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{"sheet":"Lookup Tool","index":0,"n_rows":30,"n_cols":11,"rows_kept":30,"cut":false,"hidden":false,"merged":[[0,0,0,10],[7,2,7,10],[9,2,9,10],[10,2,10,10],[11,2,11,10],[12,2,12,10],[21,0,21,4],[8,2,8,10],[5,2,6,10],[5,0,11,1]]}
["Code Lookup Tool (Professional Services Fee Schedule)"]
[null,null,{"$f":"CodeLookup[[#Headers],[Modifiers]]","v":"Modifiers"},{"$f":"CodeLookup[[#Headers],[Short Description (HCPCS and Local Only)]]","v":"Short Description (HCPCS and Local Only)"},{"$f":"CodeLookup[[#Headers],[NON-FACILITY SETTING]]","v":"NON-FACILITY SETTING"},{"$f":"CodeLookup[[#Headers],[FACILITY SETTING]]","v":"FACILITY SETTING"},{"$f":"CodeLookup[[#Headers],[FOL UP]]","v":"FOL UP"},{"$f":"CodeLookup[[#Headers],[PRE OP\n(-56)]]","v":"PRE OP\n(-56)"},{"$f":"CodeLookup[[#Headers],[INTRA OP\n(-54)]]","v":"INTRA OP\n(-54)"},{"$f":"CodeLookup[[#Headers],[POST OP\n(-55)]]","v":"POST OP\n(-55)"},{"$f":"CodeLookup[[#Headers],[PCTC\n(26/TC)]]","v":"PCTC\n(26/TC)"}]
["Enter code --> ","58662",{"$f":"IF(CodeLookup[Modifiers]=0,\" \",CodeLookup[Modifiers])","v":" "},{"$f":"CodeLookup[Short Description (HCPCS and Local Only)]","v":"See CPT"},{"$f":"CodeLookup[NON-FACILITY SETTING]","v":"Not Covered"},{"$f":"CodeLookup[FACILITY SETTING]","v":"Not Covered "},{"$f":"CodeLookup[FOL UP]","v":"090"},{"$f":"CodeLookup[PRE OP\n(-56)]","v":0.09},{"$f":"CodeLookup[INTRA OP\n(-54)]","v":0.84},{"$f":"CodeLookup[POST OP\n(-55)]","v":7.0000000000000007E-2},{"$f":"CodeLookup[PCTC\n(26/TC)]","v":0}]
["Is there a modifier?","No",{"$f":"CodeLookup[[#Headers],[MSI\n(-51)]]","v":"MSI\n(-51)"},{"$f":"CodeLookup[[#Headers],[BSI\n(-50)]]","v":"BSI\n(-50)"},{"$f":"CodeLookup[[#Headers],[ASI\n(-80)]]","v":"ASI\n(-80)"},{"$f":"CodeLookup[[#Headers],[CSI\n(-62)]]","v":"CSI\n(-62)"},{"$f":"CodeLookup[[#Headers],[TSI\n(-66)]]","v":"TSI\n(-66)"},{"$f":"CodeLookup[[#Headers],[ENDO\nBASE]]","v":"ENDO\nBASE"},{"$f":"CodeLookup[[#Headers],[FSI]]","v":"FSI"},{"$f":"CodeLookup[[#Headers],[LIC REQ]]","v":"LIC REQ"},{"$f":"CodeLookup[[#Headers],[Prior Auth]]","v":"Prior Auth"}]
[{"$f":"IF(B4=\"No\",\"\",\"Select the modifier\")","v":""},"TC",{"$f":"CodeLookup[MSI\n(-51)]","v":3},{"$f":"CodeLookup[BSI\n(-50)]","v":0},{"$f":"CodeLookup[ASI\n(-80)]","v":2},{"$f":"CodeLookup[CSI\n(-62)]","v":2},{"$f":"CodeLookup[TSI\n(-66)]","v":0},{"$f":"CodeLookup[ENDO\nBASE]","v":49320},{"$f":"CodeLookup[FSI]","v":"X"},{"$f":"CodeLookup[LIC REQ]","v":0},{"$f":"IF(CodeLookup[Prior Auth]=0,\"\",CodeLookup[Prior Auth])","v":""}]
[null,null,"NOTE: The MARFS chapters linked below are recommended for your understanding of these codes but are not to be considered explicit context and do not remove your responsibility to bill properly in accordance with the L&I Provider Agreement, applicable RCWs and WACs, and the MARFS in its entirety."]
[]
[null,null,{"$f":"CodeLookup[[#Headers],[MARFS Chapters]]","v":"MARFS Chapters"}]
[null,null,{"$f":"IFERROR(HYPERLINK(A25,A26),\"\")","v":"Chapter 2: Information for All Providers"}]
[null,null,{"$f":"IFERROR(HYPERLINK(B25,B26),\"\")","v":"Chapter 29: Surgery Services"}]
[null,null,{"$f":"IFERROR(HYPERLINK(C25,C26),\"\")","v":""}]
[null,null,"Link to Prior Authorization Details (if applicable)"]
[null,null,{"$f":"IFERROR(HYPERLINK(D25,D26),\"\")","v":""}]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[{"$f":"CodeLookup[MARFS Chapters]","v":2},{"$f":"CodeLookup[MARFS Chapters2]","v":29},{"$f":"CodeLookup[MARFS Chapters3]","v":0}]
[{"$f":"IFERROR(VLOOKUP(A24,'MARFS_URL''s'!$B$2:$D$37,2,),\"\")","v":"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter2.pdf"},{"$f":"IFERROR(VLOOKUP(B24,'MARFS_URL''s'!$B$2:$D$37,2,),\"\")","v":"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter29.pdf"},{"$f":"IFERROR(VLOOKUP(C24,'MARFS_URL''s'!$B$2:$D$37,2,),\"\")","v":""},{"$f":"VLOOKUP(K5,'MARFS_URL''s'!$B$40:$D$43,2,)","v":{"$error":"#N/A"}}]
[{"$f":"IFERROR(VLOOKUP(A24,'MARFS_URL''s'!$B$2:$D$37,3,),\"\")","v":"Chapter 2: Information for All Providers"},{"$f":"IFERROR(VLOOKUP(B24,'MARFS_URL''s'!$B$2:$D$37,3,),\"\")","v":"Chapter 29: Surgery Services"},{"$f":"IFERROR(VLOOKUP(C24,'MARFS_URL''s'!$B$2:$D$37,3,),\"\")","v":""},{"$f":"VLOOKUP(K5,'MARFS_URL''s'!$B$40:$D$43,3,)","v":{"$error":"#N/A"}}]
[]
[]
[{"$f":"CodeLookup[[#Headers],[CODE]]","v":"CODE"}]
[{"$f":"CodeLookup[CODE]","v":"58662"}]

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["Professional Services Fee Schedule"]
[]
[]
[]
[null,null,null,"DOLLAR VALUE",null,null,"MODIFIERS"]
["CODE","Modifiers","Short Description (HCPCS and Local Only)","NON-FACILITY SETTING","FACILITY SETTING","FOL UP","PRE OP\n(-56)","INTRA OP\n(-54)","POST OP\n(-55)","PCTC\n(26/TC)","MSI\n(-51)","BSI\n(-50)","ASI\n(-80)","CSI\n(-62)","TSI\n(-66)","ENDO\nBASE","FSI","LIC REQ","Prior Auth","MARFS Chapters","MARFS Chapters","MARFS Chapters"]
[10004,null,"See CPT",null,90.973799999999997,null,75.514200000000002,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[10005,null,"See CPT",null,252.11040000000003,null,130.2174,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[10006,null,"See CPT",null,107.62260000000001,null,88.595399999999998,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[10007,null,"See CPT",null,559.51859999999999,null,159.94739999999999,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[10008,null,"See CPT",null,304.43520000000001,null,100.48739999999999,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[10009,null,"See CPT",null,844.33199999999999,null,195.02879999999999,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[10010,null,"See CPT",null,494.11260000000004,null,139.73099999999999,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[10011,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,0,0,0,0,null,"N",null,"Y-CM"]
[10012,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
[10021,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,null,"X"]
[10030,null,"See CPT",null,1240.9302,null,236.6508,null,"000",0,0,0,9,2,9,0,0,0,null,"R",null,"Y-CM"]
[10035,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,null,"X"]
[10036,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[10040,null,"See CPT",null,213.4614,null,91.568399999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[10060,null,"See CPT",null,227.13720000000001,null,188.48820000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10061,null,"See CPT",null,385.8954,null,328.2192,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10080,null,"See CPT",null,478.65300000000008,null,187.89360000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[10081,null,"See CPT",null,645.73559999999998,null,305.02980000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[10120,null,"See CPT",null,275.2998,null,186.10980000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10121,null,"See CPT",null,483.40980000000008,null,327.03000000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10140,null,"See CPT",null,311.57040000000001,null,211.083,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10160,null,"See CPT",null,236.05620000000002,null,170.0556,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10180,null,"See CPT",null,482.22059999999999,null,317.51639999999998,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11000,null,"See CPT",null,106.43340000000001,null,48.757199999999997,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11001,null,"See CPT",null,48.162600000000005,null,24.973199999999999,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[11004,null,"See CPT",null,997.14419999999996,null,997.14419999999996,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11005,null,"See CPT",null,1356.8772000000001,null,1356.8772000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[11006,null,"See CPT",null,1227.2544,null,1227.2544,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11008,null,"See CPT",null,478.05839999999995,null,478.05839999999995,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[11010,null,"See CPT",null,831.84540000000004,null,488.76120000000003,null,"010",0.1,0.8,0.1,0,2,2,1,0,0,null,"R"]
[11011,null,"See CPT",null,912.1164,null,522.05880000000002,null,"000",0,0,0,0,2,2,1,0,0,null,"R"]
[11012,null,"See CPT",null,1181.4702,null,731.95260000000007,null,"000",0,0,0,0,2,2,1,0,0,null,"R"]
[11042,null,"See CPT",null,239.02919999999997,null,106.43340000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11043,null,"See CPT",null,422.166,null,270.54300000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11044,null,"See CPT",null,557.73480000000006,null,394.81439999999998,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11045,null,"See CPT",null,73.730400000000003,null,45.784199999999998,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[11046,null,"See CPT",null,131.4066,null,96.919799999999995,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[11047,null,"See CPT",null,214.6506,null,169.46100000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[11055,null,"See CPT",null,134.37959999999998,null,27.946199999999997,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11056,null,"See CPT",null,153.4068,null,38.649000000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11057,null,"See CPT",null,167.6772,null,50.540999999999997,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11102,null,"See CPT",null,189.08280000000002,null,66.595200000000006,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11103,null,"See CPT",null,93.94680000000001,null,38.649000000000001,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[11104,null,"See CPT",null,234.86700000000002,null,82.6494,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11105,null,"See CPT",null,109.4064,null,45.189599999999999,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[11106,null,"See CPT",null,290.75939999999997,null,99.892799999999994,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11107,null,"See