/31/2299 S
92544 OPTOKINETIC NYSTAGMUS TEST MAXFEE DEF 26       5.01 1/1/2024 12/31/2299 S
92545 OSCILLATING TRACKING TEST PRXOVR DEF         NA NA NA S
92545 OSCILLATING TRACKING TEST MAXFEE DEF         15.56 1/1/2024 12/31/2299 S
92545 OSCILLATING TRACKING TEST MAXFEE DEF TC       10.89 1/1/2024 12/31/2299 S
92545 OSCILLATING TRACKING TEST MAXFEE DEF 26       4.67 1/1/2024 12/31/2299 S
92546 SINUSOIDAL ROTATIONAL TEST PRXOVR DEF         NA NA NA S
92546 SINUSOIDAL ROTATIONAL TEST MAXFEE DEF         47.06 1/1/2024 12/31/2299 S
92546 SINUSOIDAL ROTATIONAL TEST MAXFEE DEF TC       37.65 1/1/2024 12/31/2299 S
92546 SINUSOIDAL ROTATIONAL TEST MAXFEE DEF 26       9.41 1/1/2024 12/31/2299 S
92547 SUPPLEMENTAL ELECTRICAL TEST PRXOVR DEF         NA NA NA S
92547 SUPPLEMENTAL ELECTRICAL TEST MAXFEE DEF         4.24 1/1/2024 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         72.47 1/1/2024 12/31/2299 S
92548 CDP-SOT 6 COND W/I&R MAXFEE DEF TC       54.35 1/1/2024 12/31/2299 S
92548 CDP-SOT 6 COND W/I&R MAXFEE DEF 26       18.12 1/1/2024 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         57.03 1/1/2024 12/31/2299 S
92549 CDP-SOT 6 COND W/I&R MCT&ADT MAXFEE DEF TC       17.11 1/1/2024 12/31/2299 S
92549 CDP-SOT 6 COND W/I&R MCT&ADT MAXFEE DEF 26       39.92 1/1/2024 12/31/2299 S
92550 TYMPANOMETRY & REFLEX THRESH PRXOVR DEF         NA NA NA S
92550 TYMPANOMETRY & REFLEX THRESH MAXFEE DEF         13.59 1/1/2024 12/31/2299 S
92551 PURE TONE HEARING TEST AIR PRXOVR DEF         NA NA NA S
92551 PURE TONE HEARING TEST AIR MAXFEE DEF         6.99 1/1/2024 12/31/2299 S
92552 PURE TONE AUDIOMETRY AIR PRXOVR DEF         NA NA NA S
92552 PURE TONE AUDIOMETRY AIR MAXFEE DEF         13.42 1/1/2024 12/31/2299 S
92553 AUDIOMETRY AIR & BONE PRXOVR DEF         NA NA NA S
92553 AUDIOMETRY AIR & BONE MAXFEE DEF         20.18 1/1/2024 12/31/2299 S
92555 SPEECH THRESHOLD AUDIOMETRY PRXOVR DEF         NA NA NA S
92555 SPEECH THRESHOLD AUDIOMETRY MAXFEE DEF         11.58 1/1/2024 12/31/2299 S
92556 SPEECH AUDIOMETRY COMPLETE PRXOVR DEF         NA NA NA S
92556 SPEECH AUDIOMETRY COMPLETE MAXFEE DEF         17.66 1/1/2024 12/31/2299 S
92557 COMPREHENSIVE HEARING TEST PRXOVR DEF         NA NA NA S
92557 COMPREHENSIVE HEARING TEST MAXFEE FAC         27.85 1/1/2024 12/31/2299 S
92557 COMPREHENSIVE HEARING TEST MAXFEE NFF         36.67 1/1/2024 12/31/2299 S
92558 EVOKED AUDITORY TEST QUAL PRXOVR DEF         NA NA NA S
92558 EVOKED AUDITORY TEST QUAL MAXFEE DEF         9.69 1/1/2024 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         12.45 1/1/2024 12/31/2299 S
92563 TONE DECAY HEARING TEST PRXOVR DEF         NA NA NA S
92563 TONE DECAY HEARING TEST MAXFEE DEF         11.58 1/1/2024 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         12.12 1/1/2024 12/31/2299 S
