Provider Claims Alerts

Heritage Health - Nebraska Total Care

Medicare Exclusion Codes List

We understand that some of these codes may not be covered services by Nebraska Medicaid at this time or relevant to certain Nebraska providers. The intent in using these codes is to include as many Medicare codes as possible to be sure that we were capturing all possible Medicare exclusion scenarios. Codes in bold are being manually reviewed for pricing until they are in production.

Medicare Exclusion Codes List (01/01/2024)
Code	Description	Medicare	Medicare Advantage
637	DRUGS/SELF ADMIN	X	X
22526	IDET SINGLE LEVEL	X	X
22527	IDET 1 OR MORE LEVELS	X	X
27215	TREAT PELVIC FRACTURE(S)	X	X
27216	TREAT PELVIC RING FRACTURE	X	X
27217	TREAT PELVIC RING FRACTURE	X	X
27218	TREAT PELVIC RING FRACTURE	X	X
37216	TRANSCATH STENT CCA W/O EPS	X	X
43842	V-BAND GASTROPLASTY	X	X
48160	PANCREAS REMOVAL/TRANSPLANT	X	X
58300	INSERT INTRAUTERINE DEVICE	X	X
61640	DILATE IC VASOSPASM INIT	X	X
61641	DILATE IC VASOSPASM ADD-ON	X	X
61642	DILATE IC VASOSPASM ADD-ON	X	X
65760	REVISION OF CORNEA	X	X
65765	REVISION OF CORNEA	X	X
65767	CORNEAL TISSUE TRANSPLANT	X	X
65771	RADIAL KERATOTOMY	X	X
69090	PIERCE EARLOBES	X	X
69710	IMPLANT/REPLACE HEARING AID	X	X
72159	MRI ANGIO SPINAL CANAL & CONTENTS W/WO CONTRAST	X	X
73225	MR ANGIO UPR EXTR W/OANDW/DYE	X	X
74263	CT COLONOGRAPHY SCREENING	X	X
76140	X-RAY CONSULTATION	X	X
76390	MR SPECTROSCOPY	X	X
78350	BONE MINERAL SINGLE PHOTON	X	X
78351	BONE MINERAL DUAL PHOTON	X	X
78609	BRAIN IMAGING (PET)	X	X
80050	GENERAL HEALTH PANEL	X	X
80055	OBSTETRIC PANEL	X	X
80320	DRUG SCREEN QUANTALCOHOLS	X	X
80321	ALCOHOLS BIOMARKERS 1OR 2	X	X
80322	ALCOHOLS BIOMARKERS 3/MORE	X	X
80323	ALKALOIDS NOS	X	X
80324	DRUG SCREEN AMPHETAMINES 1/2	X	X
80325	AMPHETAMINES 3OR 4	X	X
80326	AMPHETAMINES 5 OR MORE	X	X
80327	ANABOLIC STEROID 1 OR 2	X	X
80328	ANABOLIC STEROID 3 OR MORE	X	X
80329	ANALGESICS NON-OPIOID 1 OR 2	X	X
80330	ANALGESICS NON-OPIOID 3-5	X	X
80331	ANALGESICS NON-OPIOID 6/MORE	X	X
80332	ANTIDEPRESSANTS CLASS 1 OR 2	X	X
80333	ANTIDEPRESSANTS CLASS 3-5	X	X
80334	ANTIDEPRESSANTS CLASS 6/MORE	X	X
80335	ANTIDEPRESSANT TRICYCLIC 1/2	X	X
80336	ANTIDEPRESSANT TRICYCLIC 3-5	X	X
80337	TRICYCLIC AND CYCLICALS 6/MORE	X	X
80338	ANTIDEPRESSANT NOT SPECIFIED	X	X
80339	ANTIEPILEPTICS NOS 1-3	X	X
80340	ANTIEPILEPTICS NOS 4-6	X	X
80341	ANTIEPILEPTICS NOS 7/MORE	X	X
80342	ANTIPSYCHOTICS NOS 1-3	X	X
80343	ANTIPSYCHOTICS NOS 4-6	X	X
80344	ANTIPSYCHOTICS NOS 7/MORE	X	X
80345	DRUG SCREENING BARBITURATES	X	X
80346	BENZODIAZEPINES1-12	X	X
80347	BENZODIAZEPINES 13 OR MORE	X	X
80348	DRUG SCREENING BUPRENORPHINE	X	X
80349	CANNABINOIDS NATURAL	X	X
80350	CANNABINOIDS SYNTHETIC 1-3	X	X
80351	CANNABINOIDS SYNTHETIC 4-6	X	X
80352	CANNABINOID SYNTHETIC 7/MORE	X	X
80353	DRUG SCREENING COCAINE	X	X
80354	DRUG SCREENING FENTANYL	X	X
80355	GABAPENTIN NON-BLOOD	X	X
80356	HEROIN METABOLITE	X	X
80357	KETAMINE AND NORKETAMINE	X	X
80358	DRUG SCREENING METHADONE	X	X
80359	METHYLENEDIOXYAMPHETAMINES	X	X
80360	METHYLPHENIDATE	X	X
80361	OPIATES 1 OR MORE	X	X
80362	OPIOIDS AND OPIATE ANALOGS 1/2	X	X
80363	OPIOIDS AND OPIATE ANALOGS 3/4	X	X
80364	OPIOID ANDOPIATE ANALOG 5/MORE	X	X
80365	DRUG SCREENING OXYCODONE	X	X
80366	DRUG SCREENING PREGABALIN	X	X
80367	DRUG SCREENING PROPOXYPHENE	X	X
80368	SEDATIVE HYPNOTICS	X	X
80369	SKELETAL MUSCLE RELAXANT 1/2	X	X
80370	SKEL MUSC RELAXANT 3 OR MORE	X	X
80371	STIMULANTS SYNTHETIC	X	X
80372	DRUG SCREENING TAPENTADOL	X	X
80373	DRUG SCREENING TRAMADOL	X	X
80374	STEREOISOMER ANALYSIS	X	X
80375	DRUG/SUBSTANCE NOS 1-3	X	X
80376	DRUG/SUBSTANCE NOS 4-6	X	X
80377	DRUG/SUBSTANCE NOS 7/MORE	X	X
86910	BLOOD TYPING PATERNITY TEST	X	X
86911	BLOOD TYPING ANTIGEN SYSTEM	X	X
88000	AUTOPSY (NECROPSY) GROSS	X	X
88005	AUTOPSY (NECROPSY) GROSS	X	X
88007	AUTOPSY (NECROPSY) GROSS	X	X
88012	AUTOPSY (NECROPSY) GROSS	X	X
88014	AUTOPSY (NECROPSY) GROSS	X	X
88016	AUTOPSY (NECROPSY) GROSS	X	X
88020	AUTOPSY (NECROPSY) COMPLETE	X	X
88025	AUTOPSY (NECROPSY) COMPLETE	X	X
88027	AUTOPSY (NECROPSY) COMPLETE	X	X
88028	AUTOPSY (NECROPSY) COMPLETE	X	X
88029	AUTOPSY (NECROPSY) COMPLETE	X	X
88036	LIMITED AUTOPSY	X	X
88037	LIMITED AUTOPSY	X	X
88040	FORENSIC AUTOPSY (NECROPSY)	X	X
88045	CORONERS AUTOPSY (NECROPSY)	X	X
88099	NECROPSY (AUTOPSY) PROCEDURE	X	X
90281	HUMAN IG IM	X	X
90283	HUMAN IG IV	X	X
90287	BOTULINUM ANTITOXIN	X	X
90288	BOTULISM IG IV	X	X
90291	CMV IG IV	X	X
90384	RH IG FULL-DOSE IM	X	X
90386	RH IG IV	X	X
90389	TETANUS IG IM	X	X
90399	IMMUNE GLOBULIN	X	X
90658	IIV3 VACCINE SPLT 0.5 ML IM	X	X
90723	DTAP-HEP B-IPV VACCINE IM	X	X
90738	INACTIVATED JE VACC IM	X	X
90748	HEP B/HIB VACCINE IM	X	X
90863	PHARMACOLOGIC MGMT W/PSYTX	X	X
90875	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90876	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90882	ENVIRONMENTAL MANIPULATION	X	X
95941	IONM REMOTE/>1 PT OR PER HR	X	X
96110	DEVELOPMENTAL SCREEN	X	X
97014	ELECTRIC STIMULATION THERAPY	X	X
99026	IN-HOSPITAL ON CALL SERVICE	X	X
99027	OUT-OF-HOSP ON CALL SERVICE	X	X
99075	MEDICAL TESTIMONY	X	X
99172	OCULAR FUNCTION SCREEN	X	X
99173	VISUAL ACUITY SCREEN	X	X
99174	OCULAR INSTRUMNT SCREEN BIL	X	X
99188	APP TOPICAL FLUORIDE VARNISH	X	X
99241	OFFICE CONSULTATION	X	X
99242	OFFICE CONSULTATION	X	X
99243	OFFICE CONSULTATION	X	X
99244	OFFICE CONSULTATION	X	X
99245	OFFICE CONSULTATION	X	X
99381	INIT PM E/M NEW PAT INFANT	X	X
99382	INIT PM E/M NEW PAT 1-4 YRS	X	X
99383	PREV VISIT NEW AGE 5-11	X	X
99384	PREV VISIT NEW AGE 12-17	X	X
99385	PREV VISIT NEW AGE 18-39	X	X
99386	PREV VISIT NEW AGE 40-64	X	X
99387	INIT PM E/M NEW PAT 65+ YRS	X	X
99391	PER PM REEVAL EST PAT INFANT	X	X
99392	PREV VISIT EST AGE 1-4	X	X
99393	PREV VISIT EST AGE 5-11	X	X
99394	PREV VISIT EST AGE 12-17	X	X
99395	PREV VISIT EST AGE 18-39	X	X
99396	PREV VISIT EST AGE 40-64	X	X
99397	PER PM REEVAL EST PAT 65+ YR	X	X
99401	PREVENTIVE COUNSELING INDIV	X	X
99402	PREVENTIVE COUNSELING INDIV	X	X
99403	PREVENTIVE COUNSELING INDIV	X	X
99404	PREVENTIVE COUNSELING INDIV	X	X
99408	AUDIT/DAST 15-30 MIN	X	X
99409	AUDIT/DAST OVER 30 MIN	X	X
99411	PREVENTIVE COUNSELING GROUP	X	X
99412	PREVENTIVE COUNSELING GROUP	X	X
99429	UNLISTED PREVENTIVE SERVICE	X	X
0620T	ENDOVASCULAR VENOUS ARTERIALIZATION TIBL/PRNL VN	X	X
0620T	ENDOVASCULAR VENOUS ARTERIALIZATION TIBL/PRNL VN	X	X
0621T	TRABECULOSTOMY AB INTERNO BY LASER	X	X
0621T	TRABECULOSTOMY AB INTERNO BY LASER	X	X
0622T	TRABECULOSTOMY AB INTERNO LASER W/OPH ENDOSCOPE	X	X
0622T	TRABECULOSTOMY AB INTERNO LASER W/OPH ENDOSCOPE	X	X
0623T	AUTO QUAN AND CHARAC CORONARY ATHEROSCLEROTIC PLAQUE	X	X
0623T	AUTO QUAN AND CHARAC CORONARY ATHEROSCLEROTIC PLAQUE	X	X
0624T	AUTO QUAN AND CHARAC CORONARY PLAQ DATA PREP AND TRNSMIS	X	X
0624T	AUTO QUAN AND CHARAC CORONARY PLAQ DATA PREP AND TRNSMIS	X	X
0625T	AUTO QUAN AND CHARAC CORONARY PLAQ COMPUTERIZED ALYS	X	X
0625T	AUTO QUAN AND CHARAC CORONARY PLAQ COMPUTERIZED ALYS	X	X
0626T	AUTO QUAN AND CHARAC CORONARY PLAQ REV CPTR ALYS I AND R	X	X
0626T	AUTO QUAN AND CHARAC CORONARY PLAQ REV CPTR ALYS I AND R	X	X
0627T	PERQ NJX ALGC CELL AND /PRDCT UNI/BI FLUOR LMBR 1ST	X	X
0627T	PERQ NJX ALGC CELL AND /PRDCT UNI/BI FLUOR LMBR 1ST	X	X
0628T	PERQ NJX ALGC CELL AND /PRDCT UNI/BI FLUOR LMBR EA	X	X
0628T	PERQ NJX ALGC CELL AND /PRDCT UNI/BI FLUOR LMBR EA	X	X
0629T	PERQ NJX ALGC CELL AND /PRDCT UNI/BI CT LMBR 1ST	X	X
0629T	PERQ NJX ALGC CELL AND /PRDCT UNI/BI CT LMBR 1ST	X	X
0630T	PERQ NJX ALGC CELL AND /PRDCT UNI/BI CT LMBR EA	X	X
0630T	PERQ NJX ALGC CELL AND /PRDCT UNI/BI CT LMBR EA	X	X
0631T	TC VISIBLE LIGHT HYPERSPECTRAL IMG MEAS PER XTR	X	X
0631T	TC VISIBLE LIGHT HYPERSPECTRAL IMG MEAS PER XTR	X	X
0632T	PERQ TCAT US ABLATION NERVES INNERVATING P-ART	X	X
0632T	PERQ TCAT US ABLATION NERVES INNERVATING P-ART	X	X
0633T	CT BREAST W/3D RENDERING UNI WITHOUT CONTRAST	X	X
0633T	CT BREAST W/3D RENDERING UNI WITHOUT CONTRAST	X	X
0634T	CT BREAST W/3D RENDERING UNI WITH CONTRAST	X	X
0634T	CT BREAST W/3D RENDERING UNI WITH CONTRAST	X	X
0635T	CT BRST W/3D RENDERING UNI WO CNTRST FLWD CNTRST	X	X
0635T	CT BRST W/3D RENDERING UNI WO CNTRST FLWD CNTRST	X	X
0636T	CT BREAST W/3D RENDERING BI WITHOUT CONTRAST	X	X
0636T	CT BREAST W/3D RENDERING BI WITHOUT CONTRAST	X	X
0637T	CT BREAST W/3D RENDERING BI WITH CONTRAST	X	X
0637T	CT BREAST W/3D RENDERING BI WITH CONTRAST	X	X
0638T	CT BRST W/3D RENDERING BI WO CNTRST FLWD CNTRST	X	X
0638T	CT BRST W/3D RENDERING BI WO CNTRST FLWD CNTRST	X	X
0639T	WIRELESS SKIN SNR THERMAL ANISOTROPY MEAS AND ASSMT	X	X
0639T	WIRELESS SKIN SNR THERMAL ANISOTROPY MEAS AND ASSMT	X	X
0791T	MOTOR COG SEMI-IMMRSV VR FACIL GAIT TRAING EA 15	X	X
0791T	MOTOR COG SEMI-IMMRSV VR FACIL GAIT TRAING EA 15	X	X
0792T	APPLICATION SILVER DIAMINE FLUORIDE 38 PERCENT PHYS/QHP	X	X
0792T	APPLICATION SILVER DIAMINE FLUORIDE 38 PERCENT PHYS/QHP	X	X
0793T	PERQ TCAT THRM ABLTJ NERVES INNERVATING P-ART	X	X
0793T	PERQ TCAT THRM ABLTJ NERVES INNERVATING P-ART	X	X
0794T	PT SPEC ALG RANKING PHARMACOONCOLOGIC TX OPTIONS	X	X
0794T	PT SPEC ALG RANKING PHARMACOONCOLOGIC TX OPTIONS	X	X
0795T	TCAT INSJ PERM DUAL CHAMBER LDLS PM COMPL SYS	X	X
0795T	TCAT INSJ PERM DUAL CHAMBER LDLS PM COMPL SYS	X	X
0796T	TCAT INSJ PERM 2CHMBR LDLS PM R ATR PM COMPNT	X	X
0796T	TCAT INSJ PERM 2CHMBR LDLS PM R ATR PM COMPNT	X	X
0797T	TCAT INSJ PERM 2CHMBR LDLS PM R VENTR PM COMPNT	X	X
0797T	TCAT INSJ PERM 2CHMBR LDLS PM R VENTR PM COMPNT	X	X
0798T	TCAT RMVL PERM DUAL CHAMBER LDLS PM COMPL SYS	X	X
0798T	TCAT RMVL PERM DUAL CHAMBER LDLS PM COMPL SYS	X	X
0799T	TCAT RMVL PERM 2CHMBR LDLS PM R ATR PM COMPNT	X	X
0799T	TCAT RMVL PERM 2CHMBR LDLS PM R ATR PM COMPNT	X	X
0800T	TCAT RMVL PERM 2CHMBR LDLS PM R VENTR PM COMPNT	X	X
0800T	TCAT RMVL PERM 2CHMBR LDLS PM R VENTR PM COMPNT	X	X
0801T	TCAT RMVL AND RPLCMT PERM 2CHMBR LDLS PM 2CHMBR SYS	X	X
0801T	TCAT RMVL AND RPLCMT PERM 2CHMBR LDLS PM 2CHMBR SYS	X	X
0802T	TCAT RMVL AND RPLCMT PERM 2CHMBR LDLS PM R ATR CMPNT	X	X
0802T	TCAT RMVL AND RPLCMT PERM 2CHMBR LDLS PM R ATR CMPNT	X	X
0803T	TCAT RMVL AND RPLCMT PRM 2CHMBR LDLS PM R VNTR CMPNT	X	X
0803T	TCAT RMVL AND RPLCMT PRM 2CHMBR LDLS PM R VNTR CMPNT	X	X
0804T	PRGRMG DEV EVAL LDLS PM SYS 2CHMBR IN PERSON	X	X
0804T	PRGRMG DEV EVAL LDLS PM SYS 2CHMBR IN PERSON	X	X
0805T	TCAT SUPR AND IVC PROSTC VLV IMPLTJ PERQ FEM VN APPR	X	X
0805T	TCAT SUPR AND IVC PROSTC VLV IMPLTJ PERQ FEM VN APPR	X	X
0806T	TCAT SUPR AND IVC PROSTC VLV IMPLTJ OPEN FEM VN APPR	X	X
0806T	TCAT SUPR AND IVC PROSTC VLV IMPLTJ OPEN FEM VN APPR	X	X