CPT",null,132.00120000000001,null,54.703200000000002,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[11200,null,"See CPT",null,164.1096,null,136.1634,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11201,null,"See CPT",null,32.703000000000003,null,28.540800000000001,null,"000",0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[11300,null,"See CPT",null,189.67740000000001,null,60.054600000000001,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11301,null,"See CPT",null,226.54259999999999,null,89.784599999999998,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11302,null,"See CPT",null,255.678,null,105.83880000000001,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11303,null,"See CPT",null,281.84040000000005,null,124.2714,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11305,null,"See CPT",null,198.59639999999999,null,67.189799999999991,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11306,null,"See CPT",null,227.73180000000002,null,86.811599999999999,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11307,null,"See CPT",null,259.84019999999998,null,110.5956,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11308,null,"See CPT",null,274.70519999999999,null,124.2714,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11310,null,"See CPT",null,215.8398,null,80.271000000000001,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11311,null,"See CPT",null,253.89419999999998,null,110.001,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11312,null,"See CPT",null,287.1918,null,129.62280000000001,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11313,null,"See CPT",null,334.16520000000003,null,169.46100000000001,null,"000",0,0,0,0,2,9,0,0,0,null,"R"]
[11400,null,"See CPT",null,236.05620000000002,null,149.83920000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11401,null,"See CPT",null,287.78640000000001,null,189.08280000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11402,null,"See CPT",null,316.3272,null,206.92080000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11403,null,"See CPT",null,361.51679999999999,null,265.19159999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11404,null,"See CPT",null,410.86860000000001,null,292.54320000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11406,null,"See CPT",null,579.1404,null,440.59860000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11420,null,"See CPT",null,235.4616,null,147.46080000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11421,null,"See CPT",null,293.73240000000004,null,195.02879999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11422,null,"See CPT",null,328.81380000000001,null,242.00220000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11423,null,"See CPT",null,374.0034,null,277.08359999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11424,null,"See CPT",null,427.51740000000001,null,315.73259999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11426,null,"See CPT",null,603.51900000000001,null,482.81519999999995,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11440,null,"See CPT",null,264.59700000000004,null,189.67740000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11441,null,"See CPT",null,319.89479999999998,null,237.84,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11442,null,"See CPT",null,353.78700000000003,null,261.62400000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11443,null,"See CPT",null,416.22,null,318.7056,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11444,null,"See CPT",null,516.11279999999999,null,401.94959999999998,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11446,null,"See CPT",null,699.24959999999999,null,567.84300000000007,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11450,null,"See CPT",null,805.68300000000011,null,469.73400000000004,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R"]
[11451,null,"See CPT",null,974.54939999999999,null,590.43780000000004,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"R"]
[11462,null,"See CPT",null,783.08820000000003,null,447.13919999999996,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"R"]
[11463,null,"See CPT",null,991.79279999999994,null,596.38379999999995,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"R"]
[11470,null,"See CPT",null,843.14279999999997,null,511.95059999999995,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[11471,null,"See CPT",null,1006.6578,null,628.49220000000003,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[11600,null,"See CPT",null,364.4898,null,217.62360000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11601,null,"See CPT",null,419.19299999999998,null,263.40780000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11602,null,"See CPT",null,446.5446,null,286.59720000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11603,null,"See CPT",null,507.19379999999995,null,341.30040000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11604,null,"See CPT",null,564.87,null,375.78720000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11606,null,"See CPT",null,809.25059999999996,null,560.11320000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11620,null,"See CPT",null,365.67900000000003,null,218.81280000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11621,null,"See CPT",null,420.38220000000001,null,264.59700000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11622,null,"See CPT",null,461.40960000000001,null,299.67840000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11623,null,"See CPT",null,538.70760000000007,null,369.84120000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11624,null,"See CPT",null,612.4380000000001,null,420.38220000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11626,null,"See CPT",null,737.30400000000009,null,516.70740000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11640,null,"See CPT",null,374.0034,null,225.35339999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11641,null,"See CPT",null,433.46340000000004,null,275.2998,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11642,null,"See CPT",null,488.76120000000003,null,322.27319999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11643,null,"See CPT",null,572.59980000000007,null,401.94959999999998,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11644,null,"See CPT",null,704.601,null,498.86940000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11646,null,"See CPT",null,912.71100000000001,null,689.73599999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11719,null,"See CPT",null,24.973199999999999,null,13.081200000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11720,null,"See CPT",null,58.865400000000001,null,25.567799999999998,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[11721,null,"See CPT",null,79.676400000000001,null,42.2166,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[11730,null,"See CPT",null,211.67760000000001,null,94.54140000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11732,null,"See CPT",null,61.2438,null,30.3246,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[11740,null,"See CPT",null,105.24420000000001,null,56.486999999999995,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11750,null,"See CPT",null,293.13779999999997,null,180.75839999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11755,null,"See CPT",null,225.94799999999998,null,106.43340000000001,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[11760,null,"See CPT",null,346.65180000000004,null,198.0018,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11762,null,"See CPT",null,531.57240000000002,null,335.94900000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11765,null,"See CPT",null,306.21900000000005,null,164.1096,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11770,null,"See CPT",null,671.30340000000001,null,331.78680000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11771,null,"See CPT",null,1160.0646000000002,null,806.27760000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11772,null,"See CPT",null,1428.2292,null,1047.0906,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11900,null,"See CPT",null,103.46040000000001,null,51.730200000000004,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11901,null,"See CPT",null,127.839,null,80.865600000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[11920,null,"See CPT",null,356.76,null,194.4342,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11921,null,"See CPT",null,404.92259999999999,null,229.51560000000001,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11922,null,"See CPT",null,109.4064,null,51.730200000000004,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[11950,null,"See CPT",null,144.48780000000002,null,91.568399999999997,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11951,null,"See CPT",null,193.83959999999999,null,129.0282,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11952,null,"See CPT",null,258.0564,null,181.35299999999998,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11954,null,"See CPT",null,284.21880000000004,null,198.0018,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11960,null,"See CPT",null,1827.8003999999999,null,1827.8003999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[11970,null,"See CPT",null,1004.2794,null,1004.2794,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R"]
[11971,null,"See CPT",null,984.0630000000001,null,984.0630000000001,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"R"]
[11976,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,null,"X"]
[11980,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,1,0,0,null,"X"]