92567 TYMPANOMETRY PRXOVR DEF         NA NA NA S
92567 TYMPANOMETRY MAXFEE FAC         9.55 1/1/2024 12/31/2299 S
92567 TYMPANOMETRY MAXFEE NFF         14.34 1/1/2024 12/31/2299 S
92568 ACOUSTIC REFL THRESHOLD TST PRXOVR DEF         NA NA NA S
92568 ACOUSTIC REFL THRESHOLD TST MAXFEE DEF         11.58 1/1/2024 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         16.41 1/1/2024 12/31/2299 S
92570 ACOUSTIC IMMITANCE TESTING MAXFEE NFF         19.65 1/1/2024 12/31/2299 S
92571 FILTERED SPEECH HEARING TEST PRXOVR DEF         NA NA NA S
92571 FILTERED SPEECH HEARING TEST MAXFEE DEF         11.85 1/1/2024 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         10.90 1/1/2024 12/31/2299 S
92576 SYNTHETIC SENTENCE TEST PRXOVR DEF         NA NA NA S
92576 SYNTHETIC SENTENCE TEST MAXFEE DEF         13.73 1/1/2024 12/31/2299 S
92577 STENGER TEST SPEECH PRXOVR DEF         NA NA NA S
92577 STENGER TEST SPEECH MAXFEE DEF         16.17 1/1/2024 12/31/2299 S
92579 VISUAL AUDIOMETRY (VRA) PRXOVR DEF         NA NA NA S
92579 VISUAL AUDIOMETRY (VRA) MAXFEE FAC         16.62 1/1/2024 12/31/2299 S
92579 VISUAL AUDIOMETRY (VRA) MAXFEE NFF         21.95 1/1/2024 12/31/2299 S
92582 CONDITIONING PLAY AUDIOMETRY PRXOVR DEF         NA NA NA S
92582 CONDITIONING PLAY AUDIOMETRY MAXFEE DEF         21.88 1/1/2024 12/31/2299 S
92583 SELECT PICTURE AUDIOMETRY PRXOVR DEF         NA NA NA S
92583 SELECT PICTURE AUDIOMETRY MAXFEE DEF         27.35 1/1/2024 12/31/2299 S
92584 ELECTROCOCHLEOGRAPHY PRXOVR DEF         NA NA NA S
92584 ELECTROCOCHLEOGRAPHY MAXFEE DEF         73.66 1/1/2024 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         22.23 1/1/2024 12/31/2299 S
92587 EVOKED AUDITORY TEST LIMITED MAXFEE DEF TC       2.22 1/1/2024 12/31/2299 S
92587 EVOKED AUDITORY TEST LIMITED MAXFEE DEF 26       20.01 1/1/2024 12/31/2299 S
92588 EVOKED AUDITORY TST COMPLETE PRXOVR DEF         NA NA NA S
92588 EVOKED AUDITORY TST COMPLETE MAXFEE DEF         33.41 1/1/2024 12/31/2299 S
92588 EVOKED AUDITORY TST COMPLETE MAXFEE DEF TC       3.34 1/1/2024 12/31/2299 S
92588 EVOKED AUDITORY TST COMPLETE MAXFEE DEF 26       30.07 1/1/2024 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         73.63 1/1/2024 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         74.85 1/1/2024 12/31/2299 S
92601 COCHLEAR IMPLT F/UP EXAM <7 MAXFEE NFF         97.23 1/1/2024 12/31/2299 S
92602 REPROGRAM COCHLEAR IMPLT <7 PRXOVR DEF         NA NA NA S
92602 REPROGRAM COCHLEAR IMPLT <7 MAXFEE FAC         46.60 1/1/2024 12/31/2299 S
92602 REPROGRAM COCHLEAR IMPLT <7 MAXFEE NFF         68.30 1/1/2024 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         47.78 1/1/2024 12/31/2299 S
92603 COCHLEAR IMPLT F/UP EXAM 7/> MAXFEE NFF         65.69 1/1/2024 12/31/2299 S
92604 REPROGRAM COCHLEAR IMPLT 7/> PRXOVR DEF         NA NA NA S