0807T	PULM TISS VNTJ ALYS IN CMBN PREV ACQUIRED CT	X	X
0807T	PULM TISS VNTJ ALYS IN CMBN PREV ACQUIRED CT	X	X
0808T	PULM TISS VNTJ ALYS IN CMBN CT F/PULM TISS VNTJ	X	X
0808T	PULM TISS VNTJ ALYS IN CMBN CT F/PULM TISS VNTJ	X	X
0810T	SUBRETINAL NJX RX AGT W/VTRC AND 1+ RETINOTOMIES	X	X
0810T	SUBRETINAL NJX RX AGT W/VTRC AND 1+ RETINOTOMIES	X	X
22526	IDET SINGLE LEVEL	X	X
22526	IDET SINGLE LEVEL	X	X
22526	IDET SINGLE LEVEL	X	X
22526	IDET SINGLE LEVEL	X	X
22526	IDET SINGLE LEVEL	X	X
22527	IDET 1 OR MORE LEVELS	X	X
22527	IDET 1 OR MORE LEVELS	X	X
22527	IDET 1 OR MORE LEVELS	X	X
22527	IDET 1 OR MORE LEVELS	X	X
22527	IDET 1 OR MORE LEVELS	X	X
26125	RELEASE PALM CONTRACTURE	X	X
37216	TRANSCATH STENT CCA W/O EPS	X	X
37216	TRANSCATH STENT CCA W/O EPS	X	X
37216	TRANSCATH STENT CCA W/O EPS	X	X
43842	V-BAND GASTROPLASTY	X	X
43842	V-BAND GASTROPLASTY	X	X
43842	V-BAND GASTROPLASTY	X	X
48160	PANCREAS REMOVAL/TRANSPLANT	X	X
48160	PANCREAS REMOVAL/TRANSPLANT	X	X
48160	PANCREAS REMOVAL/TRANSPLANT	X	X
55970	SEX TRANSFORMATION M TO F	X	X
55970	SEX TRANSFORMATION M TO F	X	X
55970	SEX TRANSFORMATION M TO F	X	X
55970	SEX TRANSFORMATION M TO F	X	X
55970	SEX TRANSFORMATION M TO F	X	X
55980	SEX TRANSFORMATION F TO M	X	X
55980	SEX TRANSFORMATION F TO M	X	X
55980	SEX TRANSFORMATION F TO M	X	X
55980	SEX TRANSFORMATION F TO M	X	X
58300	INSERT INTRAUTERINE DEVICE	X	X
58300	INSERT INTRAUTERINE DEVICE	X	X
58300	INSERT INTRAUTERINE DEVICE	X	X
58300	INSERT INTRAUTERINE DEVICE	X	X
58300	INSERT INTRAUTERINE DEVICE	X	X
61640	DILATE IC VASOSPASM INIT	X	X
61640	DILATE IC VASOSPASM INIT	X	X
61640	DILATE IC VASOSPASM INIT	X	X
61641	PERQ BALO DILA IC VSPSM EA VSL SM VASC TER	X	X
61641	PERQ BALO DILA IC VSPSM EA VSL SM VASC TER	X	X
61641	PERQ BALO DILA IC VSPSM EA VSL SM VASC TER	X	X
61642	PERQ BALO DILA IC VSPSM EA VSL DIFF VASC TER	X	X
61642	PERQ BALO DILA IC VSPSM EA VSL DIFF VASC TER	X	X
61642	PERQ BALO DILA IC VSPSM EA VSL DIFF VASC TER	X	X
65760	REVISION OF CORNEA	X	X
65760	REVISION OF CORNEA	X	X
65760	REVISION OF CORNEA	X	X
65765	REVISION OF CORNEA	X	X
65765	REVISION OF CORNEA	X	X
65765	REVISION OF CORNEA	X	X
65767	CORNEAL TISSUE TRANSPLANT	X	X
65767	CORNEAL TISSUE TRANSPLANT	X	X
65767	CORNEAL TISSUE TRANSPLANT	X	X
65771	RADIAL KERATOTOMY	X	X
65771	RADIAL KERATOTOMY	X	X
65771	RADIAL KERATOTOMY	X	X
69090	PIERCE EARLOBES	X	X
69090	PIERCE EARLOBES	X	X
69090	PIERCE EARLOBES	X	X
69710	IMPLANT/REPLACE HEARING AID	X	X
69710	IMPLANT/REPLACE HEARING AID	X	X
69710	IMPLANT/REPLACE HEARING AID	X	X
74263	CT COLONOGRAPHY SCREENING	X	X
74263	CT COLONOGRAPHY SCREENING	X	X
74263	CT COLONOGRAPHY SCREENING	X	X
76390	MR SPECTROSCOPY	X	X
76390	MR SPECTROSCOPY	X	X
76390	MR SPECTROSCOPY	X	X
78350	BONE MINERAL SINGLE PHOTON	X	X
78350	BONE MINERAL SINGLE PHOTON	X	X
78350	BONE MINERAL SINGLE PHOTON	X	X
78351	BONE MINERAL DUAL PHOTON	X	X
78351	BONE MINERAL DUAL PHOTON	X	X
78351	BONE MINERAL DUAL PHOTON	X	X
78609	BRAIN IMAGING (PET)	X	X
78609	BRAIN IMAGING (PET)	X	X
78609	BRAIN IMAGING (PET)	X	X
80050	GENERAL HEALTH PANEL	X	X
80050	GENERAL HEALTH PANEL	X	X
80050	GENERAL HEALTH PANEL	X	X
80100	DRUG SCREEN; MX DRUG CLASSES EA PROC	X	X
80100	DRUG SCREEN; MX DRUG CLASSES EA PROC	X	X
80100	DRUG SCREEN; MX DRUG CLASSES EA PROC	X	X
80101	DRUG SCREEN; SNGL DRUG CLASS EA DRUG CLASS	X	X
80101	DRUG SCREEN; SNGL DRUG CLASS EA DRUG CLASS	X	X
80101	DRUG SCREEN; SNGL DRUG CLASS EA DRUG CLASS	X	X
80101	DRUG SCREEN; SNGL DRUG CLASS EA DRUG CLASS	X	X
80101	DRUG SCREEN; SNGL DRUG CLASS EA DRUG CLASS	X	X
80101	DRUG SCREEN; SNGL DRUG CLASS EA DRUG CLASS	X	X
80102	DRUG CONFIRM EA PROC	X	X
80102	DRUG CONFIRM EA PROC	X	X
86910	BLOOD TYPING PATERNITY TEST	X	X
86910	BLOOD TYPING PATERNITY TEST	X	X
86910	BLOOD TYPING PATERNITY TEST	X	X
86911	BLOOD TYPING ANTIGEN SYSTEM	X	X
86911	BLOOD TYPING ANTIGEN SYSTEM	X	X
86911	BLOOD TYPING ANTIGEN SYSTEM	X	X
88000	AUTOPSY (NECROPSY) GROSS	X	X
88000	AUTOPSY (NECROPSY) GROSS	X	X
88000	AUTOPSY (NECROPSY) GROSS	X	X
88005	AUTOPSY (NECROPSY) GROSS	X	X
88005	AUTOPSY (NECROPSY) GROSS	X	X
88005	AUTOPSY (NECROPSY) GROSS	X	X
88007	AUTOPSY (NECROPSY) GROSS	X	X
88007	AUTOPSY (NECROPSY) GROSS	X	X
88007	AUTOPSY (NECROPSY) GROSS	X	X
88012	AUTOPSY (NECROPSY) GROSS	X	X
88012	AUTOPSY (NECROPSY) GROSS	X	X
88012	AUTOPSY (NECROPSY) GROSS	X	X
88014	NECROPSY GROSS EXAM ONLY; STILLBORN/NB W/BRAIN	X	X
88014	NECROPSY GROSS EXAM ONLY; STILLBORN/NB W/BRAIN	X	X
88014	NECROPSY GROSS EXAM ONLY; STILLBORN/NB W/BRAIN	X	X
88016	AUTOPSY (NECROPSY) GROSS	X	X
88016	AUTOPSY (NECROPSY) GROSS	X	X
88016	AUTOPSY (NECROPSY) GROSS	X	X
88020	AUTOPSY (NECROPSY) COMPLETE	X	X
88020	AUTOPSY (NECROPSY) COMPLETE	X	X
88020	AUTOPSY (NECROPSY) COMPLETE	X	X
88025	AUTOPSY (NECROPSY) COMPLETE	X	X
88025	AUTOPSY (NECROPSY) COMPLETE	X	X
88025	AUTOPSY (NECROPSY) COMPLETE	X	X
88027	AUTOPSY (NECROPSY) COMPLETE	X	X
88027	AUTOPSY (NECROPSY) COMPLETE	X	X
88027	AUTOPSY (NECROPSY) COMPLETE	X	X
88028	AUTOPSY (NECROPSY) COMPLETE	X	X
88028	AUTOPSY (NECROPSY) COMPLETE	X	X
88028	AUTOPSY (NECROPSY) COMPLETE	X	X
88029	NECROPSY GROSS & MICRO; STILLBORN/NB W/BRAIN	X	X
88029	NECROPSY GROSS & MICRO; STILLBORN/NB W/BRAIN	X	X
88029	NECROPSY GROSS & MICRO; STILLBORN/NB W/BRAIN	X	X
88036	LIMITED AUTOPSY	X	X
88036	LIMITED AUTOPSY	X	X
88036	LIMITED AUTOPSY	X	X
88037	LIMITED AUTOPSY	X	X
88037	LIMITED AUTOPSY	X	X
88037	LIMITED AUTOPSY	X	X
88040	FORENSIC AUTOPSY (NECROPSY)	X	X
88040	FORENSIC AUTOPSY (NECROPSY)	X	X
88040	FORENSIC AUTOPSY (NECROPSY)	X	X
88045	CORONERS AUTOPSY (NECROPSY)	X	X
88045	CORONERS AUTOPSY (NECROPSY)	X	X
88045	CORONERS AUTOPSY (NECROPSY)	X	X
90863	PHARMACOLOGIC MGMT W/PSYTX	X	X
90863	PHARMACOLOGIC MGMT W/PSYTX	X	X
90875	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90875	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90875	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90875	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90875	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90876	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90876	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90876	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90876	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90876	PSYCHOPHYSIOLOGICAL THERAPY	X	X
90882	ENVIRONMENTAL MANIPULATION	X	X
90882	ENVIRONMENTAL MANIPULATION	X	X
90882	ENVIRONMENTAL MANIPULATION	X	X
90882	ENVIRONMENTAL MANIPULATION	X	X
90882	ENVIRONMENTAL MANIPULATION	X	X
92015	DETERMINE REFRACTIVE STATE	X	X
92015	DETERMINE REFRACTIVE STATE	X	X
92015	DETERMINE REFRACTIVE STATE	X	X
92015	DETERMINE REFRACTIVE STATE	X	X
92015	DETERMINE REFRACTIVE STATE	X	X
92310	CONTACT LENS FITTING	X	X
92310	CONTACT LENS FITTING	X	X
92310	CONTACT LENS FITTING	X	X
92314	PRESCRIPTION OF CONTACT LENS	X	X
92340	FIT SPECTACLES MONOFOCAL	X	X
92340	FIT SPECTACLES MONOFOCAL	X	X
92340	FIT SPECTACLES MONOFOCAL	X	X
92341	FIT SPECTACLES BIFOCAL	X	X
92341	FIT SPECTACLES BIFOCAL	X	X
92341	FIT SPECTACLES BIFOCAL	X	X
92342	FIT SPECTACLES MULTIFOCAL	X	X
92342	FIT SPECTACLES MULTIFOCAL	X	X
92342	FIT SPECTACLES MULTIFOCAL	X	X
92370	REPAIR \ ADJUST SPECTACLES	X	X
92370	REPAIR \ ADJUST SPECTACLES	X	X
92370	REPAIR \ ADJUST SPECTACLES	X	X
92551	PURE TONE HEARING TEST AIR	X	X
92551	PURE TONE HEARING TEST AIR	X	X
92551	PURE TONE HEARING TEST AIR	X	X
92559	GROUP AUDIOMETRIC TESTING	X	X
92559	GROUP AUDIOMETRIC TESTING	X	X
92559	GROUP AUDIOMETRIC TESTING	X	X
92560	BEKESY AUDIOMETRY SCREEN	X	X
92560	BEKESY AUDIOMETRY SCREEN	X	X
92560	BEKESY AUDIOMETRY SCREEN	X	X
92590	HEARING AID EXAM ONE EAR	X	X
92590	HEARING AID EXAM ONE EAR	X	X
92590	HEARING AID EXAM ONE EAR	X	X
92591	HEARING AID EXAM BOTH EARS	X	X
92591	HEARING AID EXAM BOTH EARS	X	X
92591	HEARING AID EXAM BOTH EARS	X	X
92592	HEARING AID CHECK ONE EAR	X	X
92592	HEARING AID CHECK ONE EAR	X	X
92592	HEARING AID CHECK ONE EAR	X	X
92593	HEARING AID CHECK BOTH EARS	X	X
92593	HEARING AID CHECK BOTH EARS	X	X
92593	HEARING AID CHECK BOTH EARS	X	X
92594	ELECTRO HEARNG AID TEST ONE	X	X
92594	ELECTRO HEARNG AID TEST ONE	X	X
92594	ELECTRO HEARNG AID TEST ONE	X	X
92595	ELECTRO HEARNG AID TST BOTH	X	X
92595	ELECTRO HEARNG AID TST BOTH	X	X
92595	ELECTRO HEARNG AID TST BOTH	X	X
95941	IONM REMOTE/>1 PT OR PER HR	X	X
95941	IONM REMOTE/>1 PT OR PER HR	X	X
95941	IONM REMOTE/>1 PT OR PER HR	X	X
96110	DEVELOPMENTAL SCREEN	X	X
96110	DEVELOPMENTAL SCREEN	X	X
96110	DEVELOPMENTAL SCREEN	X	X
97537	COMMUNITY/WORK REINTEGRATION	X	X
97810	ACUPUNCT W/O STIMUL 15 MIN	X	X
97810	ACUPUNCT W/O STIMUL 15 MIN	X	X
97810	ACUPUNCT W/O STIMUL 15 MIN	X	X
97810	ACUPUNCT W/O STIMUL 15 MIN	X	X
97811	ACUPUNCT W/O STIMUL ADDL 15M	X	X
97811	ACUPUNCT W/O STIMUL ADDL 15M	X	X
97811	ACUPUNCT W/O STIMUL ADDL 15M	X	X
97811	ACUPUNCT W/O STIMUL ADDL 15M	X	X
97813	ACUPUNCT W/STIMUL 15 MIN	X	X
97813	ACUPUNCT W/STIMUL 15 MIN	X	X
97813	ACUPUNCT W/STIMUL 15 MIN	X	X
97813	ACUPUNCT W/STIMUL 15 MIN	X	X
97814	ACUPUNCT W/STIMUL ADDL 15M	X	X
97814	ACUPUNCT W/STIMUL ADDL 15M	X	X
97814	ACUPUNCT W/STIMUL ADDL 15M	X	X
97814	ACUPUNCT W/STIMUL ADDL 15M	X	X
98943	CHIROPRACTIC MANIP TX; EXTRASPINAL 1/> REGIONS	X	X
98943	CHIROPRACTIC MANIP TX; EXTRASPINAL 1/> REGIONS	X	X
98943	CHIROPRACTIC MANIP TX; EXTRASPINAL 1/> REGIONS	X	X
98966	HC PRO PHONE CALL 5-10 MIN	X	X
98966	HC PRO PHONE CALL 5-10 MIN	X	X
98966	HC PRO PHONE CALL 5-10 MIN	X	X
98967	HC PRO PHONE CALL 11-20 MIN	X	X
98967	HC PRO PHONE CALL 11-20 MIN	X	X
98967	HC PRO PHONE CALL 11-20 MIN	X	X
98968	HC PRO PHONE CALL 21-30 MIN	X	X
98968	HC PRO PHONE CALL 21-30 MIN	X	X
98968	HC PRO PHONE CALL 21-30 MIN	X	X
99026	IN-HOSPITAL ON CALL SERVICE	X	X
99026	IN-HOSPITAL ON CALL SERVICE	X	X
99026	IN-HOSPITAL ON CALL SERVICE	X	X
99027	OUT-OF-HOSP ON CALL SERVICE	X	X
99027	OUT-OF-HOSP ON CALL SERVICE	X	X
99027	OUT-OF-HOSP ON CALL SERVICE	X	X
99053	MED SERV 10PM-8AM 24 HR FAC	X	X
99075	MEDICAL TESTIMONY	X	X
99075	MEDICAL TESTIMONY	X	X
99075	MEDICAL TESTIMONY	X	X
99172	OCULAR FUNCTION SCREEN	X	X
99173	VISUAL ACUITY SCREEN	X	X
99174	OCULAR INSTRUMNT SCREEN BIL	X	X
99199	SPECIAL SERVICE/PROC/REPORT	X	X
99199	SPECIAL SERVICE/PROC/REPORT	X	X
99199	SPECIAL SERVICE/PROC/REPORT	X	X
99199	SPECIAL SERVICE/PROC/REPORT	X	X
99241	OFFICE CONSULTATION	X	X
99241	OFFICE CONSULTATION	X	X
99242	OFFICE/OP CONSLTJ NEW/EST PT SF MDM 20 MINUTES	X	X
99242	OFFICE/OP CONSLTJ NEW/EST PT SF MDM 20 MINUTES	X	X
99244	OFFICE/OP CONSLTJ NEW/EST PT MOD MDM 40 MINUTES	X	X
99244	OFFICE/OP CONSLTJ NEW/EST PT MOD MDM 40 MINUTES	X	X
99245	OFFICE/OP CONSLTJ NEW/EST PT HIGH MDM 55 MINUTES	X	X