[11981,null,"See CPT",null,183.13679999999999,null,111.1902,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[11982,null,"See CPT",null,204.54239999999999,null,130.2174,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[11983,null,"See CPT",null,256.27259999999995,null,181.94759999999999,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[12001,null,"See CPT",null,171.2448,null,79.081800000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[12002,null,"See CPT",null,205.73160000000001,null,103.46040000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[12004,null,"See CPT",null,238.43459999999999,null,127.24440000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[12005,null,"See CPT",null,321.084,null,165.89340000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[12006,null,"See CPT",null,374.59800000000001,null,203.9478,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[12007,null,"See CPT",null,420.38220000000001,null,254.48880000000003,null,"000",0,0,0,0,2,0,1,1,0,null,"R"]
[12011,null,"See CPT",null,204.54239999999999,null,96.325200000000009,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[12013,null,"See CPT",null,212.86680000000001,null,101.67659999999999,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[12014,null,"See CPT",null,260.4348,null,130.2174,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[12015,null,"See CPT",null,311.57040000000001,null,164.70420000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[12016,null,"See CPT",null,397.78740000000005,null,224.75879999999998,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[12017,null,"See CPT",null,265.78620000000001,null,265.78620000000001,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[12018,null,"See CPT",null,301.4622,null,301.4622,null,"000",0,0,0,0,2,0,2,0,0,null,"R"]
[12020,null,"See CPT",null,551.78879999999992,null,334.16520000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12021,null,"See CPT",null,322.27319999999997,null,251.51580000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12031,null,"See CPT",null,487.57199999999995,null,268.75919999999996,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12032,null,"See CPT",null,557.14019999999994,null,336.54360000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12034,null,"See CPT",null,614.81640000000004,null,363.30060000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12035,null,"See CPT",null,714.1146,null,427.51740000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12036,null,"See CPT",null,793.19640000000004,null,501.8424,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12037,null,"See CPT",null,883.57560000000001,null,580.32960000000003,null,"010",0.1,0.8,0.1,0,2,0,0,1,0,null,"R"]
[12041,null,"See CPT",null,489.35580000000004,null,255.08340000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12042,null,"See CPT",null,570.81600000000003,null,346.65180000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12044,null,"See CPT",null,701.62800000000004,null,377.57099999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12045,null,"See CPT",null,748.0068,null,482.22059999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12046,null,"See CPT",null,923.41379999999992,null,567.84300000000007,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[12047,null,"See CPT",null,1007.847,null,629.68140000000005,null,"010",0.1,0.8,0.1,0,2,0,2,1,0,null,"R"]
[12051,null,"See CPT",null,523.84260000000006,null,300.27299999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12052,null,"See CPT",null,580.32960000000003,null,352.59780000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12053,null,"See CPT",null,671.30340000000001,null,379.35480000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12054,null,"See CPT",null,709.3578,null,385.30080000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12055,null,"See CPT",null,926.98140000000001,null,528.00480000000005,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12056,null,"See CPT",null,1064.3339999999998,null,683.79,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[12057,null,"See CPT",null,1121.4156,null,744.43920000000003,null,"010",0.1,0.8,0.1,0,2,0,2,1,0,null,"R"]
[13100,null,"See CPT",null,628.49220000000003,null,354.38159999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13101,null,"See CPT",null,733.14179999999999,null,440.59860000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13102,null,"See CPT",null,213.4614,null,127.24440000000001,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[13120,null,"See CPT",null,654.65459999999996,null,414.43619999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13121,null,"See CPT",null,782.49360000000001,null,454.27440000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13122,null,"See CPT",null,230.70480000000001,null,144.48780000000002,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[13131,null,"See CPT",null,712.33080000000007,null,427.51740000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13132,null,"See CPT",null,863.9538,null,534.54539999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13133,null,"See CPT",null,303.84060000000005,null,220.00200000000001,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[13151,null,"See CPT",null,774.76379999999995,null,491.73419999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13152,null,"See CPT",null,908.54880000000003,null,592.22160000000008,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13153,null,"See CPT",null,333.57060000000001,null,240.2184,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[13160,null,"See CPT",null,1418.7156,null,1418.7156,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14000,null,"See CPT",null,1150.5510000000002,null,895.46760000000006,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14001,null,"See CPT",null,1461.5267999999999,null,1160.0646000000002,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14020,null,"See CPT",null,1268.8764000000001,null,1005.4686,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14021,null,"See CPT",null,1559.6358,null,1256.9844000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14040,null,"See CPT",null,1365.7962,null,1104.7667999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14041,null,"See CPT",null,1654.7718,null,1348.5527999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14060,null,"See CPT",null,1378.8774000000001,null,1178.4972,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14061,null,"See CPT",null,1783.8,null,1448.4456,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14301,null,"See CPT",null,1956.2339999999999,null,1539.4194,null,"090",0.1,0.71,0.19,0,2,0,2,0,0,null,"R"]
[14302,null,"See CPT",null,379.35480000000001,null,379.35480000000001,null,"000",0,0,0,0,0,0,2,0,0,null,"R"]
[14350,null,"See CPT",null,1211.2002,null,1211.2002,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15002,null,"See CPT",null,635.03279999999995,null,386.49,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[15003,null,"See CPT",null,126.6498,null,79.676400000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[15004,null,"See CPT",null,720.65519999999992,null,460.22040000000004,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[15005,null,"See CPT",null,211.083,null,159.3528,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[15040,null,"See CPT",null,487.57199999999995,null,217.62360000000001,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15050,null,"See CPT",null,1086.9288000000001,null,829.46699999999998,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15100,null,"See CPT",null,1575.0953999999999,null,1276.0116,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15101,null,"See CPT",null,345.46260000000001,null,198.59639999999999,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15110,null,"See CPT",null,1495.4189999999999,null,1259.3628000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15111,null,"See CPT",null,199.78559999999999,null,178.38,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15115,null,"See CPT",null,1445.4726000000001,null,1221.903,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15116,null,"See CPT",null,290.75939999999997,null,262.21860000000004,null,"000",0,0,0,0,0,0,1,1,0,null,"R"]
[15120,null,"See CPT",null,1526.3382000000001,null,1225.4705999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15121,null,"See CPT",null,387.67919999999998,null,239.62380000000002,null,"000",0,0,0,0,0,0,1,1,0,null,"R"]
[15130,null,"See CPT",null,1314.6605999999999,null,1067.307,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15131,null,"See CPT",null,172.434,null,158.1636,null,"000",0,0,0,0,0,0,1,1,0,null,"R"]
[15135,null,"See CPT",null,1584.0144,null,1347.9582,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15136,null,"See CPT",null,170.65020000000001,null,158.1636,null,"000",0,0,0,0,0,0,1,1,0,null,"R"]
[15150,null,"See CPT",null,1277.2008000000001,null,1142.2266,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15151,null,"See CPT",null,209.8938,null,192.65040000000002,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15152,null,"See CPT",null,259.84019999999998,null,244.38060000000002,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15155,null,"See CPT",null,1432.9860000000001,null,1298.6064000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15156,null,"See CPT",null,281.84040000000005,null,264.59700000000004,null,"000",0,0,0,0,0,0,1,1,0,null,"R"]
[15157,null,"See CPT",null,313.35419999999999,null,287.78640000000001,null,"000",0,0,0,0,0,0,1,1,0,null,"R"]