92604 REPROGRAM COCHLEAR IMPLT 7/> MAXFEE FAC         29.86 1/1/2024 12/31/2299 S
92604 REPROGRAM COCHLEAR IMPLT 7/> MAXFEE NFF         44.85 1/1/2024 12/31/2299 S
92606 NON-SPEECH DEVICE SERVICE PRXOVR DEF         NA NA NA S
92606 NON-SPEECH DEVICE SERVICE MAXFEE DEF         40.25 1/1/2024 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         81.03 1/1/2024 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         16.20 1/1/2024 12/31/2299 S
92609 USE OF SPEECH DEVICE SERVICE PRXOVR DEF         NA NA NA S
92609 USE OF SPEECH DEVICE SERVICE MAXFEE DEF         43.99 1/1/2024 12/31/2299 S
92610 EVALUATE SWALLOWING FUNCTION PRXOVR DEF         NA NA NA S
92610 EVALUATE SWALLOWING FUNCTION MAXFEE FAC         50.17 1/1/2024 12/31/2299 S
92610 EVALUATE SWALLOWING FUNCTION MAXFEE NFF         64.09 1/1/2024 12/31/2299 S
92611 MOTION FLUOROSCOPY/SWALLOW PRXOVR DEF         NA NA NA S
92611 MOTION FLUOROSCOPY/SWALLOW MAXFEE DEF         65.34 1/1/2024 12/31/2299 S
92612 ENDOSCOPY SWALLOW (FEES) VID PRXOVR DEF         NA NA NA S
92612 ENDOSCOPY SWALLOW (FEES) VID MAXFEE FAC         44.38 1/1/2024 12/31/2299 S
92612 ENDOSCOPY SWALLOW (FEES) VID MAXFEE NFF         129.95 1/1/2024 12/31/2299 S
92614 LARYNGOSCOPIC SENSORY VID PRXOVR DEF         NA NA NA S
92614 LARYNGOSCOPIC SENSORY VID MAXFEE FAC         39.49 1/1/2024 12/31/2299 S
92614 LARYNGOSCOPIC SENSORY VID MAXFEE NFF         100.72 1/1/2024 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         35.83 1/1/2024 12/31/2299 S
92620 AUDITORY FUNCTION 60 MIN MAXFEE NFF         43.61 1/1/2024 12/31/2299 S
92621 AUDITORY FUNCTION + 15 MIN PRXOVR DEF         NA NA NA S
92621 AUDITORY FUNCTION + 15 MIN MAXFEE FAC         9.19 1/1/2024 12/31/2299 S
92621 AUDITORY FUNCTION + 15 MIN MAXFEE NFF         10.40 1/1/2024 12/31/2299 S
92622 DX ALY AUD OI SND PRCSR 1ST PRXOVR DEF         NA NA NA S
92622 DX ALY AUD OI SND PRCSR 1ST MAXFEE FAC         49.78 1/1/2024 12/31/2299 S
92622 DX ALY AUD OI SND PRCSR 1ST MAXFEE NFF         59.57 1/1/2024 12/31/2299 S
92623 DX ALY AUD OI SND PRCSR EACH PRXOVR DEF         NA NA NA S
92623 DX ALY AUD OI SND PRCSR EACH MAXFEE FAC         13.21 1/1/2024 12/31/2299 S
92623 DX ALY AUD OI SND PRCSR EACH MAXFEE NFF         15.36 1/1/2024 12/31/2299 S
92625 TINNITUS ASSESSMENT PRXOVR DEF         NA NA NA S
92625 TINNITUS ASSESSMENT MAXFEE FAC         26.98 1/1/2024 12/31/2299 S
92625 TINNITUS ASSESSMENT MAXFEE NFF         35.19 1/1/2024 12/31/2299 S
92626 EVAL AUD FUNCJ 1ST HOUR PRXOVR DEF         NA NA NA S
92626 EVAL AUD FUNCJ 1ST HOUR MAXFEE FAC         29.88 1/1/2024 12/31/2299 S
92626 EVAL AUD FUNCJ 1ST HOUR MAXFEE NFF         45.45 1/1/2024 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         12.72 1/1/2024 12/31/2299 S