99245	OFFICE/OP CONSLTJ NEW/EST PT HIGH MDM 55 MINUTES	X	X
99381	INIT PM E/M NEW PAT INFANT	X	X
99381	INIT PM E/M NEW PAT INFANT	X	X
99382	INIT PM E/M NEW PAT 1-4 YRS	X	X
99382	INIT PM E/M NEW PAT 1-4 YRS	X	X
99383	PREV VISIT NEW AGE 5-11	X	X
99383	PREV VISIT NEW AGE 5-11	X	X
99384	PREV VISIT NEW AGE 12-17	X	X
99384	PREV VISIT NEW AGE 12-17	X	X
99385	PREV VISIT NEW AGE 18-39	X	X
99385	PREV VISIT NEW AGE 18-39	X	X
99386	PREV VISIT NEW AGE 40-64	X	X
99387	INIT PM E/M NEW PAT 65+ YRS	X	X
99387	INIT PM E/M NEW PAT 65+ YRS	X	X
99391	PER PM REEVAL EST PAT INFANT	X	X
99391	PER PM REEVAL EST PAT INFANT	X	X
99392	PREV VISIT EST AGE 1-4	X	X
99392	PREV VISIT EST AGE 1-4	X	X
99393	PREV VISIT EST AGE 5-11	X	X
99393	PREV VISIT EST AGE 5-11	X	X
99394	PREV VISIT EST AGE 12-17	X	X
99394	PREV VISIT EST AGE 12-17	X	X
99395	PREV VISIT EST AGE 18-39	X	X
99395	PREV VISIT EST AGE 18-39	X	X
99396	PREV VISIT EST AGE 40-64	X	X
99397	PER PM REEVAL EST PAT 65+ YR	X	X
99397	PER PM REEVAL EST PAT 65+ YR	X	X
99397	PER PM REEVAL EST PAT 65+ YR	X	X
99401	PREVENTIVE COUNSELING INDIV	X	X
99401	PREVENTIVE COUNSELING INDIV	X	X
99401	PREVENTIVE COUNSELING INDIV	X	X
99402	PREVENTIVE COUNSELING INDIV	X	X
99402	PREVENTIVE COUNSELING INDIV	X	X
99402	PREVENTIVE COUNSELING INDIV	X	X
99403	PREVENTIVE COUNSELING INDIV	X	X
99403	PREVENTIVE COUNSELING INDIV	X	X
99403	PREVENTIVE COUNSELING INDIV	X	X
99404	PREVENTIVE COUNSELING INDIV	X	X
99404	PREVENTIVE COUNSELING INDIV	X	X
99404	PREVENTIVE COUNSELING INDIV	X	X
99408	AUDIT/DAST 15-30 MIN	X	X
99408	AUDIT/DAST 15-30 MIN	X	X
99408	AUDIT/DAST 15-30 MIN	X	X
99408	AUDIT/DAST 15-30 MIN	X	X
99408	AUDIT/DAST 15-30 MIN	X	X
99408	AUDIT/DAST 15-30 MIN	X	X
99409	AUDIT/DAST OVER 30 MIN	X	X
99409	AUDIT/DAST OVER 30 MIN	X	X
99409	AUDIT/DAST OVER 30 MIN	X	X
99411	PREVENTIVE COUNSELING GROUP	X	X
99411	PREVENTIVE COUNSELING GROUP	X	X
99411	PREVENTIVE COUNSELING GROUP	X	X
99412	PREVENTIVE COUNSELING GROUP	X	X
99412	PREVENTIVE COUNSELING GROUP	X	X
99412	PREVENTIVE COUNSELING GROUP	X	X
99441	PHONE E/M PHYS/QHP 5-10 MIN	X	X
99441	PHONE E/M PHYS/QHP 5-10 MIN	X	X
99441	PHONE E/M PHYS/QHP 5-10 MIN	X	X
99442	PHONE E/M PHYS/QHP 11-20 MIN	X	X
99442	PHONE E/M PHYS/QHP 11-20 MIN	X	X
99442	PHONE E/M PHYS/QHP 11-20 MIN	X	X
99443	PHONE E/M PHYS/QHP 21-30 MIN	X	X
99443	PHONE E/M PHYS/QHP 21-30 MIN	X	X
99443	PHONE E/M PHYS/QHP 21-30 MIN	X	X
99444	ONLINE E/M BY PHYS/QHP	X	X
99444	ONLINE E/M BY PHYS/QHP	X	X
99444	ONLINE E/M BY PHYS/QHP	X	X
99450	BASIC LIFE DISABILITY EXAM	X	X
99450	BASIC LIFE DISABILITY EXAM	X	X
99450	BASIC LIFE DISABILITY EXAM	X	X
99601	HOME INFUSION/VISIT 2 HRS	X	X
99601	HOME INFUSION/VISIT 2 HRS	X	X
99601	HOME INFUSION/VISIT 2 HRS	X	X
99601	HOME INFUSION/VISIT 2 HRS	X	X
99602	HOME INFUSION EACH ADDTL HR	X	X
99602	HOME INFUSION EACH ADDTL HR	X	X
99602	HOME INFUSION EACH ADDTL HR	X	X
99602	HOME INFUSION EACH ADDTL HR	X	X
A0021	AMB SRVC OTSD STATE-MILE TRANSPORT	X	X
A0080	NONEMERG TRNSPRT VOLUN NOT VESTED	X	X
A0090	NONEMERG TRNSPRT IND W/VESTED INT	X	X
A0100	NONEMERGENCY TRANSPORTATION; TAXI	X	X
A0110	NONEMERG TRNSPRTANDBUS INTERSTATE /STROKE WITH MOTOR <22.35 AND AGE	X	X
A0120	NONEMERG TRNSPRT: MINI-BUS MTN/OTH	X	X
A0130	NONEMERG TRNSPRT: WHEELCHAIR VAN	X	X
A0140	NONEMERG TRNSPRT AND AIR TRAVEL	X	X
A0160	NONEMERG TRNSPRT:MILE-CASE/SOCL WRK	X	X
A0170	TRNSPRT ANCILLRY: PARK FEE TOLL OTH	X	X
A0180	NONEMERG TRNSPRT: LODGING-RECIP	X	X
A0190	NONEMERG TRNSPRT: MEALS-RECIP	X	X
A0200	NONEMERG TRNSPRT: LODGING-ESCORT	X	X
A0210	NONEMERG TRNSPRT: MEALS-ESCORT	X	X
A0225	AMB SRVC NEONAT TRNSPRT EMERG 1 WAY	X	X
A0380	BLS MILEAGE	X	X
A0382	BLS ROUTINE DISPOSABLE SUPPLIES	X	X
A0384	BLS SPCLIZED SRVC DISPBL SPL; DEFIB	X	X
A0390	ALS MILEAGE	X	X
A0392	ALS SPCLIZED SRVC DISPBL SPL; DEFIB	X	X
A0394	ALS SPCLIZED SRVC DISPBL SPL; IV RX	X	X
A0396	ALS SPCLIZD SRVC DISPBL SPL;INTUBAT	X	X
A0398	ALS ROUTINE DISPOSABLE SUPPLIES	X	X
A0420	AMB WAITING TIME 1/2 HR INCREMENTS	X	X
A0422	AMB OXYGENANDO2 SPL LIFE SUSTAINING	X	X
A0424	EXTRA AMB ATTENDANT GROUND/AIR;	X	X
A0888	NONCOVERED AMB MILEAGE PER MILE	X	X
A0998	AMBULANCE RSPNANDTREATMENT NO TRNSPRT	X	X
A4209	SYRINGE W/NEEDLE STERILE 5 CC/> EA	X	X
A4210	NEEDLE-FREE INJECTION DEVICE EACH	X	X
A4232	SYRINGE NDLE EXT INSULIN PUMP STERL	X	X
A4250	URINE TEST/REAGENT STRIPS/TABLETS	X	X
A4252	BLOOD KETONE TEST/REAGENT STRIP EA	X	X
A4261	CERVICAL CAP FOR CONTRACEPTIVE USE	X	X
A4264	PERM IMPL CONTRCPTV TUBAL OCCL DEV	X	X
A4266	DIAPHRAGM FOR CONTRACEPTIVE USE	X	X
A4267	CONTRACEPTIVE SUPPLY CONDOM MALE EA	X	X
A4268	CONTRACEPT SUPPLY CONDOM FEMALE EA	X	X
A4269	CONTRACEPTIVE SUPPLY SPERMICIDE EA	X	X
A4305	DISPBL RX DEL SYS RATE 50 ML/>-HR	X	X
A4335	INCONTINENCE SUPPLY; MISCELLANEOUS	X	X
A4457	ENEMA TUBE W/WO ADAPTER ANY TYPE REPLAC ONLY EA	X	X
A4457	ENEMA TUBE W/WO ADAPTER ANY TYPE REPLAC ONLY EA	X	X
A4467	BELT STRAP SLEEV GRMNT COVER	X	X
A4468	EXSUFFLATION BELT INCL ALL SUPL AND ACCESSORIES	X	X
A4468	EXSUFFLATION BELT INCL ALL SUPL AND ACCESSORIES	X	X
A4490	SURG STOCKING ABOVE KNEE LENGTH EA	X	X
A4495	SURGICAL STOCKING THIGH LENGTH EACH	X	X
A4500	SURG STOCKING BELOW KNEE LENGTH EA	X	X
A4510	SURGICAL STOCKING FULL-LENGTH EACH	X	X
A4520	INCONTINENCE GARMENT ANY TYPE EACH	X	X
A4540	DISTAL TRANSCUT ELECTRICAL NERVE STIMULATOR	X	X
A4540	DISTAL TRANSCUT ELECTRICAL NERVE STIMULATOR	X	X
A4553	NONDISP UNDERPADS ALL SIZES	X	X
A4554	DISPOSABLE UNDERPADS ALL SIZES	X	X
A4555	E/TRANSDUCR E-STIM U CA TX RPL ONLY	X	X
A4560	NEUROMUSCULAR ELECTRICAL STIM DISP REPLC ONLY	X	X
A4560	NEUROMUSCULAR ELECTRICAL STIM DISP REPLC ONLY	X	X
A4566	SHOULDR SLING/VEST ABD RSTRN PREFAB	X	X
A4570	SPLINTS	X	X
A4575	TOPICAL HYPRBR OXYGEN CHAMB DISPBL	X	X
A4580	CAST SUPPLIES	X	X
A4590	SPECIAL CASTING MATERIAL	X	X
A4611	BATTRY HEVY DUTY; REPL PT-OWND VENT	X	X
A4612	BATTRY CABLES; REPL PT-OWNED VENT	X	X
A4613	BATTRY CHARGER; REPL PT-OWNED VENT	X	X
A4627	SPACR BAG/RESRVOR METRD DOSE INHAL	X	X
A4657	SYRINGE WITH OR WITHOUT NEEDLE EACH	X	X
A4670	AUTOMATIC BLOOD PRESSURE MONITOR	X	X
A4927	GLOVES NON-STERILE PER 100	X	X
A6000	NON-CNTC WND WARMING COVR W/DEVC	X	X
A6413	ADHESIVE BANDAGE FIRST-AID TYPE EA	X	X
A6450	LT COMPRS BANDGE WDTH >/= 5 IN	X	X
A6530	GRADIENT COMPRS STK BK 18-30 MMHG	X	X
A6533	GRADENT COMPRS STK THIGH 18-30 MMHG	X	X
A6534	GRADENT COMPRS STK THIGH 30-40 MMHG	X	X
A6535	GRADENT COMPRS STK THIGH 40-50 MMHG	X	X
A6536	GRADENT COMPRS STK FULL 18-30 MMHG	X	X
A6537	GRADENT COMPRS STK FULL 30-40 MMHG	X	X
A6538	GRADENT COMPRS STK FULL 40-50 MMHG	X	X
A6539	GRADENT COMPRS STK WAIST 18-30 MMHG	X	X
A6540	GRADENT COMPRS STK WAIST 30-40 MMHG	X	X
A6541	GRADENT COMPRS STK WAIST 40-50 MMHG	X	X
A6544	GRADENT COMPRESSION STK GARTER BELT	X	X
A6549	GRADIENT COMP STOCKING/SLEEVE NOS	X	X
A7023	MECH ALLERGEN PARTCL BAR/INH FILT CRM NASL TOPIC	X	X
A7023	MECH ALLERGEN PARTCL BAR/INH FILT CRM NASL TOPIC	X	X
A7049	EXPIRATORY PAP INTRANASAL RESISTANCE VALVE	X	X
A7049	EXPIRATORY PAP INTRANASAL RESISTANCE VALVE	X	X
A9152	1 VIT/MINERL/TRACE ELEM ORLDOSE NOS	X	X
A9153	MULTIPLE VITAMINS ORAL PER DOSE NOS	X	X
A9180	PEDICULOSIS TX TOP ADMN PT/CARETAKR	X	X
A9268	PROGRAMMER FOR TRANSIENT ORALLY INGESTED CAPSULE	X	X
A9268	PROGRAMMER FOR TRANSIENT ORALLY INGESTED CAPSULE	X	X
A9269	PROGRMMABLE TSNT ORALLY ING CAP USE EXT PROG PM	X	X
A9269	PROGRMMABLE TSNT ORALLY ING CAP USE EXT PROG PM	X	X
A9270	NONCOVERED ITEM OR SERVICE	X	X
A9272	WND SCTN DISPBL DRSG ACC ANY TYP EA	X	X
A9273	HOT WATER BOTTLE ICE CAP/COLLAR ANY	X	X
A9274	EXT AMB INSULIN DEL SYS DISPOSBL EA	X	X
A9275	HOME GLU DISPBL MON W/TEST STRIPS	X	X
A9276	SENSOR; INVSV INTRSTL GLU MON SYS	X	X
A9277	TRANSMTR; EXT INTRSTL CONT GLU MON	X	X
A9278	RECEIVER MON; EXT INTRSTL GLU MON	X	X
A9279	MON FEATURE/DEVC ALONE/INTEGRAT NOC	X	X
A9280	ALERT OR ALARM DEVICE NOC	X	X
A9281	REACH/GRABBING DEVC ANY TYPE/LEN EA	X	X
A9282	WIG ANY TYPE EACH	X	X
A9283	FOOT PRESSURE OFF LOAD/SUPP DEV EA	X	X
A9286	ANY HYGIENIC ITEM DEVICE	X	X
A9300	EXERCISE EQUIPMENT	X	X
B4100	FOOD THICKENER ADMINED ORALLY-OUNCE	X	X
B4149	ENTRAL F MANF BLNDRIZD NAT FOODS	ONLY with BO modifier	ONLY with BO modifier
B4150	ENTRAL F NUTRITIONALLY COMPLETE	ONLY with BO modifier	ONLY with BO modifier
B4152	ENTRAL F NUTRITION CMPL CAL DENSE	ONLY with BO modifier	ONLY with BO modifier
B4153	ENTRL F NUTRTN CMPL HYDROLYZD PROTS	ONLY with BO modifier	ONLY with BO modifier
B4154	ENTRAL F CMPL NO INHERITED DZ METAB	ONLY with BO modifier	ONLY with BO modifier
B4155	ENTRAL F NUTRITN INCMPL/MOD NUTRNTS	ONLY with BO modifier	ONLY with BO modifier
C1749	ENDO RETRO IMAG/ILLUM COLONOSCOPE	X	X
C1749	ENDO RETRO IMAG/ILLUM COLONOSCOPE	X	X
C9101	INJECTION OLICERIDINE 0.1 MG	X	X
C9101	INJECTION OLICERIDINE 0.1 MG	X	X
C9142	INJECTION BEVACIZUMAB-MALY BIOSIMILAR 10 MG	X	X
C9142	INJECTION BEVACIZUMAB-MALY BIOSIMILAR 10 MG	X	X
C9151	INJECTION PEGCETACOPLAN 1 MG	X	X
C9151	INJECTION PEGCETACOPLAN 1 MG	X	X
C9786	ECHOCARDIOGRAPHY IMAGE POST PROC FOR CAD OF HF	X	X
C9786	ECHOCARDIOGRAPHY IMAGE POST PROC FOR CAD OF HF	X	X
C9787	GASTRIC EPS MAPPING WITH SIM PT SX PROFILING	X	X
C9787	GASTRIC EPS MAPPING WITH SIM PT SX PROFILING	X	X
D0145	ORL EVAL PT<3 YR CNSL PRIM CAREGIVR	X	X
D0417	RETNR CRWN-PORCELN FUSD NOBLE METAL	X	X
D0418	RETNER CROWN-3/4 CAST HI NOBLE METL	X	X
D0472	RETAINER CROWN-FULL CAST NOBLE METL	X	X
D0472	RETAINER CROWN-FULL CAST NOBLE METL	X	X
D0473	RETAINER CROWN - TITANIUM	X	X
D0473	RETAINER CROWN - TITANIUM	X	X
D0474	NON-INTRAVENOUS CONSCIOUS SEDATION	X	X
D0474	NON-INTRAVENOUS CONSCIOUS SEDATION	X	X
D0480	ACESS EXFOLIATIVE CYT SMER MIC EXAM	X	X
D0480	ACESS EXFOLIATIVE CYT SMER MIC EXAM	X	X
D1320	TOBACCO CNSL CNTRLANDPREVION ORL DZ	X	X
D1330	ORAL HYGIENE INSTRUCTIONS	X	X
D1520	SPACE MAINTAINER - REMOVABLE UNI - PER QUADRANT	X	X
D1520	SPACE MAINTAINER - REMOVABLE UNI - PER QUADRANT	X	X
D2410	GOLD FOIL - ONE SURFACE	X	X
D2420	GOLD FOIL - TWO SURFACES	X	X
D2430	GOLD FOIL - THREE SURFACES	X	X
D2510	INLAY - METALLIC - ONE SURFACE	X	X
D2520	INLAY - METALLIC - TWO SURFACES	X	X
D2530	INLAY - METALLIC - 3/MORE SURFACES	X	X
D2542	ONLAY - METALLIC - TWO SURFACES	X	X
D2543	ONLAY METALLIC THREE SURFACES	X	X
D2544	ONLAY METALLIC FOUR OR MORE SURF	X	X
D2610	INLAY - PORCELN/CERAMIC - 1 SURFACE	X	X
D2620	INLAY - PORCELN/CERAMIC - 2 SURF	X	X
D2630	INLAY - PORCELN/CERAM - 3/MORE SURF	X	X
D2642	ONLAY - PORCELN/CERAMIC - 2 SURF	X	X
D2643	ONLAY - PORCELN/CERAMIC - 3 SURF	X	X
D2644	ONLAY - PORCELN/CERAM - 4/MORE SURF	X	X
D2662	ONLAY-RSN COMPOS COMPOS/RSN-2 SURF	X	X
D2663	ONLAY-RSN COMPOS COMPOS/RSN-3 SURF	X	X
D2664	ONLAY RESIN COMPOSITE 4/> SURFACES	X	X