[15200,null,"See CPT",null,1516.23,null,1195.7406000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15201,null,"See CPT",null,257.46179999999998,null,133.785,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15220,null,"See CPT",null,1390.1748,null,1083.3612000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15221,null,"See CPT",null,240.2184,null,121.2984,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15240,null,"See CPT",null,1674.3936000000001,null,1413.3642,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15241,null,"See CPT",null,316.3272,null,184.92060000000001,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15260,null,"See CPT",null,1793.9082000000001,null,1498.9866000000002,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15261,null,"See CPT",null,375.19259999999997,null,240.2184,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15271,null,"See CPT",null,283.02960000000002,null,147.46080000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[15272,null,"See CPT",null,45.189599999999999,null,30.9192,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15273,null,"See CPT",null,576.76199999999994,null,347.24639999999999,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[15274,null,"See CPT",null,153.4068,null,79.676400000000001,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15275,null,"See CPT",null,290.75939999999997,null,164.1096,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[15276,null,"See CPT",null,58.270800000000001,null,44.594999999999999,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15277,null,"See CPT",null,632.05980000000011,null,395.40900000000005,null,"000",0,0,0,0,2,0,1,1,0,null,"R"]
[15278,null,"See CPT",null,176.59620000000001,null,99.298199999999994,null,"000",0,0,0,0,0,0,1,1,0,null,"R"]
[15570,null,"See CPT",null,1647.6366,null,1304.5524,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15572,null,"See CPT",null,1578.663,null,1303.9577999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15574,null,"See CPT",null,1588.7711999999999,null,1315.2552000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15576,null,"See CPT",null,1417.5264,null,1158.8753999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15600,null,"See CPT",null,623.14080000000001,null,380.54400000000004,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15610,null,"See CPT",null,673.68180000000007,null,436.43639999999999,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15620,null,"See CPT",null,816.98040000000003,null,585.08640000000003,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15630,null,"See CPT",null,841.35900000000004,null,613.62720000000002,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15650,null,"See CPT",null,930.54899999999998,null,681.41160000000002,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15730,null,"See CPT",null,2619.8076000000001,null,1626.231,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15731,null,"See CPT",null,2019.8561999999999,null,1776.6648,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15733,null,"See CPT",null,1833.7464,null,1833.7464,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15734,null,"See CPT",null,2667.3755999999998,null,2667.3755999999998,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15736,null,"See CPT",null,2167.9115999999999,null,2167.9115999999999,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15738,null,"See CPT",null,2267.2098000000001,null,2267.2098000000001,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15740,null,"See CPT",null,1814.1246000000001,null,1490.6622,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15750,null,"See CPT",null,1660.1232000000002,null,1660.1232000000002,null,"090",0.1,0.71,0.19,0,2,0,2,0,0,null,"R"]
[15756,null,"See CPT",null,4061.7126000000003,null,4061.7126000000003,null,"090",0.1,0.71,0.19,0,2,0,2,2,0,null,"R"]
[15757,null,"See CPT",null,4039.1178000000004,null,4039.1178000000004,null,"090",0.1,0.71,0.19,0,2,0,2,2,0,null,"R"]
[15758,null,"See CPT",null,4036.1447999999996,null,4036.1447999999996,null,"090",0.1,0.71,0.19,0,2,0,2,2,0,null,"R"]
[15760,null,"See CPT",null,1522.7706000000001,null,1244.4978000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15769,null,"See CPT",null,853.84559999999999,null,853.84559999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[15770,null,"See CPT",null,1200.4974000000002,null,1200.4974000000002,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15771,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"X"]
[15772,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,1,0,0,null,"X"]
[15773,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"X"]
[15774,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,1,0,0,null,"X"]
[15775,null,"See CPT",null,686.76300000000003,null,451.3014,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[15776,null,"See CPT",null,926.38679999999999,null,616.60019999999997,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[15777,null,"See CPT",null,378.7602,null,378.7602,null,"000",0,0,0,0,0,1,1,0,0,null,"R"]
[15780,null,"See CPT",null,1531.6896000000002,null,1174.9296000000002,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15781,null,"See CPT",null,985.25220000000002,null,768.81780000000003,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15782,null,"See CPT",null,881.79179999999997,null,656.4384,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15783,null,"See CPT",null,812.81820000000005,null,628.49220000000003,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15786,null,"See CPT",null,424.5444,null,236.6508,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[15787,null,"See CPT",null,56.486999999999995,null,30.3246,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[15788,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"X"]
[15789,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"X"]
[15792,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"X"]
[15793,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"X"]
[15819,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"X"]
[15820,null,"See CPT",null,1044.1176,null,922.22460000000001,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15821,null,"See CPT",null,1120.8210000000001,null,987.03600000000006,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15822,null,"See CPT",null,838.98059999999998,null,718.87139999999999,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[15823,null,"See CPT",null,1121.4156,null,986.44140000000004,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[15824,null,"See CPT",null,1576.4879493792002,null,1576.4879493792002,null,"000",0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM"]
[15825,null,"See CPT",null,1355.5079139888001,null,1355.5079139888001,null,"000",0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM"]
[15826,null,"See CPT",null,1281.8334795552003,null,1281.8334795552003,null,"000",0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM"]
[15828,null,"See CPT",null,4390.6220248176014,null,4390.6220248176014,null,"000",0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM"]
[15829,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,1,0,0,0,null,"N",null,"Y-CM"]
[15830,null,"See CPT",null,2085.2622000000001,null,2085.2622000000001,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[15832,null,"See CPT",null,1635.7446000000002,null,1635.7446000000002,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[15833,null,"See CPT",null,1565.5817999999999,null,1565.5817999999999,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15834,null,"See CPT",null,1594.1225999999999,null,1594.1225999999999,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15835,null,"See CPT",null,1658.934,null,1658.934,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15836,null,"See CPT",null,1424.067,null,1424.067,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15837,null,"See CPT",null,1564.9872,null,1278.9846,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15838,null,"See CPT",null,1161.8483999999999,null,1161.8483999999999,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15839,null,"See CPT",null,1609.5822000000001,null,1318.8227999999999,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15840,null,"See CPT",null,1813.53,null,1813.53,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15841,null,"See CPT",null,3167.4342000000001,null,3167.4342000000001,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15842,null,"See CPT",null,4792.4759999999997,null,4792.4759999999997,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15845,null,"See CPT",null,1894.3956000000001,null,1894.3956000000001,null,"090",0.1,0.71,0.19,0,2,0,2,0,0,null,"R"]
[15847,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,2,1,0,null,"N",null,"Y-CM"]
[15850,null,"See CPT",null,0,null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"Bundledundled"]
[15851,null,"See CPT",null,197.40719999999999,null,79.081800000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[15852,null,"See CPT",null,82.0548,null,82.0548,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[15860,null,"See CPT",null,187.29900000000001,null,187.29900000000001,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[15876,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,null,"X"]
[15877,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,null,"X"]
[15878,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,null,"X"]
[15879,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,null,"X"]
[15920,null,"See CPT",null,1149.9564,null,1149.9564,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15922,null,"See CPT",null,1429.4184,null,1429.4184,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15931,null,"See CPT",null,1251.0383999999999,null,1251.0383999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15933,null,"See CPT",null,1562.6088000000002,null,1562.6088000000002,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15934,null,"See CPT",null,1694.6100000000001,null,1694.6100000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15935,null,"See CPT",null,2067.4242000000004,null,2067.4242000000004,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15936,null,"See CPT",null,1615.5282000000002,null,1615.5282000000002,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15937,null,"See CPT",null,1869.4224000000002,null,1869.4224000000002,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15940,null,"See CPT",null,1254.0114000000001,null,1254.0114000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15941,null,"See CPT",null,1670.826,null,1670.826,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15944,null,"See CPT",null,1673.2044000000001,null,1673.2044000000001,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15945,null,"See CPT",null,1824.8274000000001,null,1824.8274000000001,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15946,null,"See CPT",null,2887.3776000000003,null,2887.3776000000003,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15950,null,"See CPT",null,1143.4158,null,1143.4158,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15951,null,"See CPT",null,1614.9336000000001,null,1614.9336000000001,null,"090",0.1,0.71,0.19,0,2,0,0,1,0,null,"R"]