92627 EVAL AUD FUNCJ EA ADDL 15 MAXFEE NFF         17.26 1/1/2024 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         35.50 1/1/2024 12/31/2299 S
92640 AUD BRAINSTEM IMPLT PROGRAMG MAXFEE NFF         49.30 1/1/2024 12/31/2299 S
92650 AEP SCR AUDITORY POTENTIAL PRXOVR DEF         NA NA NA S
92650 AEP SCR AUDITORY POTENTIAL MAXFEE DEF         23.77 1/1/2024 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         74.22 1/1/2024 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         98.62 1/1/2024 12/31/2299 S
92653 AEP NEURODIAGNOSTIC I&R PRXOVR DEF         NA NA NA S
92653 AEP NEURODIAGNOSTIC I&R MAXFEE DEF         72.53 1/1/2024 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         8.32 1/1/2024 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         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
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
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         13.95 1/1/2024 12/31/2299 S
97016 VASOPNEUMATIC DEVICE THERAPY PRXOVR DEF         NA NA NA S
97016 VASOPNEUMATIC DEVICE THERAPY MAXFEE DEF         12.90 1/1/2024 12/31/2299 S
97018 PARAFFIN BATH THERAPY PRXOVR DEF         NA NA NA S
97018 PARAFFIN BATH THERAPY MAXFEE DEF         5.53 1/1/2024 12/31/2299 S
97022 WHIRLPOOL THERAPY PRXOVR DEF         NA NA NA S
97022 WHIRLPOOL THERAPY MAXFEE DEF         11.41 1/1/2024 12/31/2299 S
97024 DIATHERMY EG MICROWAVE PRXOVR DEF         NA NA NA S
97024 DIATHERMY EG MICROWAVE MAXFEE DEF         4.68 1/1/2024 12/31/2299 S
97032 APPL MODALITY 1+ESTIM EA 15 PRXOVR DEF         NA NA NA S
97032 APPL MODALITY 1+ESTIM EA 15 MAXFEE DEF         12.29 1/1/2024 12/31/2299 S
97034 APP MDLTY 1+CNTRST BTH EA 15 PRXOVR DEF         NA NA NA S
97034 APP MDLTY 1+CNTRST BTH EA 15 MAXFEE DEF         10.20 1/1/2024 12/31/2299 S
97035 APP MDLTY 1+ULTRASOUND EA 15 PRXOVR DEF         NA NA NA S
97035 APP MDLTY 1+ULTRASOUND EA 15 MAXFEE DEF         10.42 1/1/2024 12/31/2299 S
97036 APP MDLTY 1+HUBBRD TNK EA 15 PRXOVR DEF         NA NA NA S
97036 APP MDLTY 1+HUBBRD TNK EA 15 MAXFEE DEF         16.12 1/1/2024 12/31/2299 S
97037 APPL MODALITY 1+LLLT PO PAIN PRXOVR DEF         NA NA NA S
97037 APPL MODALITY 1+LLLT PO PAIN MANUAL DEF         NA NA NA S
97110 THERAPEUTIC EXERCISES PRXOVR DEF         NA NA NA S
97110 THERAPEUTIC EXERCISES MAXFEE DEF         18.91 1/1/2024 12/31/2299 S
97112 NEUROMUSCULAR REEDUCATION PRXOVR DEF         NA NA NA S
97112 NEUROMUSCULAR REEDUCATION MAXFEE DEF         19.47 1/1/2024 12/31/2299 S
97113 AQUATIC THERAPY/EXERCISES PRXOVR DEF         NA NA NA S
97113 AQUATIC THERAPY/EXERCISES MAXFEE DEF         22.29 1/1/2024 12/31/2299 S
97116 GAIT TRAINING THERAPY PRXOVR DEF         NA NA NA S
97116 GAIT TRAINING THERAPY MAXFEE DEF         16.57 1/1/2024 12/31/2299 S
97124 MASSAGE THERAPY PRXOVR DEF         NA NA NA S