D2780	CROWN - 3/4 CAST HIGH NOBLE METAL	X	X
D2781	CROWN - 3/4 CAST PREDOM BASE METL	X	X
D2782	CROWN - 3/4 CAST NOBLE METAL	X	X
D2783	CROWN - 3/4 PORCELAIN/CERAMIC	X	X
D2953	EA ADD INDIRECT FAB POST SAME TOOTH	X	X
D2957	EA ADD PREFABR POST - SAME TOOTH	X	X
D2960	LABIAL VENEER RESIN LAM- CHAIRSIDE	X	X
D3222	PART PULPOTMY APEXOGNEIS PERM TOOTH	X	X
D3230	PULPAL THERAPY - ANT PRIMARY TOOTH	X	X
D3240	PULPAL THERAPY - POST PRIMARY TOOTH	X	X
D3331	TX RC OBSTRUCTION; NON-SURG ACCESS	X	X
D3332	INCMPL ENDO TX;INOP UNRSTR/FX TOOTH	X	X
D3333	INTRL ROOT REPAIR PERFORATION DEFEC	X	X
D4230	ANAT CROWN EXP 4/> CONT TEETH QUAD	X	X
D4231	ANAT CROWN EXP 1- 3 TEETH PER QUAD	X	X
D4245	APICALLY POSITIONED FLAP	X	X
D4263	BONE REPL GRAFT - RET NAT TOOTH - 1ST SITE QUAD	X	X
D4263	BONE REPL GRAFT - RET NAT TOOTH - 1ST SITE QUAD	X	X
D4264	BONE REPL GR - RET NAT TOOTH - EA ADD SITE QUAD	X	X
D4264	BONE REPL GR - RET NAT TOOTH - EA ADD SITE QUAD	X	X
D4266	GUID TISS REGEN-RESORB BARRIER-SITE	X	X
D4267	GUID TISS REGEN-NONRESORB BARRIER	X	X
D4268	SURGICAL REVISION PROC PER TOOTH	X	X
D4268	SURGICAL REVISION PROC PER TOOTH	X	X
D4274	MESIAL/DISTAL WEDGE PROCEDURE SINGLE TOOTH	X	X
D5862	PRECISION ATTACHMENT BY REPORT	X	X
D5867	REPL PART SEMI-PRCISN/PRCISN ATTCH	X	X
D5875	MOD REMV PROSTH FOLLOW IMPL SURG	X	X
D5913	NASAL PROSTHESIS	X	X
D5914	AURICULAR PROSTHESIS	X	X
D5915	ORBITAL PROSTHESIS	X	X
D5916	OCULAR PROSTHESIS	X	X
D5991	VESICULOBULLOUS DZ MEDICAMENT CARR	X	X
D6010	SURG PLCMT IMPL BODY: ENDOSTEAL	X	X
D6012	SURG PLCMT INTERIM IMPL PROS: ENDOS	X	X
D6058	ABUT SUPP PORCELN/CERAMIC CROWN	X	X
D6059	ABUT PORCLN TO MTL CRWN HI NOBL MTL	X	X
D6060	ABUT PORCLN TO METL CROWN BASE METL	X	X
D6061	ABUT PORCLN TO MTL CROWN NOBLE MTL	X	X
D6062	ABUT SUPP CAST MTL CRWN HI NOBL MTL	X	X
D6063	ABUT SUPP CAST METL CROWN BASE METL	X	X
D6064	ABUT SUPP CAST METL CROWN NOBL METL	X	X
D6065	IMPLANT SUPP PORCELN/CERAMIC CROWN	X	X
D6066	IMPL SUPP PORCELN FUSED METAL CROWN	X	X
D6067	IMPLANT SUPPORTED METAL CROWN	X	X
D6068	ABUT SUPP RETAIN PORCELN/CERAM FPD	X	X
D6069	ABUT RETN PORCLN MTL FPD HI NOBL MT	X	X
D6070	ABUT RETN PORCLN METL FPD BASE METL	X	X
D6071	ABUT SUPP RETN PORCLN FUSD METL FPD	X	X
D6072	ABUT SUPP RETAIN CAST METAL FPD	X	X
D6073	ABUT RETN CAST METL FPD BASE METL	X	X
D6074	ABUT RETN CAST METL FPD NOBL METL	X	X
D6075	IMPLANT SUPP RETAIN CERAMIC FPD	X	X
D6076	IMPL SUPP RETN PORCLN FUSD METL FPD	X	X
D6077	IMPLANT SUPP RETAIN CAST METAL FPD	X	X
D6091	REPL IMPL/ABUT PROS PER ATTACHMENT	X	X
D6092	RECEMENT IMPL/ABUT SUPPORTED CROWN	X	X
D6093	RECEMENT IMPL/ABUT FIX PART DENTURE	X	X
D6095	REPAIR IMPLANT ABUTMENT BY REPORT	X	X
D6210	PONTIC - CAST HIGH NOBLE METAL	X	X
D6212	PONTIC - CAST NOBLE METAL	X	X
D6240	PONTIC-PORCELN FUSED HI NOBLE METL	X	X
D6242	PONTIC - PORCELN FUSED NOBLE METAL	X	X
D6245	PONTIC - PORCELAIN/CERAMIC	X	X
D6250	PONTIC - RESIN W/HIGH NOBLE METAL	X	X
D6251	PONTIC RESIN W/PREDOM BASE METAL	X	X
D6252	PONTIC RESIN W/NOBLE METAL	X	X
D6548	RETN-PORCELN/CERAM RSN BOND PROSTH	X	X
D6720	RETAINER CROWN-RESIN HI NOBLE METAL	X	X
D6721	RETAINER CROWN-RESIN PDMT BASE METL	X	X
D6722	RETAINER CROWN-RESIN W/NOBLE METAL	X	X
D6740	RETAINER CROWN - PORCELAIN/CERAMIC	X	X
D6750	RET CROWN-PORC FUSED HI NOBLE METL	X	X
D6752	RETNR CRWN-PORCELN FUSD NOBLE METAL	X	X
D6780	RETNER CROWN-3/4 CAST HI NOBLE METL	X	X
D6781	RETNR CRWN-3/4 CAST PDMT BASE METAL	X	X
D6782	RETAINER CROWN-3/4 CAST NOBLE METAL	X	X
D6783	RETAINER CROWN-3/4 PORCELAIN/CERAMC	X	X
D6790	RETNR CRWN-FULL CAST HI NOBLE METAL	X	X
D6792	RETAINER CROWN-FULL CAST NOBLE METL	X	X
D6920	CONNECTOR BAR	X	X
D6920	CONNECTOR BAR	X	X
D6950	PRECISION ATTACHMENT	X	X
D7292	PLCMT TEMP ANC DEVC SCREW RETN PLATE RQR FLAP;	X	X
D7293	PLACEMENT TEMP ANC DEVC RQR FLAP; INC DEVC REMV	X	X
D7294	PLACEMENT TEMP ANC DEVC W/O FLAP; INC DEVC REMV	X	X
D7995	SYNTH GFT-MAND/FACE BONES BY RPT	X	X
D7996	IMPLNT-MANDIB-AUGMENTATION BR	X	X
D7998	INTRAORAL PLCMT FIX DEVC NOT W/FX	X	X
D8690	ORTHODONTIC TREATMENT	X	X
D9120	FIXED PARTIAL DENTURE SECTIONING	X	X
D9210	LOC ANES-NOT CONJUNC W/OP/SURG PROC	X	X
D9612	TX PARENTERAL RX 2/> ADMIN DIFF MED	X	X
D9911	APPLIC DESENZT RSN CERVAND/ROOT-TOOTH	X	X
D9920	BEHAVIOR MANAGEMENT BY REPORT	X	X
D9941	FABRICATION OF ATHLETIC MOUTHGUARD	X	X
D9970	ENAMEL MICROABRASION	X	X
D9971	ODONTPLSTY 1-2 TEETH;REMV ENAML PRJ	X	X
D9973	EXTERNAL BLEACHING - PER TOOTH	X	X
D9974	INTERNAL BLEACHING - PER TOOTH	X	X
E0172	SEAT LIFT MECH PLACE OVR/TOP TOILET	X	X
E0203	TX LTBOX MINI 10000 LUX TABLE TOP	X	X
E0231	NON-CNTC WND WARM DEVC W/CARDANDCOVR	X	X
E0232	WOUND WARMING WOUND COVER	X	X
E0240	BATH/SHOWER CHAIR W/WO WHLS ANY SZ	X	X
E0241	BATHTUB WALL RAIL EACH	X	X
E0242	BATHTUB RAIL FLOOR BASE	X	X
E0243	TOILET RAIL EACH	X	X
E0244	RAISED TOILET SEAT	X	X
E0245	TUB STOOL OR BENCH	X	X
E0246	TRANSFER TUB RAIL ATTACHMENT	X	X
E0265	HOS BED TOT ELEC W/RAIL W/MATTRSS	X	X
E0265	HOS BED TOT ELEC W/RAIL W/MATTRSS	X	X
E0265	HOS BED TOT ELEC W/RAIL W/MATTRSS	X	X
E0266	HOS BED TOT ELEC W/RAIL W/O MATTRSS	X	X
E0266	HOS BED TOT ELEC W/RAIL W/O MATTRSS	X	X
E0266	HOS BED TOT ELEC W/RAIL W/O MATTRSS	X	X
E0270	HOSP BED INST TYPE: W/MATTRSS	X	X
E0273	BED BOARD	X	X
E0274	OVER-BED TABLE	X	X
E0296	HOS BED TOT ELEC W/O RAIL W/MATTRSS	X	X
E0296	HOS BED TOT ELEC W/O RAIL W/MATTRSS	X	X
E0296	HOS BED TOT ELEC W/O RAIL W/MATTRSS	X	X
E0297	HOS BED TOT ELEC W/O RAIL/MATTRSS	X	X
E0297	HOS BED TOT ELEC W/O RAIL/MATTRSS	X	X
E0297	HOS BED TOT ELEC W/O RAIL/MATTRSS	X	X
E0315	BED ACCESS: BOARD/TABL/SUPPRT DEVC	X	X
E0446	TOPICAL OXYGEN DELIVERY SYSTEM NOS	X	X
E0457	CHEST SHELL	X	X
E0459	CHEST WRAP	X	X
E0481	INTRAPULM PERCUSS VENT SYSANDREL ACSS	X	X
E0492	POWER SRCAND CTRL ELEC ORAL DVC NEUMUSC ELC STM TNG	X	X
E0492	POWER SRCAND CTRL ELEC ORAL DVC NEUMUSC ELC STM TNG	X	X
E0493	ORAL DVC NM ELC STIM TONGUE MUSC PWR SAND C ELC 90D	X	X
E0493	ORAL DVC NM ELC STIM TONGUE MUSC PWR SAND C ELC 90D	X	X
E0625	PATIENT LIFT BATHROOM OR TOILET NOC	X	X
E0637	COMB SIT STAND FRAME/TABLE SEATLIFT	X	X
E0638	STAND FRAME/TABLE SYS 1 POS ANY SZ	X	X
E0641	STAND FRAME/TABLE SYS MX-POS ANY SZ	X	X
E0642	STAND FRAME/TABLE SYS MOBILE ANY SZ	X	X
E0936	CONT PASS MOTION EXER DEVC NOT KNEE	X	X
E0970	NO 2 FOOTPLATES EXCEPT ELEV LEGREST	X	X
E1085	HEMI-WHLCHAIR;FIX ARM DTACH FOOTRST	X	X
E1086	HEMI-WHLCHAIR; DTACHBL ARMS FOOTRST	X	X
E1089	HI-STRGTH WHLCHAIR; FIX ARM FOOTRST	X	X
E1090	HI-STRGTH WHLCHAR;DTACH ARM FOOTRST	X	X
E1130	STD WHLCHAIR; FIX ARM DTACH FOOTRST	X	X
E1140	WHLCHAIR; DTACHBLE ARMS FOOTRESTS	X	X
E1250	LGHTWT WHLCHR;FIX ARM DTACH FOOTRST	X	X
E1260	LGHTWT WHLCHAIR; DTACH ARMS FOOTRST	X	X
E1285	HEVY-DUTY WHLCHR;FIX ARM DTACH FOOT	X	X
E1290	HEVY-DUTY WHLCHR; DTACH ARM FOOTRST	X	X
E1300	WHIRLPOOL PORTABLE	X	X
E1358	O2 ACCESS DC POWER ADAPTER REPL EA	X	X
E8000	GAIT TRAINER PED SZ POST SUPP	X	X
E8001	GAIT TRAINER PED SZ UPRIGHT SUPP	X	X
E8002	GAIT TRAINER PED SZ ANT SUPP	X	X
G0122	COLOREC CANCER SCREENING; BA ENEMA	X	X
G0151	SRVC PT HOM HLTH/HOSPICE EA 15 MIN	X	Need denial From MA plan
G0152	SRVC OT HOM HLTH/HOSPICE EA 15 MIN	X	Need denial From MA plan
G0153	SRVC SPCHANDLANG PATH HH/HOSPIC EA 15	X	Need denial From MA plan
G0156	SRVC HH/HOSPICE AIDE EA 15 MIN	X	Need denial From MA plan
G0219	PET BDY; MELANOMA NON-COVR INDICAT	X	X
G0235	PET IMAGING ANY SITE NOS	X	X
G0252	PET IMAG DX BREST CAAND/SURG PLAN	X	X
G0255	CPT/SNCT PER LIMB ANY NERVE	X	X
G0282	E-STIM 1/> AREAS WND CARE NOT G0281	X	X
G0295	ELECMAGNET TX 1/>AREA NOT G0329/OTH	X	X
G0299	DIR SNS RN HH/HOSPICE SET EA 15 MIN	X	Need denial From MA plan
G0300	DIR SNS LPN HH/HOSPCE SET EA 15 MIN	X	Need denial From MA plan
G0310	IM CNSLG PHYS/OTH Q HCP VAC NA SAME DOS 5-15 MM	X	X
G0310	IM CNSLG PHYS/OTH Q HCP VAC NA SAME DOS 5-15 MM	X	X
G0311	IM CNSLG PHYS/OTH Q HCP VAC NA SAME DOS 16-30 MM	X	X
G0311	IM CNSLG PHYS/OTH Q HCP VAC NA SAME DOS 16-30 MM	X	X
G0312	IM CNSLG PHYS/Q HCP VAC NA SAME DOS A< 21 5-15 M	X	X
G0312	IM CNSLG PHYS/Q HCP VAC NA SAME DOS A< 21 5-15 M	X	X
G0313	IM CNSLG PHYS/Q HCP VAC NA SAME DOS A<21 16-30 M	X	X
G0313	IM CNSLG PHYS/Q HCP VAC NA SAME DOS A<21 16-30 M	X	X
G0314	IM CNSL PHYS/OTH Q HCP COVID-19 AGE <21 16-30 M	X	X
G0314	IM CNSL PHYS/OTH Q HCP COVID-19 AGE <21 16-30 M	X	X
G0315	IM CNSL PHYS/OTH Q HCP COVID-19 AGE <21 5-15 MIN	X	X
G0315	IM CNSL PHYS/OTH Q HCP COVID-19 AGE <21 5-15 MIN	X	X
G0428	COLL MENISC IMPL FIL MENISCAL DEFEC	X	X
G9013	ESRD DEMO BASIC BUNDLE LEVEL I	X	X
G9014	ESRD DEMO EXPND BUNDLE W/VENUS ACSS	X	X
G9016	SMOK CESSATN CNSL IND ABSNC/ADD EANDM	X	X
G9050	ONC; PRIM FOCUS; WRKUP EVAL/STAG	X	X
G9051	ONC; PRIM FOCUS; TX DECISION OPTNS	X	X
G9052	ONC; PRIM; SURVEILLANCE RECUR;	X	X
G9053	ONC; PRIM; EXPECT MGMT EVIDENCE CA;	X	X
G9054	ONC;PRIM;SUP PT TERM CA;PALLIATV TX	X	X
G9055	ONC;PRIM;OTH UNS NOT OTHERWISE LIST	X	X
G9056	ONC;PRAC GUIDE;MGMT ADHERS TO GUIDE	X	X
G9057	ONC; PRAC; MGMT DIFFER CLIN TRIAL	X	X
G9058	ONC; MGMT DIFFR PHYS DISAGREE GUIDE	X	X
G9059	ONC;PRAC;MGMT DIFFERS PT OPT ALT TX	X	X
G9060	ONC; PRAC; MGMT DIFFER COMORBID ILL	X	X
G9061	ONC; PTS COND NOT ADDRESSED GUIDE	X	X
G9062	ONC; PRAC; MGMT DIFFERS OTH REASON	X	X
G9147	OIVIT MSR: RQ; AND/UUN; AND/GLU; AND/K+	X	X
H0001	ALCOHOL AND/OR DRUG ASSESSMENT	X	X
H0002	BHVAL HLTH SCR DETRM ADMIS TX PROGM	X	X
H0003	ALCOHLAND/RX SCR;LAB ANALY ALCOHLAND/RX	X	X
H0004	BEHAVIORAL HEALTH CNSLANDTX-15 MIN	X	X
H0005	ALCOHLAND/RX SRVC; GRP CNSL CLINICIAN	X	X
H0006	ALCOHOL ANDOR DRUG SRVC; CASE MGMT	X	X
H0007	ALCOHL ANDOR RX SRVC; CRISIS INTERVEN	X	X
H0008	ALCOHLAND/RX SRVC;SUB-AC DTOX HOSP IP	X	X
H0009	ALCOHLAND/RX SRVC; ACUTE DTOX HOSP IP	X	X
H0010	ALCOHLAND/RX SRVC; SUB-AC DTOX RES IP	X	X
H0011	ALCOHLAND/RX SRVC;AC DTOX RES PROG IP	X	X
H0012	ALCOHLAND/RX SRVC; SUB-AC DTOX RES OP	X	X
H0013	ALCOHLAND/RX SRVC;AC DTOX RES PROG OP	X	X
H0014	ALCOHL AND/ RX SRVC; AMB DTOXFICATION	X	X
H0015	ALCOHLAND/RX SRVC; INTENSV OP; INTRVN	X	X
H0016	ALCOHL ANDOR RX SRVC; MEDICAL/SOMATIC	X	X
H0017	BHVAL HEALTH; RES W/O ROOMANDBD-DIEM	X	X
H0018	BHVAL HLTH; SHRT-TERM RES PER DIEM	X	X
H0019	BHVAL HLTH; LNG-TERM RES PER DIEM	X	X
H0020	ALCOHLAND/RX SRVC;METHDONE ADMNAND/SRVC	X	X
H0021	ALCOHOL ANDOR DRUG TRAINING SERVICE	X	X
H0022	ALCOHOL ANDOR DRUG INTERVEN SERVICE	X	X
H0023	BEHAVIORAL HEALTH OUTREACH SERVICE	X	X
H0024	BHVAL HLTH PRV INFORM DISSEMIN SRVC	X	X
H0025	BHVAL HEALTH PREV EDUCATION SERVICE	X	X
H0026	ALCOHLAND/RX PREV PRC SRVC CMTY-BASED	X	X
H0027	ALCOHL ANDOR RX PREV ENVIR SERVICE	X	X
H0028	ALCOHLAND/RX PREV PROB IDANDREF SRVC	X	X
H0029	ALCOHL ANDOR RX PREVENTION ALT SRVC	X	X