[15952,null,"See CPT",null,1639.3122000000001,null,1639.3122000000001,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15953,null,"See CPT",null,1807.5839999999998,null,1807.5839999999998,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15956,null,"See CPT",null,2094.7757999999999,null,2094.7757999999999,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15958,null,"See CPT",null,2132.2356,null,2132.2356,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15999,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,0,0,1,1,null,"N"]
[16000,null,"See CPT",null,137.3526,null,79.081800000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[16020,null,"See CPT",null,154.596,null,96.919799999999995,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[16025,null,"See CPT",null,286.00259999999997,null,196.8126,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[16030,null,"See CPT",null,357.94919999999996,null,231.89400000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[16035,null,"See CPT",null,337.13819999999998,null,337.13819999999998,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[16036,null,"See CPT",null,137.3526,null,137.3526,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[17000,null,"See CPT",null,122.4876,null,98.703599999999994,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17003,null,"See CPT",null,12.486599999999999,null,3.5676000000000001,null,"000",0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17004,null,"See CPT",null,309.19200000000001,null,173.02860000000001,null,"010",0.1,0.8,0.1,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17106,null,"See CPT",null,618.38400000000001,null,488.76120000000003,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17107,null,"See CPT",null,805.68300000000011,null,637.41120000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17108,null,"See CPT",null,1133.3075999999999,null,928.76519999999994,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[17110,null,"See CPT",null,208.7046,null,119.51459999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17111,null,"See CPT",null,243.78599999999997,null,145.67700000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17250,null,"See CPT",null,165.89340000000001,null,66.595200000000006,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[17260,null,"See CPT",null,181.94759999999999,null,125.4606,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17261,null,"See CPT",null,270.54300000000001,null,152.81219999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17262,null,"See CPT",null,326.43540000000002,null,194.4342,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17263,null,"See CPT",null,352.59780000000001,null,215.24520000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17264,null,"See CPT",null,376.97640000000001,null,230.11020000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17266,null,"See CPT",null,428.11200000000002,null,269.94839999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17270,null,"See CPT",null,271.13759999999996,null,166.488,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17271,null,"See CPT",null,302.65140000000002,null,184.32600000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17272,null,"See CPT",null,344.27339999999998,null,213.4614,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17273,null,"See CPT",null,380.54400000000004,null,241.40759999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17274,null,"See CPT",null,443.57159999999999,null,294.92160000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17276,null,"See CPT",null,514.92359999999996,null,354.97620000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17280,null,"See CPT",null,255.678,null,152.2176,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17281,null,"See CPT",null,327.62459999999999,null,208.11,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17282,null,"See CPT",null,374.0034,null,240.2184,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17283,null,"See CPT",null,440.00400000000002,null,299.0838,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17284,null,"See CPT",null,500.05860000000001,null,350.21940000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17286,null,"See CPT",null,638.60040000000004,null,472.70699999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17311,null,"See CPT",null,1223.6867999999999,null,624.33000000000004,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17312,null,"See CPT",null,748.0068,null,331.78680000000003,null,"000",0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17313,null,"See CPT",null,1151.1456000000001,null,560.70780000000002,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17314,null,"See CPT",null,716.49300000000005,null,307.40820000000002,null,"000",0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17315,null,"See CPT",null,139.13639999999998,null,88.000799999999998,null,"000",0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17340,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[17360,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[17380,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,null,"X"]
[17999,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,0,0,1,1,null,"N"]
[19000,null,"See CPT",null,189.67740000000001,null,74.919600000000003,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[19001,null,"See CPT",null,47.568000000000005,null,36.865200000000002,null,"000",0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[19020,null,"See CPT",null,868.11599999999999,null,562.49160000000006,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R"]
[19030,null,"See CPT",null,304.43520000000001,null,132.5958,null,"000",0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19081,null,"See CPT",null,950.7654,null,288.38099999999997,null,"000",0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19082,null,"See CPT",null,749.19600000000003,null,145.08240000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19083,null,"See CPT",null,963.84660000000008,null,272.32679999999999,null,"000",0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19084,null,"See CPT",null,741.46620000000007,null,134.9742,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19085,null,"See CPT",null,1487.0946000000001,null,316.3272,null,"000",0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19086,null,"See CPT",null,1164.2267999999999,null,157.56899999999999,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19100,null,"See CPT",null,284.8134,null,121.89299999999999,null,"000",0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19101,null,"See CPT",null,609.46500000000003,null,400.7604,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19105,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,1,0,0,null,"X"]
[19110,null,"See CPT",null,898.44060000000002,null,632.65440000000001,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19112,null,"See CPT",null,855.03480000000002,null,582.11339999999996,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19120,null,"See CPT",null,941.2518,null,745.62839999999994,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19125,null,"See CPT",null,1036.3878,null,825.89940000000001,null,"090",0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[19126,null,"See CPT",null,281.84040000000005,null,281.84040000000005,null,"000",0,0,0,0,0,0,1,1,0,null,"R",null,"Y-CM"]
[19281,null,"See CPT",null,442.97700000000003,null,174.21780000000001,null,"000",0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19282,null,"See CPT",null,317.51639999999998,null,86.811599999999999,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19283,null,"See CPT",null,483.40980000000008,null,175.40700000000001,null,"000",0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19284,null,"See CPT",null,363.89519999999999,null,88.000799999999998,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19285,null,"See CPT",null,714.1146,null,148.65,null,"000",0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19286,null,"See CPT",null,592.22160000000008,null,74.919600000000003,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19287,null,"See CPT",null,1238.5518,null,221.19120000000001,null,"000",0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19288,null,"See CPT",null,965.6303999999999,null,111.1902,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19294,null,"See CPT",null,288.97560000000004,null,288.97560000000004,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19296,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,null,"X"]
[19297,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[19298,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,null,"X"]
[19300,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"X"]
[19301,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"X"]
[19302,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"X"]
[19303,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"X"]
[19305,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"X"]
[19306,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"X"]