97124 MASSAGE THERAPY MAXFEE DEF         14.95 1/1/2024 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         21.71 1/1/2024 12/31/2299 S
97129 THER IVNTJ 1ST 15 MIN MAXFEE NFF         22.02 1/1/2024 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         21.06 1/1/2024 12/31/2299 S
97140 MANUAL THERAPY 1/> REGIONS PRXOVR DEF         NA NA NA S
97140 MANUAL THERAPY 1/> REGIONS MAXFEE DEF         17.66 1/1/2024 12/31/2299 S
97150 GROUP THERAPEUTIC PROCEDURES PRXOVR DEF         NA NA NA S
97150 GROUP THERAPEUTIC PROCEDURES MAXFEE DEF         14.77 1/1/2024 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         72.62 1/1/2024 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         72.62 1/1/2024 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         72.62 1/1/2024 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         49.20 1/1/2024 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         70.50 1/1/2024 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         70.50 1/1/2024 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         70.50 1/1/2024 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         46.44 1/1/2024 12/31/2299 S
97530 THERAPEUTIC ACTIVITIES PRXOVR DEF         NA NA NA S
97530 THERAPEUTIC ACTIVITIES MAXFEE DEF         20.29 1/1/2024 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         24.59 1/1/2024 12/31/2299 S
97535 SELF CARE MNGMENT TRAINING PRXOVR DEF         NA NA NA S
97535 SELF CARE MNGMENT TRAINING MAXFEE DEF         24.60 1/1/2024 12/31/2299 S
97537 COMMUNITY/WORK REINTEGRATION PRXOVR DEF         NA NA NA S
97537 COMMUNITY/WORK REINTEGRATION MAXFEE DEF         22.38 1/1/2024 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
97550 CAREGIVER TRAING 1ST 30 MIN PRXOVR DEF         NA NA NA S
97550 CAREGIVER TRAING 1ST 30 MIN MAXFEE DEF         40.37 1/1/2024 12/31/2299 S
97551 CAREGIVER TRAING EA ADDL 15 PRXOVR DEF         NA NA NA S
97551 CAREGIVER TRAING EA ADDL 15 MAXFEE FAC         18.71 1/1/2024 12/31/2299 S
97551 CAREGIVER TRAING EA ADDL 15 MAXFEE NFF         20.14 1/1/2024 12/31/2299 S
97552 GROUP CAREGIVER TRAINING PRXOVR DEF         NA NA NA S
97552 GROUP CAREGIVER TRAINING MAXFEE DEF         16.56 1/1/2024 12/31/2299 S
97597 DBRDMT OPN WND 1ST 20 CM/< PRXOVR DEF         NA NA NA S
97597 DBRDMT OPN WND 1ST 20 CM/< MAXFEE FAC         11.39 1/1/2024 12/31/2299 S
97597 DBRDMT OPN WND 1ST 20 CM/< MAXFEE NFF         42.27 1/1/2024 12/31/2299 S
97598 DBRDMT OPN WND ADDL 20CM/< PRXOVR DEF         NA NA NA S
97598 DBRDMT OPN WND ADDL 20CM/< MAXFEE FAC         11.72 1/1/2024 12/31/2299 S
97598 DBRDMT OPN WND ADDL 20CM/< MAXFEE NFF         27.34 1/1/2024 12/31/2299 S
97750 PHYSICAL PERFORMANCE TEST PRXOVR DEF         NA NA NA S
97750 PHYSICAL PERFORMANCE TEST MAXFEE DEF         21.24 1/1/2024 12/31/2299 S
97755 ASSISTIVE TECHNOLOGY ASSESS PRXOVR DEF         NA NA NA S