H0030	BEHAVIORAL HEALTH HOTLINE SERVICE	X	X
H0031	MENTAL HEALTH ASSESS NON-PHYSICIAN	X	X
H0032	MENTL HLTH SRVC PLAN DVLP NON-PHYS	X	X
H0033	ORAL MEDADMIN DIR OBSERVATION	X	X
H0034	MEDICATION TRNANDSUPPORT PER 15 MIN	X	X
H0035	MENTAL HEALTH PART HOSP TX < 24 HR	X	X
H0036	CMTY PSYC SUPP TX FCE-TO-FCE-15 MIN	X	X
H0037	CMTY PSYC SUPPORTIVE TX PROGM-DIEM	X	X
H0038	SELF-HELP/PEER SERVICES PER 15 MIN	X	X
H0039	ASSERTIVE CMTY TX FCE-TO-FCE-15 MIN	X	X
H0040	ASSERTIVE CMTY TX PROGM PER DIEM	X	X
H0041	FOSTER CARE CHLD NON-TX-DIEM	X	X
H0042	FOSTER CARE CHLD NON-TX-MONTH	X	X
H0043	SUPPORTED HOUSING PER DIEM	X	X
H0044	SUPPORTED HOUSING PER MONTH	X	X
H0045	RESPITE CARE SRVC NOT HOME PER DIEM	X	X
H0046	MENTAL HEALTH SERVICES NOS	X	X
H0047	ALCOHOL ANDOR OTH DRUG ABS SRVC NOS	X	X
H0048	ALC AND/OTH RX TST: CLCTANDHNDL NOT BLD	X	X
H0049	ALCOHOL AND/OR DRUG SCREENING	X	X
H0050	ALCOHOL AND/ DRUG SRVC BRF PER 15 MIN	X	X
H1000	PRENATAL CARE AT-RISK ASSESSMENT	X	X
H1001	PRENATAL @RISK ENHNCD SRVC; ANTPRTM	X	X
H1002	PRENATAL @RISK ENHNCD SRVC; COORD	X	X
H1003	PRENATAL @RISK ENHNCD SRVC; ED	X	X
H1004	PRENATAL @RISK ENHNCD SRVC; F/U HOM	X	X
H1005	PRENATAL @RISK ENHNCD SRVC PKG	X	X
H1010	NON-MEDICAL FAM PLANNING ED-SESSION	X	X
H1011	FAM ASSESS LIC BHVAL HLTH STATE DEF	X	X
H2000	COMP MULTIDISCIPLINARY EVALUATION	X	X
H2001	REHABILITATION PROGRAM PER 1/2 DAY	X	X
H2010	COMP MEDICATION SERVICES PER 15 MIN	X	X
H2011	CRISIS INTERVEN SERVICE PER 15 MIN	X	X
H2012	BEHAVIORAL HEALTH DAY TX PER HOUR	X	X
H2013	PSYC HEALTH FACL SERVICE PER DIEM	X	X
H2014	SKILLS TRAININGANDDVLP PER 15 MINUTES	X	X
H2015	COMP CMTY SUPPORT SRVC PER 15 MIN	X	X
H2016	COMP CMTY SUPPORT SRVC PER DIEM	X	X
H2017	PSYCHOSOCIAL REHAB SRVC 15 MUNUTES	X	X
H2018	PSYCHOSOCIAL REHAB SRVC PER DIEM	X	X
H2019	THERAPEUTIC BEHAVIORAL SRVC 15 MIN	X	X
H2020	THERAPEUTIC BEHAVIORAL SRVC DIEM	X	X
H2021	CMTY-BASED WRAP-AROUND SRVC 15 MIN	X	X
H2022	CMTY-BASED WRAP-AROUND SRVC DIEM	X	X
H2023	SUPPORTED EMPLOYMENT PER 15 MINUTES	X	X
H2024	SUPPORTED EMPLOYMENT PER DIEM	X	X
H2025	ONGOING SUPP MNTAIN EMPLOY 15 MIN	X	X
H2026	ONGOING SUPP MNTAIN EMPLOYMENT DIEM	X	X
H2027	PSYCHOEDUCATIONAL SERVICE 15 MIN	X	X
H2028	SEXLOFFENDER TX SERVICE PER 15 MIN	X	X
H2029	SEXUAL OFFENDER TX SERVICE PER DIEM	X	X
H2030	MENTAL HEALTH CLUBHOUSE SRVC 15 MIN	X	X
H2031	MENTAL HEALTH CLUBHOUSE SRVC DIEM	X	X
H2032	ACTIVITY THERAPY PER 15 MINUTES	X	X
H2033	MULTISYS THERAPY JUVS PER 15 MIN	X	X
H2034	ALCAND/RX ABS HALFWAY HOUSE SRVC DIEM	X	X
H2035	ALCOHOL ANDOR OTH DRUG TX PROGM-HOUR	X	X
H2036	ALCOHOL ANDOR OTH DRUG TX PROGM-DIEM	X	X
H2037	DVLPMNTL DLAY PREV ACTV CHLD 15 MIN	X	X
H2038	SKILLS TRAINING AND DEVELOPMENT PER DIEM	X	X
H2038	SKILLS TRAINING AND DEVELOPMENT PER DIEM	X	X
H2040	COORDINATED SC TEAM-BASED FIRST EP PSY PER MONTH	X	X
H2040	COORDINATED SC TEAM-BASED FIRST EP PSY PER MONTH	X	X
H2041	COORDINATED SC TEAM-BASED FIRST EP PSY PER ENC	X	X
H2041	COORDINATED SC TEAM-BASED FIRST EP PSY PER ENC	X	X
J0739	INJECTION CABOTEGRAVIR 1 MG FDA-APPROVED PRSC	X	X
J0739	INJECTION CABOTEGRAVIR 1 MG FDA-APPROVED PRSC	X	X
J0739	INJECTION CABOTEGRAVIR 1 MG FDA-APPROVED PRSC	X	X
J0739	INJECTION CABOTEGRAVIR 1 MG FDA-APPROVED PRSC	X	X
J1576	INJECTION IMMUNE GLOBULIN IV NON-LYOPH 500 MG	X	X
J1576	INJECTION IMMUNE GLOBULIN IV NON-LYOPH 500 MG	X	X
J1812	INSULIN FIASP PER 5 UNITS	X	X
J1812	INSULIN FIASP PER 5 UNITS	X	X
J1826	INJECTION INTERFERON BETA-1A 30 MCG	X	X
J3520	EDETATE DISODIUM PER 150 MG	X	X
J3535	DRUG ADMIN THRU METERED DOSE INHAL	X	X
J3570	LAETRILE AMYGDALIN VITAMIN B17	X	X
J7213	INJECTION COAGULATION FACTOR IX IXINITY 1 IU	X	X
J7213	INJECTION COAGULATION FACTOR IX IXINITY 1 IU	X	X
J7297	LNG-RLS INTRAUTERINE COC SYS 52 MG	X	Need denial From MA plan
J7298	LNG-RLS INTRAUTERINE COC SYS 52 MG	X	Need denial From MA plan
J7300	INTRAUTERINE COPPER CONTRACEPTIVE	X	X
J7301	LNG-RLS INTRAUTERNE COC SYS 13.5 MG	X	X
J7302	LEVONORGESTREL IU 52 MG	X	X
J7302	LEVONORGESTREL IU 52 MG	X	X
J7304	CONTRACEPTIVE SPL HORMONE PATCH EA	X	X
J7306	LEVONORGESTREL CONTRACPTV IMPL SYS	X	X
J7307	ETONOGESTREL IMPL SYS INCL IMPLANDSPL	X	X
J7330	AUTOL CULTURD CHONDROCYTES IMPL	X	X
J7330	AUTOL CULTURD CHONDROCYTES IMPL	X	X
J8499	PRSC RX ORAL NONCHEMOTHAPEUTIC NOS	X	X
J8515	CABERGOLINE ORAL 0.25 MG	X	X
J8565	GEFITINIB ORAL 250 MG	X	X
K0740	REPR/SRVC O2 EQP TECH PER 15 MINS	X	X
K1036	SUPPLIES AND ACCESSORIES LOW FREQ US DIA TX DVC PM	X	X
K1036	SUPPLIES AND ACCESSORIES LOW FREQ US DIA TX DVC PM	X	X
L2861	ADD LOW EXT JNT KNEE/ANK CSTM EA	X	X
L3215	ORTHOPED FTWEAR LADIES OXFORD EA	X	X
L3216	ORTHO FTWEAR LADIES SHOE DPTH INLAY	X	X
L3217	ORTHOPED FTWEAR LADIES HITOP INLAY	X	X
L3219	ORTHOPED FTWEAR MENS SHOE OXFORD EA	X	X
L3221	ORTHOPD FTWEAR MENS SHOE DPTH INLAY	X	X
L3222	ORTHO FTWEAR MENS HITOP DPTH INLAY	X	X
L3891	ADD UP EXT JNT WRIST/ELB CSTM EA	X	X
L7600	PROSETIC DONNING SLEEVE MATERIAL EA	X	X
L7900	MALE VACUUM ERECTION SYSTEM	X	X
L7902	TENSION RING VAC ERECT DEVC REPL EA	X	X
L8680	IMPL NEUROSTIMULATOR ELECTRODE EA	X	X
L8685	IMPL NEUROSTIM 1 ARRAY RECHARGEABLE	X	X
L8686	IMPL NEUROSTIM 1 ARRAY NON-RECHARGE	X	X
L8687	IMPL NEUROSTIM 2 ARRAY RECHARGEABLE	X	X
L8688	IMPL NEUROSTIM 2 ARRAY NON-RECHARGE	X	X
L8692	AUDITORY OSSEOINTEGRAT DEV BDY WORN	X	X
M0075	CELLULAR THERAPY	X	X
M0076	PROLOTHERAPY	X	X
M0100	INTRAGASTR HYPOTHM USE GASTR FREEZ	X	X
M0222	INTRAVENOUS INJ BEBTELOVIMAB INC INJ AND PA MON	X	X
M0222	INTRAVENOUS INJ BEBTELOVIMAB INC INJ AND PA MON	X	X
M0223	IV INJ BEBTELOVIMAB INC INJ AND PA MON HOME/RES	X	X
M0223	IV INJ BEBTELOVIMAB INC INJ AND PA MON HOME/RES	X	X
M0300	IV CHELATION THERAPY	X	X
M0301	FABRIC WRAPPING ABDOMINAL ANEURYSM	X	X
P2031	HAIR ANALYSIS	X	X
P7001	CULT BACTERL URINE; QUAN SENS STUDY	X	X
Q0144	AZITHROMYCIN ORAL CAP/POWDER 1 GM	X	X
Q0222	INJECTION BEBTELOVIMAB 175 MG	X	X
Q0222	INJECTION BEBTELOVIMAB 175 MG	X	X
Q3028	INJ INTERFERON BETA-1A 1 MCG SUBQ	X	X
R0076	TRANS PRTBLE EKG FACL/LOCATION-PT	X	X
S0012	BUTORPHANL TARTRAT NASL SPRAY 25 MG	X	X
S0014	TACRINE HYDROCHLORIDE 10 MG	X	X
S0017	INJECTION AMINOCAPROIC ACID 5 GRAMS	X	X
S0020	INJ BUPIVICAINE HYDROCHLORIDE 30 ML	X	X
S0021	INJ CEFOPERAZONE SODIUM 1 GM	X	X
S0023	INJ CIMETIDINE HYDROCHLORIDE 300 MG	X	X
S0028	INJECTION FAMOTIDINE 20 MG	X	X
S0030	INJECTION METRONIDAZOLE 500 MG	X	X
S0032	INJECTION NAFCILLIN SODIUM 2 GRAMS	X	X
S0034	INJECTION OFLOXACIN 400 MG	X	X
S0039	INJ SULFMETHOXAZLANDTRIMETHOPRM 10 ML	X	X
S0040	INJ TICARCLLN AND CLAVULANAT K+3.1 GM	X	X
S0071	INJ ACYCLOVIR NA 50 MG	X	X
S0072	INJ AMIKACIN SULFATE 100 MG	X	X
S0073	INJECTION AZTREONAM 500 MG	X	X
S0074	INJECTION CEFOTETAN DISODIUM 500 MG	X	X
S0077	INJ CLINDAMYCIN PHOSPHATE 300 MG	X	X
S0078	INJ FOSPHENYTOIN SODIUM 750 MG	X	X
S0080	INJ PENTAMIDINE ISETHIONATE 300 MG	X	X
S0081	INJ PIPERACILLIN SODIUM 500 MG	X	X
S0088	IMATINIB 100 MG	X	X
S0090	SILDENAFIL CITRATE 25 MG	X	X
S0091	GRANISETRON HYDROCHLORIDE 1 MG	X	X
S0092	INJ HYDMORPHONE HYDROCHLORID 250 MG	X	X
S0093	INJECTION MORPHINE SULFATE 500 MG	X	X
S0104	ZIDOVUDINE ORAL 100 MG	X	X
S0106	BUPROPION HCI SR TAB 150 MG 60 TABS	X	X
S0107	INJECTION, OMALIZUMAB, 25 MG	X	X
S0108	MERCAPTOPURINE ORAL 50 MG	X	X
S0109	METHADONE ORAL 5MG	X	X
S0114	INJECTION TREPROSTINIL SODIUM 05 MG	X	X
S0115	BORTEZOMIB, 3.5 MG	X	X
S0116	BEVACIZUMAB 100 MG	X	X
S0117	TRETINOIN TOPICAL 5 GRAMS	X	X
S0119	ONDANSETRON ORAL 4 MG	X	X
S0122	INJECTION MENOTROPINS 75 IU	X	X
S0126	INJECTION FOLLITROPIN ALFA 75 IU	X	X
S0128	INJECTION FOLLITROPIN BETA 75 IU	X	X
S0132	INJECTION GANIRELIX ACETATE 250 MCG	X	X
S0136	CLOZAPINE 25 MG	X	X
S0137	DIDANOSINE 25 MG	X	X
S0138	FINASTERIDE 5 MG	X	X
S0139	MINOXIDIL 10 MG	X	X
S0140	SAQUINAVIR 200 MG	X	X
S0142	COLISTMTHATE SODUIM INHAL CONC-MG	X	X
S0145	INJ PEGYLATD IFN ALFA-2A 180 MCG ML	X	X
S0148	INJ PEGYLATD INTRFER ALFA-2B 10 MCG	X	X
S0155	STERILE DILUTANT EPOPROSTENOL 50 ML	X	X
S0156	EXEMESTANE 25 MG	X	X
S0157	BECAPLERMIN GEL 0.01% 0.5 GM	X	X
S0160	DEXTROAMPHETAMINE SULFATE 5 MG	X	X
S0162	INJECTION EFALIZUMAB 125 MG	X	X
S0164	INJECTION PANTOPRAZOLE SODIUM 40 MG	X	X
S0166	INJECTION OLANZAPINE 2.5 MG	X	X
S0169	CALCITROL 0.25 MICROGRAM	X	X
S0170	ANASTROZOLE ORAL 1 MG	X	X
S0171	INJECTION BUMETANIDE 0.5 MG	X	X
S0172	CHLORAMBUCIL ORAL 2 MG	X	X
S0174	DOLASETRON MESYLATE ORAL 50 MG	X	X
S0175	FLUTAMIDE ORAL 125 MG	X	X
S0176	HYDROXYUREA ORAL 500 MG	X	X
S0177	LEVAMISOLE HYDROCHLORIDE ORAL 50 MG	X	X
S0178	LOMUSTINE ORAL 10 MG	X	X
S0179	MEGESTROL ACETATE ORAL 20 MG	X	X
S0181	ONDANSETRON HYDROCHLORIDE	X	X
S0181	ONDANSETRON HYDROCHLORIDE	X	X
S0181	ONDANSETRON HYDROCHLORIDE	X	X
S0182	PROCARBAZINE HYDROCHLORD ORAL 50 MG	X	X
S0183	PROCHLORPERAZINE MALEATE ORAL 5 MG	X	X
S0187	TAMOXIFEN CITRATE ORAL 10 MG	X	X
S0189	TESTOSTERONE PELLET 75 MG	X	X
S0190	MIFEPRISTONE ORAL 200 MG	X	X
S0191	MISOPROSTOL ORAL 200 MCG	X	X
S0194	DIALYS/STRESS VIT SUPL ORAL 100 CAP	X	X
S0195	PNEUMCOCCL VAC IM 5-9 YR NOT PREV	X	X
S0195	PNEUMCOCCL VAC IM 5-9 YR NOT PREV	X	X
S0197	PRENATAL VITAMINS 30-DAY SUPPLY	X	X
S0198	INJECTION PEGAPTANIB SODIUM 0.3 MG	X	X
S0199	MED INDUCED AB ORAL INGEST MED	X	X
S0201	PART HOSITALIZATN SRVC<24 HR-DIEM	X	X
S0207	PARAMED INTERCEPT NON-HOS-BASED ALS	X	X
S0208	PARAMED INTRCPT ALS NON-TRNSPRT	X	X
S0209	WHEELCHAIR VAN MILEAGE PER MILE	X	X
S0215	NON-EMERG TRANSPORTATION; PER MILE	X	X
S0220	MED CONF MD W/TEAM HLTH PROF;30 MIN	X	X
S0221	MED CONF MD W/TEAM HLTH PROF;60 MIN	X	X
S0250	COMP GERIATRIC ASSESSANDTX PLANNING	X	X
S0255	HOSPICE REF BY NRS SOCL WRKER/OTH DESNATD STAFF	X	X
S0257	CNSLANDDISCUSS AD/EOL PTAND/SURROGATE	X	X
S0260	HX AND PHYS RELATED TO SURGICAL PROC	X	X
S0265	GENETIC CNSL PHYS SUP EA 15 MINS	X	X
S0270	PHYS MGT PT HOME CARE STD MON RATE	X	X
S0271	PHYS MGT PT HM CARE HOSPICE MO RATE	X	X
S0272	PHYS MGT PT HM CARE EPISODC MO RATE	X	X
S0273	PHYS VST MEMBER HOME OUT CAPITATION	X	X
S0274	NP VST MEMBR HOM OUTSIDE CAPITATION	X	X
S0280	MED HOME PROG COMP CARE COORD INIT	X	X
S0281	MED HOME PROGRAM CARE COORD MAINT	X	X
S0285	CNSLT BEFORE SCREEN COLONOSCOP	X	X
S0302	CMPL EARLY PRD SCREEN DXANDTX SRVC	X	X
S0310	HOSPITALIST SERVICES	X	X
S0311	COMP MGMT CARE COORD ADV ILL	X	X
S0315	DZ MGMT PROGM; INIT ASSESSANDINIT PRO	X	X
S0316	DZ MGMT PROGM FOLLOW-UP/REASSESS	X	X
S0317	DISEASE MANAGEMENT PROGM; PER DIEM	X	X
S0320	TEL CALLS RN DZ MGMT MEMB MONITR;MO	X	X
S0340	LIFESTYL MOD MGMT COR ART DZ; 1 QTR	X	X
S0341	LIFESTYL MOD MGMT CAD; 2ND/3RD QTR	X	X
S0342	LIFESTYL MOD MGMT COR ART DZ; 4 QTR	X	X
S0353	TX PLAN CARE COORD MGMT CA INIT TX	X	X
S0354	TX PLAN CARE MGMT CA EST PT CHG REG	X	X
S0390	ROUTINE FOOT CARE; PER VISIT	X	X