[19307,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"X"]
[19316,null,"See CPT",null,1412.175,null,1412.175,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19318,null,"See CPT",null,1946.7204000000002,null,1946.7204000000002,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19325,null,"See CPT",null,1100.01,null,1100.01,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19328,null,"See CPT",null,991.19820000000016,null,991.19820000000016,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19330,null,"See CPT",null,1154.7132000000001,null,1154.7132000000001,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19340,null,"See CPT",null,1353.9041999999999,null,1353.9041999999999,null,"090",0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[19342,null,"See CPT",null,1359.8502000000001,null,1359.8502000000001,null,"090",0.1,0.71,0.19,0,2,1,0,1,0,null,"R",null,"Y-CM"]
[19350,null,"See CPT",null,1501.365,null,1202.8758,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19355,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,0,0,0,null,"X"]
[19357,null,"See CPT",null,2078.1270000000004,null,2078.1270000000004,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19361,null,"See CPT",null,2771.4306000000001,null,2771.4306000000001,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19364,null,"See CPT",null,4832.3141999999998,null,4832.3141999999998,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19367,null,"See CPT",null,3148.4070000000002,null,3148.4070000000002,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19368,null,"See CPT",null,3857.1702000000005,null,3857.1702000000005,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19369,null,"See CPT",null,3584.8434000000002,null,3584.8434000000002,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19370,null,"See CPT",null,1199.3082000000002,null,1199.3082000000002,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19371,null,"See CPT",null,1271.2547999999999,null,1271.2547999999999,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19380,null,"See CPT",null,1441.3103999999998,null,1441.3103999999998,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19396,null,"See CPT",null,509.57220000000001,null,252.70500000000001,null,"000",0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19499,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,1,0,1,1,null,"N"]
[20100,null,"See CPT",null,1066.7124000000001,null,1066.7124000000001,null,"010",0.1,0.8,0.1,0,2,1,2,0,0,null,"R"]
[20101,null,"See CPT",null,1115.4696000000001,null,375.19259999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20102,null,"See CPT",null,1160.0646000000002,null,454.27440000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20103,null,"See CPT",null,1037.577,null,613.0326,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[20150,null,"See CPT",null,1787.3676,null,1787.3676,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[20200,null,"See CPT",null,408.49020000000002,null,166.488,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[20205,null,"See CPT",null,563.68080000000009,null,271.13759999999996,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[20206,null,"See CPT",null,429.89580000000001,null,101.08199999999999,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[20220,null,"See CPT",null,444.76080000000002,null,152.81219999999999,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[20225,null,"See CPT",null,735.52019999999993,null,228.32640000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[20240,null,"See CPT",null,249.13740000000001,null,249.13740000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[20245,null,"See CPT",null,611.24879999999996,null,611.24879999999996,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[20250,null,"See CPT",null,688.54679999999996,null,688.54679999999996,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20251,null,"See CPT",null,751.57440000000008,null,751.57440000000008,null,"010",0.1,0.8,0.1,0,2,0,2,0,0,null,"R"]
[20500,null,"See CPT",null,220.5966,null,155.7852,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20501,null,"See CPT",null,274.70519999999999,null,65.406000000000006,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[20520,null,"See CPT",null,399.57119999999998,null,264.59700000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20525,null,"See CPT",null,862.17,null,440.59860000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20526,null,"See CPT",null,148.05540000000002,null,101.08199999999999,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[20527,null,"See CPT",null,156.9744,null,115.947,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[20550,null,"See CPT",null,103.46040000000001,null,68.97359999999999,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[20551,null,"See CPT",null,104.64960000000001,null,68.97359999999999,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[20552,null,"See CPT",null,96.919799999999995,null,66.595200000000006,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[20553,null,"See CPT",null,111.78479999999999,null,75.514200000000002,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[20555,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,0,0,0,null,"X"]
[20560,null,"See CPT",null,48.162600000000005,null,26.757000000000001,null,"000",0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[20561,null,"See CPT",null,68.378999999999991,null,39.243600000000001,null,"000",0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[20600,null,"See CPT",null,95.73060000000001,null,63.027600000000007,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[20604,null,"See CPT",null,148.65,null,80.865600000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[20605,null,"See CPT",null,98.703599999999994,null,65.406000000000006,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[20606,null,"See CPT",null,161.7312,null,90.973799999999997,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[20610,null,"See CPT",null,117.1362,null,79.676400000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[20611,null,"See CPT",null,180.75839999999999,null,104.64960000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[20612,null,"See CPT",null,115.947,null,72.541200000000003,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[20615,null,"See CPT",null,461.40960000000001,null,286.00259999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20650,null,"See CPT",null,406.11180000000002,null,288.38099999999997,null,"010",0.1,0.8,0.1,0,2,0,1,1,0,null,"R"]
[20660,null,"See CPT",null,419.7876,null,419.7876,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[20661,null,"See CPT",null,916.8732,null,916.8732,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20662,null,"See CPT",null,937.08960000000002,null,937.08960000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20663,null,"See CPT",null,863.9538,null,863.9538,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[20664,null,"See CPT",null,1573.3116,null,1573.3116,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20665,null,"See CPT",null,209.8938,null,171.83940000000001,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[20670,null,"See CPT",null,671.30340000000001,null,258.65100000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20680,null,"See CPT",null,1100.01,null,748.0068,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20690,null,"See CPT",null,1063.7394000000002,null,1063.7394000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20692,null,"See CPT",null,1998.4505999999999,null,1998.4505999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20693,null,"See CPT",null,794.98019999999997,null,794.98019999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20694,null,"See CPT",null,781.899,null,610.65419999999995,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20696,null,"See CPT",null,2107.2624000000001,null,2107.2624000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20697,null,"See CPT",null,3553.9242000000004,null,3553.9242000000004,null,"000",0,0,0,3,0,0,2,1,0,null,"R"]
[20700,null,"See CPT",null,149.83920000000001,null,149.83920000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[20701,null,"See CPT",null,113.5686,null,113.5686,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[20702,null,"See CPT",null,252.11040000000003,null,252.11040000000003,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[20703,null,"See CPT",null,183.73140000000001,null,183.73140000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[20704,null,"See CPT",null,266.38080000000002,null,266.38080000000002,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[20705,null,"See CPT",null,218.2182,null,218.2182,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[20802,null,"See CPT",null,4858.4766,null,4858.4766,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20805,null,"See CPT",null,5768.8091999999997,null,5768.8091999999997,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20808,null,"See CPT",null,6957.4146000000001,null,6957.4146000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20816,null,"See CPT",null,3637.7628,null,3637.7628,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20822,null,"See CPT",null,3146.6232,null,3146.6232,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20824,null,"See CPT",null,3644.3033999999998,null,3644.3033999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20827,null,"See CPT",null,3229.2726000000002,null,3229.2726000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20838,null,"See CPT",null,4938.7476000000006,null,4938.7476000000006,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20900,null,"See CPT",null,726.00660000000005,null,321.084,null,"000",0,0,0,0,2,0,2,1,0,null,"R"]
[20902,null,"See CPT",null,488.76120000000003,null,488.76120000000003,null,"000",0,0,0,0,2,0,2,1,0,null,"R"]