97755 ASSISTIVE TECHNOLOGY ASSESS MAXFEE DEF         28.53 1/1/2024 12/31/2299 S
97760 ORTHOTIC MGMT&TRAING 1ST ENC PRXOVR DEF         NA NA NA S
97760 ORTHOTIC MGMT&TRAING 1ST ENC MAXFEE DEF         34.47 1/1/2024 12/31/2299 S
97761 PROSTHETIC TRAING 1ST ENC PRXOVR DEF         NA NA NA S
97761 PROSTHETIC TRAING 1ST ENC MAXFEE DEF         23.58 1/1/2024 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         42.83 1/1/2024 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         26.25 1/1/2024 12/31/2299 S
97811 ACUPUNCT W/O STIMUL ADDL 15M PRXOVR DEF         NA NA NA S
97811 ACUPUNCT W/O STIMUL ADDL 15M MAXFEE DEF         18.38 1/1/2024 12/31/2299 S
97813 ACUPUNCT W/STIMUL 15 MIN PRXOVR DEF         NA NA NA S
97813 ACUPUNCT W/STIMUL 15 MIN MAXFEE DEF         32.71 1/1/2024 12/31/2299 S
97814 ACUPUNCT W/STIMUL ADDL 15M PRXOVR DEF         NA NA NA S
97814 ACUPUNCT W/STIMUL ADDL 15M MAXFEE DEF         24.83 1/1/2024 12/31/2299 S
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         18.50 1/1/2024 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         356.48 1/1/2024 12/31/2299 Y
V5040 BODY-WORN HEARING AID BONE PRXOVR DEF         NA NA NA Y
V5040 BODY-WORN HEARING AID BONE MAXFEE DEF         356.48 1/1/2024 12/31/2299 Y
V5050 HEARING AID MONAURAL IN EAR PRXOVR DEF         NA NA NA Y
V5050 HEARING AID MONAURAL IN EAR MAXFEE DEF         254.63 1/1/2024 12/31/2299 Y
V5060 BEHIND EAR HEARING AID PRXOVR DEF         NA NA NA Y
V5060 BEHIND EAR HEARING AID MAXFEE DEF         254.63 1/1/2024 12/31/2299 Y
V5070 GLASSES AIR CONDUCTION PRXOVR DEF         NA NA NA Y
V5070 GLASSES AIR CONDUCTION MAXFEE DEF         254.63 1/1/2024 12/31/2299 Y
V5080 GLASSES BONE CONDUCTION PRXOVR DEF         NA NA NA Y
V5080 GLASSES BONE CONDUCTION MAXFEE DEF         254.63 1/1/2024 12/31/2299 Y
V5130 IN EAR BINAURAL HEARING AID PRXOVR DEF         NA NA NA Y
V5130 IN EAR BINAURAL HEARING AID MAXFEE DEF         509.25 1/1/2024 12/31/2299 Y
V5140 BEHIND EAR BINAUR HEARING AI PRXOVR DEF         NA NA NA Y
V5140 BEHIND EAR BINAUR HEARING AI MAXFEE DEF         509.25 1/1/2024 12/31/2299 Y
V5150 GLASSES BINAURAL HEARING AID PRXOVR DEF         NA NA NA Y
V5150 GLASSES BINAURAL HEARING AID MAXFEE DEF         509.25 1/1/2024 12/31/2299 Y
V5160 DISPENSING FEE BINAURAL PRXOVR DEF         NA NA NA Y
V5160 DISPENSING FEE BINAURAL MAXFEE DEF         305.55 1/1/2024 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         840 1/1/2024 12/31/2299 Y
V5172 HEARING AID MONAURAL ITC PRXOVR DEF         NA NA NA Y
V5172 HEARING AID MONAURAL ITC MAXFEE DEF         840 1/1/2024 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         840 1/1/2024 12/31/2299 Y
V5190 HEARING AID MONAURAL GLASSES PRXOVR DEF         NA NA NA Y
V5190 HEARING AID MONAURAL GLASSES MAXFEE DEF         254.63 1/1/2024 12/31/2299 Y