S0395	IMPRESSION CAST FOOT-PRACTITIONER	X	X
S0400	GLOBL FEE XTRACORP SHOCK WAVE LITH	X	X
S0500	DISPOSABLE CONTACT LENS PER LENS	X	X
S0504	SINGLE VISION PRSC LENS PER LENS	X	X
S0506	BIFOCAL VISION PRSC LENS PER LENS	X	X
S0508	TRIFOCAL VISION PRSC LENS PER LENS	X	X
S0510	NON-PRESCRIPTION LENS PER LENS	X	X
S0512	DAILY WEAR SPCLTY CNTC LENS-LENS	X	X
S0514	COLOR CONTACT LENS PER LENS	X	X
S0515	SCLERAL LENS LQD BANDGE DEVICE-LENS	X	X
S0516	SAFETY EYEGLASS FRAMES	X	X
S0518	SUNGLASSES FRAMES	X	X
S0580	POLYCARBONATE LENS	X	X
S0581	NONSTANDARD LENS	X	X
S0590	INTEGRL LENS SRVC MISC REPORTED SEP	X	X
S0592	COMP CONTACT LENS EVALUATION	X	X
S0595	DISPNS NEW SPCTCL LENS PT SPL FRME	X	X
S0596	PHAKIC IOL CORRECT REFRACTIVE ERROR	X	X
S0601	SCREENING PROCTOSCOPY	X	X
S0610	ANNUAL GYN EXAMINATION NEW PATIENT	X	X
S0612	ANNUAL GYN EXAMINATION EST PATIENT	X	X
S0613	ANNUAL GYN EX CLIN BRST EX NO PELV	X	X
S0618	AUDIOMETRY FOR HEARING AID EVAL	X	X
S0620	ROUTINE OPHTH EX W/REFRAC; NEW PT	X	X
S0621	ROUTINE OPHTH EX W/REFRAC; EST PT	X	X
S0622	PHYSICAL EXAM COLLEGE NEW/EST PT	X	X
S0625	SCREEN FOR VISION-THREATENING CONDITIONS INCL IMAGING INTERPRET & REPORT	X	X
S0625	SCREEN FOR VISION-THREATENING CONDITIONS INCL IMAGING INTERPRET & REPORT	X	X
S0625	SCREEN FOR VISION-THREATENING CONDITIONS INCL IMAGING INTERPRET & REPORT	X	X
S0630	REMV SUTURS; MD NOT MD WHO CLOS WND	X	X
S0800	LASER IN SITU KERATOMILEUSIS	X	X
S0810	PHOTOREFRACTIVE KERATECTOMY	X	X
S0812	PHOTOTHERAPEUTIC KERATECTOMY	X	X
S1001	DELUXE ITEM PATIENT AWARE	X	X
S1002	CUSTOMIZED ITEM	X	X
S1015	IV TUBING EXTENSION SET	X	X
S1016	NON-PVC IV ADMN SET RX NOT STABLE	X	X
S1030	CONT NONINVAS GLU MON DEVC PURCHASE	X	X
S1031	CONT NONINVAS GLU MON DEVC RENTAL	X	X
S1034	ARTIF PANC DEVC SYS CMNCT ALL DEVC	X	X
S1035	SNSR;INVASV DSPBL ART PANC DEVC SYS	X	X
S1036	TRANSMTTR;EXT USE ART PANC DEVC SYS	X	X
S1037	RECVER; EXT USE ARTIF PANC DEVC SYS	X	X
S1040	CRANIAL REMOLD ORTHOT PED CUST FAB	X	X
S2053	TPLNT SM INTESTINEANDLIVER ALLOGFTS	X	X
S2054	TRANSPLANTATION MULTIVISCERAL ORGN	X	X
S2055	HARV DONR MX-VSCRL ORGN; CADVR DONR	X	X
S2060	LOBAR LUNG TRANSPLANTATION	X	X
S2061	DONOR LOBECT TPLNT LIVING DONOR	X	X
S2065	SIMULTANEOUS PANC KIDNEY TPLNT	X	X
S2066	BREAST RECON W/GAP FLAP UNILATERAL	X	X
S2067	BRST RECN 1 BRST DIEPAND/GAP FLP(S)	X	X
S2068	BREAST RECON DIEP/SIEA FLAP UNI	X	X
S2070	CYSTO; LASER TX URETERAL CALC	X	X
S2079	LAP ESOPHAGOMYOTOMY HELLER TYPE	X	X
S2080	LASER-ASSISTED UVULOPALATOPLASTY	X	X
S2082	LAP SURG; ADJ GASTRIC BAND INCL PLCMT SUBQ PORT	X	X
S2083	ADJ GASTRIC BAND DIAM SUBQ PORT	X	X
S2095	TRNSCATH OCCL/EMBOLIZ TUMR DESTRUC	X	X
S2102	ISLET CELL TISS TPLNT PANC; ALLOGEN	X	X
S2103	ADRENAL TISSUE TRANSPLANT TO BRAIN	X	X
S2107	ADOPTIVE IMMUNOTX COURSE TREATMENT	X	X
S2112	ARTHROSCOPY KNEE SURG HARVEST CART	X	X
S2115	OSTEOT PERIACETABULAR W/INTRL FIX	X	X
S2117	ARTHROEREISIS SUBTALAR	X	X
S2118	MTL-ON-MTL TOT HIP RSRFC ACETABANDFEM	X	X
S2120	LDL APHERES HEPARN XTRCRP LDL PRECP	X	X
S2140	CORD BLD HARVEST TPLNT ALLOGENEIC	X	X
S2142	CORD BLOOD STEM-CELL TPLNT ALLOGEN	X	X
S2150	BN MARRW/STEM CELL HARV TPLNTANDCOMP;	X	X
S2152	SOLID ORGAN; TPLNT AND RELATED COMP	X	X
S2202	ECHOSCLEROTHERAPY	X	X
S2205	MIN INVAS DIR CAB; ART GFT 1 CAG	X	X
S2206	MIN INVAS DIR CAB; ART GFT 2 CAG	X	X
S2207	MIN INVAS DIR CAB; VEN ONLY 1 CVG	X	X
S2208	MIN INVAS DIR CAB; 1 ARTANDVG 1 VG	X	X
S2209	MIN INVAS DIR CAB; 2 ART GFTAND1 VG	X	X
S2225	MYRINGOTOMY LASER-ASSISTED	X	X
S2230	IMPL MAGNT CMPNT SEMI-IMPL HEAR DVC	X	X
S2235	IMPL AUDITRY BRAIN STEM IMPLANT	X	X
S2260	INDUCD AB 17-24 WEEKS ANY SURG METH	X	X
S2262	AB MATERNAL INDICATION 25 WEEKS/GT	X	X
S2265	INDUCED ABORTION 25 TO 28 WEEKS	X	X
S2266	INDUCED ABORTION 29 TO 31 WEEKS	X	X
S2267	INDUCED ABORTION 32 WEEKS/GREATER	X	X
S2300	SCOPE SHLDR;W/THERML-INDUCD CPSLORR	X	X
S2325	HIP CORE DECOMPRESSION	X	X
S2340	CHEMODNERVAT ABDUCTR MUSC VOCL CORD	X	X
S2341	CHEMODENERVAT ADDUCT MUSC VOCAL CRD	X	X
S2342	NASL ENDO POSTOP DEBRID UNI/BIL	X	X
S2348	DECOMP PERQ DISC RF 1/MX LUMB	X	X
S2350	DISKECT ANT-OSTEOPHYT;LUMB 1 INTRSP	X	X
S2351	DSKCT ANT-OSTEOPHYT;LUMB ADD INTRSP	X	X
S2360	PERCUTANEOUS VERTEBROPLASTY	X	X
S2361	EACH ADDITIONAL CERVICAL VERTEBRAL BODY	X	X
S2400	REPAIR CONGEN HERNIA FETUS-UTERO	X	X
S2401	REPAIR URIN TRACT OBST FETUS-UTERO	X	X
S2402	REPAIR CONGEN CYST MALF FETUS-UTERO	X	X
S2403	REPAIR EPS IN THE FETUS IN UTERO	X	X
S2404	REPR MYELOMENINGO FETUS PROC-UTERO	X	X
S2405	REPR SACROCOC TRATOMA FETUS IN UTRO	X	X
S2409	REP CONGN MALFORM FETUS-UTERO NOC	X	X
S2411	FETOSCOPIC LASER THERAPY TX OF TTTS	X	X
S2900	SURG TECH RQR USE ROBOTIC SURG SYS	X	X
S3000	DIAB IND; RET EYE EX DILAT BIL	X	X
S3005	PRFRM MSR EVAL PT SELF ASSESS DPRSS	X	X
S3600	STAT LABORATORY REQUEST	X	X
S3601	EMERG STAT LAB CHRG PT HB/NRS FACL	X	X
S3620	NEWBORN METABOLIC SCREENING PANEL	X	X
S3625	MATERNAL SERUM TRIPLE MARKER SCREEN INCLUDING ALPHA-FETOPROTEIN	X	X
S3625	MATERNAL SERUM TRIPLE MARKER SCREEN INCLUDING ALPHA-FETOPROTEIN	X	X
S3625	MATERNAL SERUM TRIPLE MARKER SCREEN INCLUDING ALPHA-FETOPROTEIN	X	X
S3626	ESTRIOL HUMAN CHORIONIC GONADOTROPIN HCG AND INHIBIN A	X	X
S3626	ESTRIOL HUMAN CHORIONIC GONADOTROPIN HCG AND INHIBIN A	X	X
S3626	ESTRIOL HUMAN CHORIONIC GONADOTROPIN HCG AND INHIBIN A	X	X
S3630	EOSINOPHIL COUNT BLOOD DIRECT	X	X
S3645	HIV-1 ANTIBOD TEST MUCOS TRANSUDATE	X	X
S3650	SALIVA TEST HORMONE LEVEL;MENOPAUSE	X	X
S3652	SLIVA TST HORMONE LEVL;PRTERM LABOR	X	X
S3655	ANTISPERM ANTIBODIES TEST	X	X
S3708	GASTROINTESTINAL FAT ABSORB STUDY	X	X
S3711	CIRCULATING TUMOR CELL TEST	X	X
S3713	KRAS MUTATION ANALYSIS	X	X
S3713	KRAS MUTATION ANALYSIS	X	X
S3713	KRAS MUTATION ANALYSIS	X	X
S3713	KRAS MUTATION ANALYSIS	X	X
S3721	PCA3 TESTING	X	X
S3722	DOSE OPTIMIZATION AUC ANAL INF 5-FU	X	X
S3800	GENETIC TESTING ALS	X	X
S3818	COMPLETE GENE SEQUENCE ANALYSIS	X	X
S3819	COMPLETE GENE SEQUENCE ANALYSIS	X	X
S3820	COMPLETED BRCA1 AND BRCA2 GENE SEQUENCE ANALYSIS FOR SUSCEP	X	X
S3822	SINGLE MUTATION ANALYSIS FOR SUSCE TO BREAST AND OVARION CANCER	X	X
S3823	3-MUTATION ANALYSIS FOR SUSCEP/BREAST &OVARION CANCER IN ASHKENAZI INDI	X	X
S3828	COMPLETE GENE SEQUENCE ANALYSIS, MLH1 GENE	X	X
S3829	COMPLETE GENE SEQUENCE ANALYSIS, MLH2 GENE	X	X
S3830	COMPLETE MLH1 AND MLH2 GENE SEQUENCE ANALYSIS	X	X
S3831	SINGLE MUTATION ANALYSIS	X	X
S3833	COMPLETE APC GENE SEQUENCE ANAL/SUSCEPTIBILITY TO (FAP)	X	X
S3833	COMPLETE APC GENE SEQUENCE ANAL/SUSCEPTIBILITY TO (FAP)	X	X
S3834	SINGLE-MUTATION ANALYSIS /SUSCEPTIBILITY TO (FAP)&ATTENUATED FAP	X	X
S3834	SINGLE-MUTATION ANALYSIS /SUSCEPTIBILITY TO (FAP)&ATTENUATED FAP	X	X
S3835	COMPLETE GENE SEQUENCE ANALYSIS FOR CYSTIC FIBROSIS GENETIC TESTING	X	X
S3837	COMPLETE GENE SEQUENCE ANALYSIS FOR HEMOCHROMATOSIS GENETIC TESTING	X	X
S3840	DNA ANALYSIS RET PROTO-ONCOGENE	X	X
S3841	GENETIC TESTING FOR RETINOBLASTOMA	X	X
S3842	GENETIC TST VON HIPPEL-LINDAU DZ	X	X
S3843	DNA ANALYSIS OF THE F5 GENE FOR SUSCEP TO FACTOR V LEIDEN THROMBOPHILIA	X	X
S3844	DNA ANALY GJB2 CONGN PFND DEAFNESS	X	X
S3845	GENETIC TESTING ALPHA-THALASSEMIA	X	X
S3846	GENETIC TST HGB E BETA-THALASSEMIA	X	X
S3847	GENETIC TESTING FOR TAY-SACHS DISEASE	X	X
S3848	GENETIC TESTING FOR GAUCHER DISEASE	X	X
S3849	GENETIC TESTING NIEMANN-PICK DZ	X	X
S3850	GENETIC TESTING SICKLE CELL ANEMIA	X	X
S3851	GENETIC TESTING FOR CANAVAN DISEASE	X	X
S3852	DNA ANALY APOE EPSILON 4 ALLELE ALZ	X	X
S3853	GENETIC TST MYOTONIC MUSC DYSTROPHY	X	X
S3854	GENE PROFILE PANEL BREAST	X	X
S3855	GENETIC TESTING FOR DETECTION OF MUTATIONS IN THE PRESENILIN - 1 GENE	X	X
S3855	GENETIC TESTING FOR DETECTION OF MUTATIONS IN THE PRESENILIN - 1 GENE	X	X
S3855	GENETIC TESTING FOR DETECTION OF MUTATIONS IN THE PRESENILIN - 1 GENE	X	X
S3855	GENETIC TESTING FOR DETECTION OF MUTATIONS IN THE PRESENILIN - 1 GENE	X	X
S3855	GENETIC TESTING FOR DETECTION OF MUTATIONS IN THE PRESENILIN - 1 GENE	X	X
S3855	GENETIC TESTING FOR DETECTION OF MUTATIONS IN THE PRESENILIN - 1 GENE	X	X
S3860	GENET TEST CARDIAC ION-COMP	X	X
S3861	GENETIC TEST SCN5AANDVARIANTS SPCT BS	X	X
S3862	GENET TEST CARDIAC ION-SPEC	X	X
S3865	COMP GENE SEQUENCE ANALYSIS HCM	X	X
S3866	GENETIC ANALYSIS GENE MUTAT HCM	X	X
S3870	CGD MICROARRAY TEST DD ASD AND/OR ID	X	X
S3890	DNA ANALYSIS FECAL COLORECTAL CANCER SCREENING	X	X
S3890	DNA ANALYSIS FECAL COLORECTAL CANCER SCREENING	X	X
S3890	DNA ANALYSIS FECAL COLORECTAL CANCER SCREENING	X	X
S3900	SURFACE ELECTROMYOGRAPHY	X	X
S3902	BALLISTOCARDIOGRAM	X	X
S3904	MASTERS TWO STEP	X	X
S4005	INTERIM LABOR FACILITY GLOBAL	X	X
S4011	IN VITRO FERTILIZATION;	X	X
S4013	COMPLETE CYCLE GIFT CASE RATE	X	X
S4014	COMPLETE CYCLE ZIFT CASE RATE	X	X
S4015	COMPLETE IVF CYCLE CASE RATE NOS	X	X
S4016	FROZEN IVF CYCLE CASE RATE	X	X
S4017	INCPL CYCL TX CANCELD PRIOR TO STIM	X	X
S4018	FRZN EMB TRANS CANCL CASE RATE	X	X
S4020	IVF PROC CANCL BEFR ASPIR CASE RATE	X	X
S4021	IVF PROC CANCL AFTR ASPIR CASE RATE	X	X
S4022	ASSIST OOCYTE FERTILIZ CASE RATE	X	X
S4023	DONOR EGG CYCLE INCPL CASE RATE	X	X
S4025	DONOR SRVC IN VITRO FERTILIZATION	X	X
S4026	PROCUREMENT DONR SPERM SPERM BANK	X	X
S4027	STORAGE PREVIOUSLY FROZEN EMBRYOS	X	X
S4028	MICSURG EPIDIDYMAL SPERM ASPIR	X	X
S4030	SPERM PROCUREMENTANDCRYOPRES; 1 VISIT	X	X
S4031	SPERM PROCUREANDCRYOPRES; SUBSQT VST	X	X
S4035	STIM INTRAUTERINE INSEMIN CASE RATE	X	X
S4037	CRYOPRESERVD EMBRYO TRNSF CASE RATE	X	X
S4040	MON AND STOR CRYOPRESRV EMBRYOS 30 DA	X	X
S4042	MGMT OVULATION INDUCTION PER CYCLE	X	X
S4981	INSRT LEVONORGESTREL INTRAUTRN SYS	X	X
S4989	CONTRACEPT IUD INCL IMPLANDSUPPLIES	X	X
S4990	NICOTINE PATCHES LEGEND	X	X
S4991	NICOTINE PATCHES NON-LEGEND	X	X
S4993	CONTRACEPTIVE PILLS BIRTH CONTROL	X	X
S4995	SMOKING CESSATION GUM	X	X
S5000	PRESCRIPTION DRUG GENERIC	X	X
S5001	PRESCRIPTION DRUG BRAND NAME	X	X
S5010	5% DXTROS AND 0.45% NL SALINE 1000 ML	X	X
S5011	5% DEXTROSE-LACTATD RINGERS 1000ML	X	X
S5012	5% DXTROS W/K+ CHLORID 1000 ML	X	X
S5013	5% DXTROS/0.45% S KCLANDMGSO4 1000 ML	X	X
S5014	5% DXTRS/0.45% NS KCIANDMGSO4 1500 ML	X	X
S5035	HOME INFUS TX ROUTINE INFUS DEVC	X	X
S5036	HOME INFUS TX REPAIR INFUS DEVICE	X	X
S5100	DAY CARE SERVICES ADULT; PER 15 MIN	X	X
S5101	DAY CARE SRVC ADULT; PER HALF DAY	X	X
S5102	DAY CARE SERVICES ADULT; PER DIEM	X	X
S5105	DAY CARE CNTR-BASD; SRVC NOT W/FEE	X	X
S5108	HOM CARE TRN HOM CARE CLIENT 15 MIN	X	X
S5109	HOME CARE TRN HOME CARE CLIENT SESS	X	X
S5110	HOME CARE TRAINING FAM; PER 15 MIN	X	X
S5111	HOME CARE TRAINING FAM; PER SESSION	X	X
S5115	HOME CARE TRN NON-FAM; PER 15 MIN	X	X
S5116	HOME CARE TRN NON-FAM; PER SESSION	X	X