[20910,null,"See CPT",null,855.03480000000002,null,855.03480000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20912,null,"See CPT",null,864.54840000000002,null,864.54840000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20920,null,"See CPT",null,714.70920000000001,null,714.70920000000001,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[20922,null,"See CPT",null,1087.5234,null,869.89980000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20924,null,"See CPT",null,906.76499999999999,null,906.76499999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20930,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
[20931,null,"See CPT",null,192.0558,null,192.0558,null,"000",0,0,0,0,0,0,1,1,0,null,"R"]
[20932,null,"See CPT",null,1328.3363999999999,null,1328.3363999999999,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[20933,null,"See CPT",null,1219.5246000000002,null,1219.5246000000002,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[20934,null,"See CPT",null,1327.1472000000001,null,1327.1472000000001,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[20936,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
[20937,null,"See CPT",null,291.35400000000004,null,291.35400000000004,null,"000",0,0,0,0,0,0,2,1,0,null,"R"]
[20938,null,"See CPT",null,320.48939999999999,null,320.48939999999999,null,"000",0,0,0,0,0,0,2,1,0,null,"R"]
[20939,null,"See CPT",null,121.2984,null,121.2984,null,"000",0,0,0,0,0,1,0,0,0,null,"R",null,"Y-UR"]
[20950,null,"See CPT",null,498.27480000000003,null,155.7852,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[20955,null,"See CPT",null,4376.2559999999994,null,4376.2559999999994,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20956,null,"See CPT",null,4674.7452000000003,null,4674.7452000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20957,null,"See CPT",null,4868.5847999999996,null,4868.5847999999996,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20962,null,"See CPT",null,4727.07,null,4727.07,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20969,null,"See CPT",null,4813.2870000000003,null,4813.2870000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20970,null,"See CPT",null,5038.6403999999993,null,5038.6403999999993,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20972,null,"See CPT",null,5023.1808000000001,null,5023.1808000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[20973,null,"See CPT",null,5306.8050000000003,null,5306.8050000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20974,null,"See CPT",null,147.46080000000001,null,88.000799999999998,null,"000",0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[20975,null,"See CPT",null,305.02980000000002,null,305.02980000000002,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[20979,null,"See CPT",null,99.892799999999994,null,55.297800000000002,null,"000",0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[20982,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,1,0,0,null,"X"]
[20983,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,1,0,0,null,"X"]
[20985,null,"See CPT",null,255.08340000000001,null,255.08340000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[20999,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,0,0,1,1,null,"N"]
[21010,null,"See CPT",null,1329.5255999999999,null,1329.5255999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[21011,null,"See CPT",null,687.35760000000005,null,466.16640000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21012,null,"See CPT",null,608.2758,null,608.2758,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21013,null,"See CPT",null,979.30619999999999,null,719.46600000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21014,null,"See CPT",null,934.11660000000006,null,934.11660000000006,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21015,null,"See CPT",null,1250.4438,null,1250.4438,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[21016,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"X"]
[21025,null,"See CPT",null,1425.8507999999999,null,1179.0917999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21026,null,"See CPT",null,972.17100000000005,null,767.62860000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21029,null,"See CPT",null,1387.7963999999999,null,1106.5506,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[21030,null,"See CPT",null,843.14279999999997,null,650.49239999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[21031,null,"See CPT",null,706.38480000000004,null,489.9504,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[21032,null,"See CPT",null,682.00620000000004,null,467.9502,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[21034,null,"See CPT",null,2342.7240000000002,null,2014.5048000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21040,null,"See CPT",null,855.62940000000003,null,655.84379999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[21044,null,"See CPT",null,1548.3383999999999,null,1548.3383999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21045,null,"See CPT",null,2141.7492000000002,null,2141.7492000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21046,null,"See CPT",null,1802.8271999999999,null,1802.8271999999999,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-CM"]
[21047,null,"See CPT",null,2233.3176000000003,null,2233.3176000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21048,null,"See CPT",null,1815.9084,null,1815.9084,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-CM"]
[21049,null,"See CPT",null,2176.2360000000003,null,2176.2360000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21050,null,"See CPT",null,1557.8520000000001,null,1557.8520000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[21060,null,"See CPT",null,1412.175,null,1412.175,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[21070,null,"See CPT",null,1093.4694,null,1093.4694,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[21073,null,"See CPT",null,687.95220000000006,null,441.19319999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[21076,null,"See CPT",null,1532.8788000000002,null,1247.4708000000001,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[21077,null,"See CPT",null,3764.4126000000001,null,3071.1089999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21079,null,"See CPT",null,2584.1316000000002,null,2067.4242000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21080,null,"See CPT",null,2993.2164000000002,null,2358.7782000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21081,null,"See CPT",null,2747.6466,null,2153.0466000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21082,null,"See CPT",null,2522.8878,null,1959.8016,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21083,null,"See CPT",null,2411.1030000000001,null,1820.0706,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21084,null,"See CPT",null,2750.6196,null,2106.0732000000003,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21085,null,"See CPT",null,1210.0110000000002,null,853.84559999999999,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[21086,null,"See CPT",null,2804.1335999999997,null,2264.8314,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21087,null,"See CPT",null,2804.1335999999997,null,2264.8314,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21088,null,"See CPT",null,"By Report",null,"By Report",null,"090",0.1,0.69,0.21,0,0,0,0,0,0,null,"N"]
[21089,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,0,0,1,1,1,null,"N"]
[21100,null,"See CPT",null,1149.9564,null,635.03279999999995,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21110,null,"See CPT",null,1617.9066,null,1337.85,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21116,null,"See CPT",null,415.03080000000006,null,80.271000000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[21120,null,"See CPT",null,1222.4975999999999,null,925.79219999999998,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-CM"]
[21121,null,"See CPT",null,1149.3617999999999,null,951.95460000000014,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21122,null,"See CPT",null,1356.2826,null,1356.2826,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21123,null,"See CPT",null,1537.6356000000001,null,1537.6356000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21125,null,"See CPT",null,5030.3159999999998,null,1189.7946000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21127,null,"See CPT",null,7727.4216000000006,null,1364.0124000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21137,null,"See CPT",null,1342.6068,null,1342.6068,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21138,null,"See CPT",null,1632.7716,null,1632.7716,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21139,null,"See CPT",null,1956.2339999999999,null,1956.2339999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21141,null,"See CPT",null,2391.4812000000002,null,2391.4812000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21142,null,"See CPT",null,2454.5088000000001,null,2454.5088000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21143,null,"See CPT",null,2528.2392000000004,null,2528.2392000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21145,null,"See CPT",null,2777.9712,null,2777.9712,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21146,null,"See CPT",null,2899.8642000000004,null,2899.8642000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21147,null,"See CPT",null,3051.4872,null,3051.4872,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21150,null,"See CPT",null,2934.9456,null,2934.9456,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21151,null,"See CPT",null,3226.8942000000002,null,3226.8942000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21154,null,"See CPT",null,3471.8694,null,3471.8694,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21155,null,"See CPT",null,3847.6565999999998,null,3847.6565999999998,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21159,null,"See CPT",null,4605.7716,null,4605.7716,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21160,null,"See CPT",null,4992.8562000000002,null,4992.8562000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21172,null,"See CPT",null,3742.4123999999997,null,3742.4123999999997,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21175,null,"See CPT",null,3939.2249999999999,null,3939.2249999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21179,null,"See CPT",null,2711.3760000000002,null,2711.3760000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21180,null,"See CPT",null,3026.5140000000001,null,3026.5140000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21181,null,"See CPT",null,1324.7688000000001,null,1324.7688000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[21182,null,"See CPT",null,3760.8450000000003,null,3760.8450000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21183,null,"See CPT",null,4089.6588000000002,null,4089.6588000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21184,null,"See CPT",null,4397.6615999999995,null,4397.6615999999995,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21188,null,"See CPT",null,2844.5664000000002,null,2844.5664000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21193,null,"See CPT",null,2204.1822000000002,null,2204.1822000000002,null,"090",0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-CM"]