V5200 DISP FEE CONTRALATERAL MONAU PRXOVR DEF         NA NA NA Y
V5200 DISP FEE CONTRALATERAL MONAU MAXFEE DEF         203.70 1/1/2024 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         1680 1/1/2024 12/31/2299 Y
V5212 HEARING AID BINAURAL ITE/ITC PRXOVR DEF         NA NA NA Y
V5212 HEARING AID BINAURAL ITE/ITC MAXFEE DEF         1680 1/1/2024 12/31/2299 Y
V5213 HEARING AID BINAURAL ITE/BTE PRXOVR DEF         NA NA NA Y
V5213 HEARING AID BINAURAL ITE/BTE MAXFEE DEF         1680 1/1/2024 12/31/2299 Y
V5214 HEARING AID BINAURAL ITC/ITC PRXOVR DEF         NA NA NA Y
V5214 HEARING AID BINAURAL ITC/ITC MAXFEE DEF         1680 1/1/2024 12/31/2299 Y
V5215 HEARING AID BINAURAL ITC/BTE PRXOVR DEF         NA NA NA Y
V5215 HEARING AID BINAURAL ITC/BTE MAXFEE DEF         1680 1/1/2024 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         1680 1/1/2024 12/31/2299 Y
V5230 HEARING AID BINAURAL GLASSES PRXOVR DEF         NA NA NA Y
V5230 HEARING AID BINAURAL GLASSES MAXFEE DEF         254.63 1/1/2024 12/31/2299 Y
V5240 DISP FEE CONTRALATERAL BINAU PRXOVR DEF         NA NA NA Y
V5240 DISP FEE CONTRALATERAL BINAU MAXFEE DEF         203.70 1/1/2024 12/31/2299 Y
V5241 DISPENSING FEE; MONAURAL PRXOVR DEF         NA NA NA Y
V5241 DISPENSING FEE; MONAURAL MAXFEE DEF         203.70 1/1/2024 12/31/2299 Y
V5246 HEARING AID; PROG; MON; ITE PRXOVR DEF         NA NA NA Y
V5246 HEARING AID; PROG; MON; ITE MAXFEE DEF         356.48 1/1/2024 12/31/2299 Y
V5247 HEARING AID; PROG; MON; BTE PRXOVR DEF         NA NA NA Y
V5247 HEARING AID; PROG; MON; BTE MAXFEE DEF         356.48 1/1/2024 12/31/2299 Y
V5252 HEARING AID; PROG; BIN; ITE PRXOVR DEF         NA NA NA Y
V5252 HEARING AID; PROG; BIN; ITE MAXFEE DEF         712.95 1/1/2024 12/31/2299 Y
V5253 HEARING AID; PROG; BIN; BTE PRXOVR DEF         NA NA NA Y
V5253 HEARING AID; PROG; BIN; BTE MAXFEE DEF         712.95 1/1/2024 12/31/2299 Y
V5256 HEARING AID; DIGIT; MON; ITE PRXOVR DEF         NA NA NA Y
V5256 HEARING AID; DIGIT; MON; ITE MAXFEE DEF         763.88 1/1/2024 12/31/2299 Y
V5257 HEARING AID; DIGIT; MON; BTE PRXOVR DEF         NA NA NA Y
V5257 HEARING AID; DIGIT; MON; BTE MAXFEE DEF         763.88 1/1/2024 12/31/2299 Y
V5260 HEARING AID; DIGIT; BIN; ITE PRXOVR DEF         NA NA NA Y
V5260 HEARING AID; DIGIT; BIN; ITE MAXFEE DEF         1527.75 1/1/2024 12/31/2299 Y
V5261 HEARING AID; DIGIT; BIN; BTE PRXOVR DEF         NA NA NA Y
V5261 HEARING AID; DIGIT; BIN; BTE MAXFEE DEF         1527.75 1/1/2024 12/31/2299 Y
V5264 EAR MOLD/INSERT PRXOVR DEF         NA NA NA S
V5264 EAR MOLD/INSERT MAXFEE DEF         25.46 1/1/2024 12/31/2299 S
V5266 BATTERY FOR HEARING DEVICE PRXOVR DEF         NA NA NA N
V5266 BATTERY FOR HEARING DEVICE MAXFEE DEF         1.02 1/1/2024 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