S5120	CHORE SERVICES; PER 15 MINUTES	X	X
S5121	CHORE SERVICES; PER DIEM	X	X
S5125	ATTENDANT CARE SERVICES; PER 15 MIN	X	X
S5126	ATTENDANT CARE SERVICES; PER DIEM	X	X
S5130	HOMEMAKER SERVICE NOS; PER 15 MIN	X	X
S5131	HOMEMAKER SERVICE NOS; PER DIEM	X	X
S5135	COMPANION CARE ADULT; PER 15 MIN	X	X
S5136	COMPANION CARE ADULT ; PER DIEM	X	X
S5140	FOSTER CARE ADULT; PER DIEM	X	X
S5141	FOSTER CARE ADULT; PER MONTH	X	X
S5145	FOSTER CARE THERAPEUTIC CHILD; DIEM	X	X
S5146	FOSTER CARE THERAPEUTIC CHLD; MONTH	X	X
S5150	UNSKLD RESPITE CARE NOT HOSPICE; 15	X	X
S5151	UNSKLD RESPITE CARE NOT HOSPICE;PER	X	X
S5160	EMERG RESPONSE SYSTEM; INSTLANDTST	X	X
S5161	EMERG RESPONSE SYS; SRVC FEE-MONTH	X	X
S5165	HOME MODIFICATIONS; PER SERVICE	X	X
S5170	HOME DEL MEALS INCL PREP; MEAL	X	X
S5175	LAUNDRY SERVICE EXT PROF; ORDER	X	X
S5180	HOME HEALTH RESP TX INIT EVALUATION	X	X
S5181	HOME HEALTH RESP TX NOS PER DIEM	X	X
S5185	MED REMINDR SRVC NON-FCE-TO-FCE; MO	X	X
S5190	WELLNESS ASSESS PRFRM NON-PHYSICIAN	X	X
S5199	PERSONAL CARE ITEM NOS EACH	X	X
S5497	HOME INFUS TX CATH CARE NOC; DIEM	X	X
S5498	HOME INFUS TX CATH CARE SIMPLE DIEM	X	X
S5501	HOME INFUS TX CATH CARE COMPLX DIEM	X	X
S5502	HIT CATH CARE IMPL ACSS DEVC PD	X	X
S5517	HIT SPL RESTOR CATH PATENCY/DECLOT	X	X
S5518	HIT ALL SPL NECES FOR CATH REPAIR	X	X
S5520	HIT ALL SPL NECES PICC LINE INSERT	X	X
S5521	HIT SPL NECES MIDLINE CATH INSERT	X	X
S5522	HIT INSRT PICC NURSE SRVC ONLY	X	X
S5523	HIT INSRT ML VEN CATH NRS SRVC ONLY	X	X
S5550	INSULIN RAPID ONSET; 5 UNITS	X	X
S5551	INSULIN MOST RAPID ONSET; 5 UNITS	X	X
S5552	INSULIN INTERMED ACTING; 5 UNITS	X	X
S5553	INSULIN LONG ACTING; 5 UNITS	X	X
S5560	INSULIN DEVC REUSABLE PEN;1.5 ML SZ	X	X
S5561	INSULIN DEVC REUSABLE PEN; 3 ML SZ	X	X
S5565	INSULIN CARTRIDGE NOT PUMP; 150 U	X	X
S5566	INSULIN CARTRIDGE NOT PUMP; 300 U	X	X
S5570	INSULIN DISPOSABLE PEN; 1.5 ML SZ	X	X
S5571	INSULIN DISPOSABLE PEN; 3 ML SZ	X	X
S8030	SCLERAL APPLICATION TANTALUM RING	X	X
S8035	MAGNETIC SOURCE IMAGING	X	X
S8037	MR CHOLANGIOPANCREATOGRAPHY	X	X
S8040	TOPOGRAPHIC BRAIN MAPPING	X	X
S8042	MAGNETIC RESONANCE IMAG LOW-FIELD	X	X
S8049	INTRAOPERATIVE RAD THERAP (1 ADMIN)	X	X
S8055	US GUID MXIFETL PG RDUC TECH CMPNT	X	X
S8080	SCINTIMAMMO UNI W/SPL RADIOPHARM	X	X
S8085	F-18 FDG IMAG 2-HD COINCDENC DETCT	X	X
S8092	ELECTRON BEAM COMPUTED TOMOGRAPHY	X	X
S8096	PORTABLE PEAK FLOW METER	X	X
S8097	ASTHMA KIT	X	X
S8100	HOLD CHAMB W/INHAL/NEBULIZR;NO MASK	X	X
S8101	HOLD CHAMB W/INHAL/NEBULIZR; W/MASK	X	X
S8110	PEAK EXPIRATORY FLOW RATE	X	X
S8120	O2 CNTN GASEOUS 1 U = 1 CUBIC FOOT	X	X
S8121	O2 CONTENTS LQD 1 U EQUALS 1 POUND	X	X
S8130	INTERFERENTIAL CURR STIM 2 CHANNEL	X	X
S8131	INTERFERENTIAL CURR STIM 4 CHANNEL	X	X
S8185	FLUTTER DEVICE	X	X
S8186	SWIVEL ADAPTOR	X	X
S8189	TRACHEOSTOMY SUPPLY NOC	X	X
S8190	ELECTRONIC SPIROMETER (OR MICROSPIROMETER)	X	X
S8210	MUCUS TRAP	X	X
S8262	MANDIB ORTHO REPOSITION DEVICE EACH	X	X
S8265	HABERMAN FEEDER CLEFT LIP/PALATE	X	X
S8270	ENURESIS ALARM BUZZAND/VIBRATION DEVC	X	X
S8301	INFECTION CONTROL SUPPLIES NOS	X	X
S8400	INCONT PANTS EACH	X	X
S8415	SUPPLIES HOME DELIVERY OF INFANT	X	X
S8420	GRADENT PRESS AID SLEEVEANDGLOVE CSTM	X	X
S8421	GRADENT PRESS AID SLVANDGLOV RDY MADE	X	X
S8422	GRADENT PRESS AID SLEEV CSTM MED WT	X	X
S8423	GRADENT PRESS AID SLEEV CSTM HVY WT	X	X
S8424	GRADENT PRESS AID SLEEVE READY MADE	X	X
S8425	GRADENT PRESS AID GLOVE CSTM MED WT	X	X
S8426	GRADENT PRESS AID GLOVE CSTM HVY WT	X	X
S8427	GRADENT PRESS AID GLOVE READY MADE	X	X
S8428	GRADENT PRESS AID GAUNTLET RDY MADE	X	X
S8429	GRADIENT PRESSURE EXTERIOR WRAP	X	X
S8430	PADDING COMPRESSION BANDAGE ROLL	X	X
S8431	COMPRESSION BANDAGE ROLL	X	X
S8450	SPLINT PREFABRICATED DIGIT	X	X
S8451	SPLINT PREFABRICATED WRIST OR ANKLE	X	X
S8452	SPLINT PREFABRICATED ELBOW	X	X
S8460	CAMISOLE POST-MASTECTOMY	X	X
S8490	INSULIN SYRINGES	X	X
S8930	E-STIM AUR ACP PNT;EA 15 MIN 1-1 PT	X	X
S8940	EQUESTRIAN/HIPPOTHERAPY PER SESSION	X	X
S8948	APPLIC MODAL 1/MORE AREAS; LW-LEVL	X	X
S8950	COMPLEX LYMPHEDEMA TX EA 15 MIN	X	X
S8990	PHYS/MANIP TX MAINT NOT RESTORATION	X	X
S8999	RESUSCITATION BAG	X	X
S9001	HOME UTERIN MON W/WO ASSOC NRS SRVC	X	X
S9007	ULTRAFILTRATION MONITOR	X	X
S9015	AUTO EEG MONITORING	X	X
S9024	PARANASAL SINUS ULTRASOUND	X	X
S9025	OMNICARDIOGRAM/CARDIOINTEGRAM	X	X
S9034	ESWL FOR GALL STONES	X	X
S9055	PROCUREN/OTH GROWTH FACTOR PREP	X	X
S9056	COMA STIMULATION PER DIEM	X	X
S9061	HOME ADMIN AEROSOLIZED DRUG TX DIEM	X	X
S9083	GLOBAL FEE URGENT CARE CENTERS	X	X
S9088	SERVICES PROV AN URGENT CARE CENTER	X	X
S9090	VERT AXIAL DECOMPRS PER SESSION	X	X
S9097	HOME VISIT FOR WOUND CARE	X	X
S9098	HOME VISIT PHOTOTHERAPY SRVC DIEM	X	X
S9109	CONGESTIVE HEART FAILURE TELEMONTORING	X	X
S9110	TELEMON PT HOME ALL EQUIP; PER MTH	X	X
S9117	BACK SCHOOL PER VISIT	X	X
S9122	HOM HLTH AIDE/CNA PROV CARE HOM; HR	X	X
S9123	NRS CARE HOM; REGISTERED NURSE-HOUR	X	X
S9124	NURSING CARE THE HOME; LPN PER HOUR	X	X
S9125	RESPITE CARE IN THE HOME PER DIEM	X	X
S9126	HOSPICE CARE IN THE HOME PER DIEM	X	X
S9127	SOCIAL WORK VISIT THE HOME PER DIEM	X	X
S9128	SPEECH THERAPY IN THE HOME PER DIEM	X	X
S9129	OCCUPATIONAL THERAPY HOME PER DIEM	X	X
S9131	PHYSICAL THERAPY; HOME PER DIEM	X	X
S9140	DM MGMT PROGM F/U VST NON-MD PROV	X	X
S9141	DIAB MGMT PROGM F/U VISIT MD PROV	X	X
S9145	INSULIN PUMP INIT INSTRUCT USE PUMP	X	X
S9150	EVALUATION BY OCCULARIST	X	X
S9152	SPEECH THERAPY RE-EVALUATION	X	X
S9208	HOME MGMT PRETERM LABOR PER DIEM	X	X
S9209	HOME MANGEMENT PPROM DIEM	X	X
S9211	HOME MGMT GESTATIONAL HTN; DIEM	X	X
S9212	HOME MANAGEMENT POSTPARTUM HTN DIEM	X	X
S9213	HOME MANAGEMENT PREECLAMPSIA; DIEM	X	X
S9214	HOME MGMT GESTATIONAL DIABETES;DIEM	X	X
S9325	HIT PAIN MANAGEMENT INFUS; PER DIEM	X	X
S9326	HIT CONT PAIN MGMT INFUS; PER DIEM	X	X
S9327	HIT INTERMIT PAIN MGMT INFUS; DIEM	X	X
S9328	HIT IMPLANTED PUMP PAIN MGMT; DIEM	X	X
S9329	HIT CHEMOTHERAPY INFUSION; PER DIEM	X	X
S9330	HIT CONT CHEMOTHAPY INFUS; PER DIEM	X	X
S9331	HIT INTERMIT CHEMOTHAPY INFUS; DIEM	X	X
S9335	HOM TX HD; ADMIN SPL AND EQP PER DIEM	X	X
S9336	HIT CONT ANTICOAGULNT INFUS TX DIEM	X	X
S9338	HOME INFUS TX IMMUOTHAPY; PER DIEM	X	X
S9339	HOME TX; PERITONL DIALYSIS PER DIEM	X	X
S9340	HOME TX; ENTERAL NUTRITION; DIEM	X	X
S9341	HT; ENTERL NUTRIT VIA GRAVITY; DIEM	X	X
S9342	HT; ENTERAL NUTRIT VIA PUMP; DIEM	X	X
S9343	HT; ENTERAL NUTRIT VIA BOLUS; DIEM	X	X
S9345	HIT ANTI-HEMOPHILIC AGENT; PER DIEM	X	X
S9346	HIT ALPHA-1-PROTENAS INHIBITR; DIEM	X	X
S9347	HIT UNINTRPED LNG-TERM IV/SUBQ;DIEM	X	X
S9348	HIT SYMPATHOMIMETIC/INOTROPIC DIEM	X	X
S9349	HOME INFUS TX TOCOLYTIC; PER DIEM	X	X
S9351	HIT CONT ANTI-EMETIC; PER DIEM	X	X
S9353	HOME INFUS TX CONT INSULIN; DIEM	X	X
S9355	HOME INFUS TX CHELATION; PER DIEM	X	X
S9357	HIT ENZYME REPL IV TX; PER DIEM	X	X
S9359	HIT ANTI-TUMR NECROS FACTOR IV TX;	X	X
S9361	HIT DIURETIC IV TX; PER DIEM	X	X
S9363	HIT ANTI-SPASMOTIC TX; PER DIEM	X	X
S9364	HIT TPN; CARE COORDINATION DIEM	X	X
S9365	HIT TPN; 1 LITER PER DAY PER DIEM	X	X
S9366	HIT TPN; >1 L BUT NOT > 2 L-DA-DIEM	X	X
S9367	HIT TPN; >2 L BUT NOT >3 L-DAY-DIEM	X	X
S9368	HOM INFUS TX TPN; > 3 L-DAY-DIEM	X	X
S9370	HT INTERMITTENT ANTI-EMETIC INJ TX;	X	X
S9372	HT; INTERMIT ANTICOAGULANT INJ TX;	X	X
S9373	HIT HYDRATION TX; PER DIEM	X	X
S9374	HIT HYDRATION TX; 1 LITER DAY	X	X
S9375	HIT HYDRAT; >1 LITR NO>2 LITR DAY	X	X
S9376	HIT HYDRAT; >2 LITR NO>3 LITR DAY	X	X
S9377	HIT HYDRATION TX; >3 LITERS DAY	X	X
S9379	HOME INFUS TX INFUSION TX NOC; DIEM	X	X
S9381	DEL/HI RISK REQ ESCRT/PROTECT VST	X	X
S9401	ANTICOAGULAT CLIN NO LAB PER SESS	X	X
S9430	PHARM COMPOUNDING AND DISPENSING SERV	X	X
S9433	MED FOOD NUTR ORAL 100% NUTR INTAKE	X	X
S9434	MOD SOLID FOOD SUP INBORN ERR METAB	X	X
S9435	MEDICAL FOODS INBORN ERRORS METAB	X	X
S9436	CHLDBRTH PREP/LAMAZE CLASS PER SESS	X	X
S9437	CHILDBIRTH REFRESH CLASS PER SESS	X	X
S9438	CESAREAN BRTH CLASS NON-MD PER SESS	X	X
S9439	VBAC CLASSES NON-MD PER SESSION	X	X
S9441	ASTHMA ED NON-MD PROV PER SESSION	X	X
S9442	BIRTHING CLASSES NON-PHYS PROV-SESS	X	X
S9443	LACTATION CLASS NON-PHYS PROV-SESS	X	X
S9444	PARENTING CLASSES NON-MD PER SESS	X	X
S9445	PT ED NOC NON-MD PROV IND SESSION	X	X
S9446	PT ED NOC NON-MD PROV GROUP SESSION	X	X
S9447	INFANT SAFETY CLASS NON-MD PER SESS	X	X
S9449	WEIGHT MGMT CLASS NON-PHYS PER SESS	X	X
S9451	EXERCISE CLASSES NON-PHYS PER SESS	X	X
S9452	NUTRITION CLASSES NON-PHYS PER SESS	X	X
S9453	SMOKING CESSATION CLASS NON-MD SESS	X	X
S9454	STRESS MGMT CLASS NON-PHYS PER SESS	X	X
S9455	DIABETIC MGMT PROGM GROUP SESSION	X	X
S9460	DIABETIC MGMT PROGM NURSE VISIT	X	X
S9465	DIABETIC MGMT PROGM DIETITIAN VISIT	X	X
S9470	NUTRITIONAL CNSL DIETITIAN VISIT	X	X
S9472	CARD REHAB PROGM NON-PHYS PROV DIEM	X	X
S9473	PULM REHAB PROGM NON-PHYS PROV DIEM	X	X
S9474	ENTRSTML TX RN CERT ENTRSTML TX DAY	X	X
S9475	AMB SET SBSTNC ABS TX/DTOX SRVC DAY	X	X
S9476	VESTIBULR REHAB NON-PHYS PROV-DIEM	X	X
S9480	INTENSIVE OP PSYC SERVICES PER DIEM	X	X
S9482	FAMILY STABILIZATN SRVC PER 15 MIN	X	X
S9484	CRISIS INTERVEN MENTL HLTH SRVC-HR	X	X
S9485	CRISIS INTERVENT MENTAL HEALTH SERV	X	X
S9490	HIT CORTICOSTEROID INFUS; ADMN SRVC	X	X
S9494	HIT ANTIBIOTIC/ANTIFUNGAL; DIEM	X	X
S9497	HIT ANTIBIOTIC/ANTIFUNGAL; Q3 HRS	X	X
S9500	HIT ANTIBIOTIC/ANTIFUNGAL; Q24 HRS	X	X
S9501	HIT ANTIBIOTIC/ANTIFUNGAL; Q12 HRS	X	X
S9502	HIT ABX ANTIVIRL/ANTIFUNGAL; Q8 HRS	X	X
S9503	HIT ABX ANTIVIRL/ANTIFUNGAL; Q6 HRS	X	X
S9504	HIT ABX ANTIVIRL/ANTIFUNGAL; Q4 HRS	X	X
S9529	HOME OR SNF PATIENT	X	X
S9537	HOM TX HEMATOPOIETIC H INJ TX;-DIEM	X	X
S9538	HOME TRANSFUSION BLOOD PROD; DIEM	X	X
S9542	HOME INJECTABLE THERAPY NOC-DIEM	X	X
S9558	HOME INFUS TX GROWTH HORMONE-DIEM	X	X
S9559	HOME INFUS TX INTERFERON PER DIEM	X	X
S9560	HOME INJ TX; HORMONAL THERAPY DIEM	X	X
S9562	HOM INJ TX PALIVIZUMAB-PER DIEM	X	X
S9563	HOME INJECTABLE THERAPY IMMUNOTHERAPY PER DIEM	X	X
S9563	HOME INJECTABLE THERAPY IMMUNOTHERAPY PER DIEM	X	X
S9590	HOM TX IRRIG TX; W/ADMN-PER DIEM	X	X
S9810	HOME THERAPY; NOC PER HOUR	X	X
S9900	SRVC JOUR-LISTED CS PRACT HEAL-DIEM	X	X
S9901	CHRISTIAN SCI NURSE VISIT	X	X
S9960	AMB SERVC AIR NON-ER 1 WAY FIX WING	X	X
S9961	AMB SERVC AIR NON-ER 1 WAY ROT WING	X	X
S9970	HEALTH CLUB MEMBERSHIP ANNUAL	X	X
S9975	TPLNT REL LODG MEALS AND TRNSPRT DIEM	X	X
S9976	LODGING PER DIEM NOS	X	X
S9977	MEALS PER DIEM NOS	X	X
S9981	MEDICAL RECORDS COPYING FEE ADMIN	X	X
S9982	MEDICAL RECORDS COPYING FEE-PAGE	X	X
S9986	NOT MEDICALLY NECESSARY SERVICE	X	X
S9988	SERV PART OF PHASE 1 CLINICAL TRIAL	X	X
S9989	SERVICES PROVIDED OUTSIDE USA	X	X
S9990	SRVC PROV PART PHASE II CLIN TRIAL	X	X
S9991	SRVC PROV PART PHASE III CLIN TRIAL	X	X
S9992	TRNSPRT COSTS CLIN TRIAL PRTCPANDCOMP	X	X
S9994	LODG COST CLIN TRIAL PRTCPANDCAREGVR	X	X
S9996	MEALS CLIN TRIAL PRTCPANDONE CAREGIVR	X	X
S9999	SALES TAX	X	X
T1000	PRIV DUTY/INDEPENDENT NRS TO 15 MIN	X	X
T1001	NURSING ASSESSMENT/EVALUATION	X	X
T1002	RN SERVICES UP TO 15 MINUTES	X	X
T1003	LPN/LVN SERVICES UP TO 15 MINUTES	X	X
T1004	SRVC QUALIFIED NRS AIDE TO 15 MIN	X	X
T1005	RESPITE CARE SERVICES TO 15 MIN	X	X
T1006	ALCOHLAND/SBSTNC ABS FAM/COUPLE CNSL	X	X
T1007	ALCOHOLAND/SUBSTANCE ABUSE SERVICES	X	X
T1009	CHILD SIT IND ALCAND/SUBSTNC ABS SRVC	X	X
T1010	MEALS REC ALCOHLAND/SUBSTNC ABS SRVC	X	X
T1012	ALCOHOLAND/SBSTNC ABS SRVC SKL DVLP	X	X
T1013	SIGN LANGE/ORAL INTEPR SRVC-15 MIN	X	X
T1014	TELEHEALTH TRANS MIN PROF SRVC	X	X
T1015	CLINIC VST/ENCOUNTER ALL-INCLUSIVE	X	X
T1016	CASE MANAGEMENT EACH 15 MINS	X	X
T1017	TARGETED CASE MANAGEMENT EA 15 MINS	X	X
T1018	SCHOOL-BASD IND ED PROG SERV BUNDLD	X	X
T1019	PERSONAL CARE SERVICES PER 15 MINS	X	X
T1020	PERSONAL CARE SERVICES PER DIEM	X	X
T1021	HOME HLTH AIDE/CERT NURSE ASST VST	X	X
T1022	CONTRACT HOME HEALTH AGCY SRVC DAY	X	X
T1023	SCR IND PARTICIP SPEC PROG PROJ/TX	X	X
T1024	EVALANDTX TEAM MX/SEV HANDICAP CHILD	X	X
T1025	MXDISCPLIN CHILD CMPLX IMPAIR DIEM	X	X
T1026	MXDISCPLIN CHILD W/CMPLX IMPAIR HR	X	X
T1027	FAM TRAIN AND CNSL CHILD DVLP 15 MINS	X	X
T1028	ASSESS HOME PHYSICAL AND FAMILY ENVIR	X	X
T1029	COMP ENVIR LEAD INVESTIGAT-DWELL	X	X
T1030	NRS CARE HOME REGISTERED NURSE-DIEM	X	X
T1031	NURSING CARE THE HOME LPN PER DIEM	X	X
T1032	SERVICES PRFRM BY DOULA BIRTH WORKER PER 15 MIN	X	X
T1032	SERVICES PRFRM BY DOULA BIRTH WORKER PER 15 MIN	X	X
T1033	SERVICES PERFORM BY DOULA BIRTH WORKER PER DIEM	X	X
T1033	SERVICES PERFORM BY DOULA BIRTH WORKER PER DIEM	X	X
T1040	COMM BH CLINIC SVC PER DIEM	X	X
T1041	COMM BH CLINIC SVC PER MONTH	X	X
T1502	ADMN ORL IMAND/SUBQ MED HLTH PROF	X	X
T1503	ADMN MED NOT ORALAND/INJ AGENCY/PROF	X	X
T1505	ELECTRON MED COMPL MANAGE DEVC NOS	X	X
T1999	MISC TX ITEMSANDSPL RTAIL PURCHSE NOC	X	X
T2001	N-EMERG TRNSPRT; PT ATTENDNT/ESCORT	X	X
T2002	NON-EMERG TRANSPORTATION; PER DIEM	X	X
T2003	NON-EMERG TRNSPRT; ENCOUNTER/TRIP	X	X
T2004	N-EMERG TRNSPRT;COMMER CARR MX-PASS	X	X
T2005	NONEMERGENCY TRNSPRT; STRETCHER VAN	X	X
T2006	AMBULANCE RESPONSE&TX NO TRANSPORT	X	X
T2007	TRNSPRT WAIT TIME NON-ER VEH 1/2 HR	X	X
T2010	PASRR LEVEL I ID SCREEN PER SCREEN	X	X
T2011	PASRR LEVEL II EVALUATION PER EVAL	X	X
T2012	HABILITATION ED WAIVER; DIEM	X	X
T2013	HABILITATION ED WAIVER; HOUR	X	X
T2014	HABILITATN PREVOCATIONL WAIVR;DIEM	X	X
T2015	HABILITATION PREVOCATIONAL WAIVR;HR	X	X
T2016	HABILITATION RES WAIVER; PER DIEM	X	X
T2017	HABILITATION RES WAIVER; PER 15 MIN	X	X
T2018	HABILITATN SUPP EMPLMNT WAIVR;DIEM	X	X
T2019	HABILTATN SUPP EMPLMNT WAIVR;15 MIN	X	X
T2020	DAY HABILITATION WAIVER; PER DIEM	X	X
T2021	DAY HABILITATION WAIVER; PER 15 MIN	X	X
T2022	CASE MANAGEMENT; PER MONTH	X	X
T2023	TARGETED CASE MANAGEMENT; PER MONTH	X	X
T2024	SRVC ASSESS/PLAN CARE DVLP WAIVER	X	X
T2025	WAIVER SERVICES; NOS	X	X
T2026	SPCLIZED CHILDCARE WAIVER; PER DIEM	X	X
T2027	SPCLIZED CHILDCARE WAIVER; 15 MIN	X	X
T2028	SPECIALIZED SUPPLY NOS WAIVER	X	X
T2029	SPECIALIZED MEDICAL EQP NOS WAIVER	X	X
T2030	ASSISTED LIVING WAIVER; PER MONTH	X	X
T2031	ASSISTED LIVING WAIVER; PER DIEM	X	X
T2032	RES CARE NOS WAIVER; PER MONTH	X	X
T2033	RES CARE NOS WAIVER; PER DIEM	X	X
T2034	CRISIS INTERVEN WAIVER; PER DIEM	X	X
T2035	UTILITY SERVICES MED EQP WAIVER	X	X
T2036	TX CAMPING OVRNGT WAIVER; EA SESS	X	X
T2037	TX CAMPING DA WAIVER; EA SESS	X	X
T2038	CMTY TRANSITION WAIVER; PER SERVICE	X	X
T2039	VEHICLE MOD WAIVER; PER SERVICE	X	X
T2040	FINANCIAL MGMT WAIVER; 15 MIN	X	X
T2041	SUPP BROKER SLF-DIRED WAIVR; 15 MIN	X	X
T2042	HOSPICE ROUTINE HOME CARE PER DIEM	X	X
T2043	HOSPICE CONTINUOUS HOME CARE PER HR	X	X
T2044	HOSPICE INPAT RESPITE CARE PER DIEM	X	X
T2045	HOSPICE GENERAL INPAT CARE PER DIEM	X	X
T2046	HOSPICE LT CARE RM AND BD PER DIEM	X	X
T2048	BHVAL HLTH; LTC RES W/ROOMANDBD-DIEM	X	X
T2049	NON-EMERG TRNSPRT; VAN MILEAGE;MILE	X	X
T2050	FINANCIAL MANAGEMENT SELF-DIRECTED WAIVER PD	X	X
T2050	FINANCIAL MANAGEMENT SELF-DIRECTED WAIVER PD	X	X
T2051	SUPPORTS BROKERAGE SELF-DIRECTED WAIVER PD	X	X
T2051	SUPPORTS BROKERAGE SELF-DIRECTED WAIVER PD	X	X
T2101	HUMN BRST MILK PRC STORANDDSTRB ONLY	X	X
T4521	ADLT SZ DISPBL INCONT BRF/DIAPER SM	X	X
T4522	ADLT SZ DISPBL INCONT BRF/DIAPER MD	X	X
T4523	ADLT SZ DISPBL INCONT BRF/DIAPER LG	X	X
T4524	ADLT DISPBL INCONT BRF/DIAPER X-LG	X	X
T4525	ADLT SZD DISPBL INCONT UNDWEAR SM	X	X
T4526	ADLT SZD DISPBL INCONT UNDWEAR MED	X	X
T4527	ADLT SZD DISPBL INCONT UNDWEAR LG	X	X
T4528	ADLT SZD DISPBL INCONT UNDWEAR X-LG	X	X
T4529	PED SZ DISPBL INCONT BRF/DIAPER S/M	X	X
T4530	PED SZ DISPBL INCONT BRF/DIAPER LG	X	X
T4531	PED SZ DISPBL INCONT UNDWEAR SM/MED	X	X
T4532	PED SZ DISPBL INCONT UNDWEAR LG EA	X	X
T4533	YOUTH SZD DISPBL INCONT BRF/DIAPER	X	X
T4534	YOUTH SZD DISPBL INCONT UNDWEAR EA	X	X
T4535	DISPBL LINER/PAD/UNDGRMNT INCONT EA	X	X
T4536	INCONT PROD UNDWEAR/PULLON REUSE SZ	X	X
T4537	INCONT PROD UNDPAD REUSBL BED SZ EA	X	X
T4538	DIAPER SRVC REUSBL DIAPER EA DIAPER	X	X
T4539	INCONT PROD DIAPER/BRF REUSBL SZ EA	X	X
T4540	INCONT PROD UNDPAD REUSBL CHAIR SZ	X	X
T4541	INCONT PRODUCT DISPBL UNDPAD LG EA	X	X
T4542	INCONT PROD DISPBL UNDPAD SM SZ EA	X	X
T4543	ADULT DISP INCONTINENCE PROD ABV XL	X	X
T4544	ADULT SIZE DISPBL PULLUP ABVE XL EA	X	X
T5001	PSTN SEAT PERSON SPECL/ORTHO NEEDS	X	X
T5999	SUPPLY NOT OTHERWISE SPECIFIED	X	X
V2025	DELUXE FRAME	X	Need denial From MA plan
V2526	CONTACT LENS HPI W/BLUE-VIOLET FILTER PER LENS	X	X
V2526	CONTACT LENS HPI W/BLUE-VIOLET FILTER PER LENS	X	X
V2702	DELUXE LENS FEATURE	X	X
V2787	ASTIGMATISM CORRECTING FUNCTION IOL	X	X
V2788	PRESBYOPIA CORRECTING FUNCT IO LENS	X	X
V5008	HEARING SCREENING	X	Need denial From MA plan
V5010	ASSESSMENT FOR HEARING AID	X	Need denial From MA plan
V5011	FIT/ORIENTATION/CHECK HEARING AID	X	Need denial From MA plan
V5014	REPAIR/MODIFICATION OF HEARING AID	X	Need denial From MA plan
V5020	CONFORMITY EVALUATION	X	Need denial From MA plan
V5030	HEAR AID MONAURL BDY WRN AIR CONDCT	X	Need denial From MA plan
V5040	HEAR AID MONAURL BDY WORN BN CONDCT	X	Need denial From MA plan
V5050	HEARING AID MONAURAL IN THE EAR	X	Need denial From MA plan
V5060	HEARING AID MONAURAL BEHIND THE EAR	X	Need denial From MA plan
V5070	GLASSES AIR CONDUCTION	X	Need denial From MA plan
V5080	GLASSES BONE CONDUCTION	X	Need denial From MA plan
V5090	DISPENSING FEE UNSPEC HEARING AID	X	Need denial From MA plan
V5095	SEMI-IMPL MID EAR HEARING PROSTH	X	Need denial From MA plan
V5100	HEARING AID BILATERAL BODY WORN	X	Need denial From MA plan
V5110	DISPENSING FEE BILATERAL	X	Need denial From MA plan
V5120	BINAURAL BODY	X	Need denial From MA plan
V5130	BINAURAL IN THE EAR	X	Need denial From MA plan
V5140	BINAURAL BEHIND THE EAR	X	Need denial From MA plan
V5150	BINAURAL GLASSES	X	Need denial From MA plan
V5160	DISPENSING FEE BINAURAL	X	Need denial From MA plan
V5190	HEARING AID CROS GLASSES	X	Need denial From MA plan
V5200	DISPENSING FEE CROS	X	Need denial From MA plan
V5230	HEARING AID BICROS GLASSES	X	Need denial From MA plan
V5240	DISPENSING FEE BICROS	X	Need denial From MA plan
V5241	DISPNS FEE MONAURL HEARING AID TYPE	X	Need denial From MA plan
V5242	HEARING AID ANALOG MONAURAL CIC	X	Need denial From MA plan
V5243	HEARING AID ANALOG MONAURAL ITC	X	Need denial From MA plan
V5244	HEARING AID PROG ANALOG MONAURL CIC	X	Need denial From MA plan
V5245	HEARING AID PROG ANALOG MONAURL ITC	X	Need denial From MA plan
V5246	HEARING AID PROG ANALOG MONAURL ITE	X	Need denial From MA plan
V5247	HEARING AID PROG ANALOG MONAURL BTE	X	Need denial From MA plan
V5248	HEARING AID ANALOG BINAURAL CIC	X	Need denial From MA plan
V5249	HEARING AID ANALOG BINAURAL ITC	X	Need denial From MA plan
V5250	HEARING AID PROG ANALOG BINAURL CIC	X	Need denial From MA plan
V5251	HEARING AID PROG ANALOG BINAURL ITC	X	Need denial From MA plan
V5252	HEARING AID PROG BINAURAL ITE	X	Need denial From MA plan
V5253	HEARING AID PROG BINAURAL BTE	X	Need denial From MA plan
V5254	HEARING AID DIGITAL MONAURAL CIC	X	Need denial From MA plan
V5255	HEARING AID DIGITAL MONAURAL ITC	X	Need denial From MA plan
V5256	HEARING AID DIGITAL MONAURAL ITE	X	Need denial From MA plan
V5257	HEARING AID DIGITAL MONAURAL BTE	X	Need denial From MA plan
V5258	HEARING AID DIGITAL BINAURAL CIC	X	Need denial From MA plan
V5259	HEARING AID DIGITAL BINAURAL ITC	X	Need denial From MA plan
V5260	HEARING AID DIGITAL BINAURAL ITE	X	Need denial From MA plan
V5261	HEARING AID DIGITAL BINAURAL BTE	X	Need denial From MA plan
V5262	HEARING AID DISPBL TYPE MONAURAL	X	Need denial From MA plan
V5263	HEARING AID DISPBL TYPE BINAURAL	X	Need denial From MA plan
V5264	EAR MOLD/INSERT NOT DISPBL ANY TYPE	X	Need denial From MA plan
V5265	EAR MOLD/INSERT DISPOSABLE ANY TYPE	X	Need denial From MA plan
V5266	BATTERY FOR USE IN HEARING DEVICE	X	Need denial From MA plan
V5267	HA/ALD/SUPP/ACCESS NOT O/W SPEC	X	Need denial From MA plan
V5268	ASST LISTENING DEVICE TEL AMP TYPE	X	Need denial From MA plan
V5269	ASST LISTENING DEVICE ALERTING TYPE	X	Need denial From MA plan
V5270	ASST LISTENING DEVICE TV AMP TYPE	X	Need denial From MA plan
V5271	ASST LISTEN DEVC TV CAPTION DECODER	X	Need denial From MA plan
V5272	ASSISTIVE LISTENING DEVICE TDD	X	Need denial From MA plan
V5273	ASSTIVE LISTEN DEVC W/COCHLEAR IMPL	X	Need denial From MA plan
V5274	ASSISTIVE LEARNING DEVICE NOS	X	Need denial From MA plan
V5275	EAR IMPRESSION EACH	X	Need denial From MA plan
V5281	ALD PERS FM/DM SYS MONAURL ANY TYPE	X	Need denial From MA plan
V5282	ALD PERS FM/DM SYS BINAURL ANY TYPE	X	Need denial From MA plan
V5283	ALD PERS FM/DM NCK LOOP INDUCT RECV	X	Need denial From MA plan
V5284	ALD PERS FM/DM EAR LEVEL RECEIVER	X	Need denial From MA plan
V5285	ALD PERS FM/DM DIR AUDIO INPUT RECV	X	Need denial From MA plan
V5286	ALD PERS BLUE TOOTH FM/DM RECEIVR	X	Need denial From MA plan
V5287	ALD PERS FM/DM RECEIVER NOS	X	Need denial From MA plan
V5288	ALD PERS FM/DM TRANSMITTER ALD	X	Need denial From MA plan
V5289	ALD PERS FM/DM ADPTR/BOOT CPLG RECV	X	Need denial From MA plan
V5290	ALD TRANSMITT MICROPHONE ANY TYPE	X	Need denial From MA plan
V5298	HEARING AID NOC	X	Need denial From MA plan
V5336	REPR/MOD AUGMENTATIV CMNCT SYS/DEVC	X	X
V5362	SPEECH SCREENING	X	X
V5363	LANGUAGE SCREENING	X	X
V5364	DYSPHAGIA SCREENING	X	X