[21194,null,"See CPT",null,2553.2123999999999,null,2553.2123999999999,null,"090",0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-CM"]
[21195,null,"See CPT",null,2417.6435999999999,null,2417.6435999999999,null,"090",0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-CM"]
[21196,null,"See CPT",null,2581.7532000000001,null,2581.7532000000001,null,"090",0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-CM"]
[21198,null,"See CPT",null,1855.152,null,1855.152,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21199,null,"See CPT",null,1814.7192,null,1814.7192,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21206,null,"See CPT",null,1735.0427999999999,null,1735.0427999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21208,null,"See CPT",null,3093.1092000000003,null,1315.2552000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21209,null,"See CPT",null,1498.9866000000002,null,1116.6588000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21210,null,"See CPT",null,3316.0842000000002,null,1350.3366000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21215,null,"See CPT",null,7882.0176000000001,null,1401.4721999999999,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[21230,null,"See CPT",null,1340.8230000000001,null,1340.8230000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21235,null,"See CPT",null,1331.904,null,1018.5498,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21240,null,"See CPT",null,1871.2061999999999,null,1871.2061999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[21242,null,"See CPT",null,1814.1246000000001,null,1814.1246000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[21243,null,"See CPT",null,2869.5396000000001,null,2869.5396000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[21244,null,"See CPT",null,1811.1516000000001,null,1811.1516000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21245,null,"See CPT",null,2139.3707999999997,null,1647.0419999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21246,null,"See CPT",null,1522.1760000000002,null,1522.1760000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21247,null,"See CPT",null,2827.9176000000002,null,2827.9176000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21248,null,"See CPT",null,1774.8810000000001,null,1409.202,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21249,null,"See CPT",null,2409.3192000000004,null,1977.6396,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21255,null,"See CPT",null,2412.2921999999999,null,2412.2921999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21256,null,"See CPT",null,2209.5335999999998,null,2209.5335999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21260,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"X"]
[21261,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"X"]
[21263,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"X"]
[21267,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[21268,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[21270,null,"See CPT",null,1830.1788000000001,null,1333.6877999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21275,null,"See CPT",null,1512.6624000000002,null,1512.6624000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21280,null,"See CPT",null,1048.8744000000002,null,1048.8744000000002,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21282,null,"See CPT",null,715.30380000000002,null,715.30380000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[21295,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"X"]
[21296,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"X"]
[21299,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,null,"N"]
[21315,null,"See CPT",null,278.86740000000003,null,104.64960000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[21320,null,"See CPT",null,404.32799999999997,null,168.8664,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[21325,null,"See CPT",null,816.38580000000002,null,816.38580000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21330,null,"See CPT",null,975.73860000000002,null,975.73860000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21335,null,"See CPT",null,1295.6333999999999,null,1295.6333999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21336,null,"See CPT",null,1176.1188000000002,null,1176.1188000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21337,null,"See CPT",null,771.79079999999999,null,541.68060000000003,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21338,null,"See CPT",null,1230.8219999999999,null,1230.8219999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21339,null,"See CPT",null,1386.6072000000001,null,1386.6072000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21340,null,"See CPT",null,1344.9852000000001,null,1344.9852000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21343,null,"See CPT",null,1966.3422,null,1966.3422,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21344,null,"See CPT",null,2502.6714000000002,null,2502.6714000000002,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21345,null,"See CPT",null,1453.2024000000001,null,1144.605,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21346,null,"See CPT",null,1877.7467999999999,null,1877.7467999999999,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[21347,null,"See CPT",null,1887.2603999999999,null,1887.2603999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21348,null,"See CPT",null,1951.4772,null,1951.4772,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21355,null,"See CPT",null,814.00739999999996,null,588.654,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[21356,null,"See CPT",null,994.76580000000001,null,727.79039999999998,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[21360,null,"See CPT",null,938.87339999999995,null,938.87339999999995,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21365,null,"See CPT",null,1932.45,null,1932.45,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21366,null,"See CPT",null,2276.7233999999999,null,2276.7233999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[21385,null,"See CPT",null,1318.8227999999999,null,1318.8227999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21386,null,"See CPT",null,1236.768,null,1236.768,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21387,null,"See CPT",null,1375.3098,null,1375.3098,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21390,null,"See CPT",null,1438.3374000000001,null,1438.3374000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21395,null,"See CPT",null,1802.8271999999999,null,1802.8271999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21400,null,"See CPT",null,386.49,null,299.0838,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21401,null,"See CPT",null,937.68420000000003,null,589.84320000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21406,null,"See CPT",null,1049.4689999999998,null,1049.4689999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21407,null,"See CPT",null,1150.5510000000002,null,1150.5510000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21408,null,"See CPT",null,1614.3389999999999,null,1614.3389999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[21421,null,"See CPT",null,1186.2269999999999,null,994.76580000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21422,null,"See CPT",null,1123.7939999999999,null,1123.7939999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21423,null,"See CPT",null,1434.1752000000001,null,1434.1752000000001,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21431,null,"See CPT",null,1273.6332000000002,null,1273.6332000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21432,null,"See CPT",null,1299.7955999999999,null,1299.7955999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21433,null,"See CPT",null,3086.5686000000001,null,3086.5686000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21435,null,"See CPT",null,2509.212,null,2509.212,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21436,null,"See CPT",null,3623.4924000000001,null,3623.4924000000001,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21440,null,"See CPT",null,1291.4712,null,1032.8202000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21445,null,"See CPT",null,1493.0406,null,1196.3352,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21450,null,"See CPT",null,1110.1182000000001,null,896.65679999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21451,null,"See CPT",null,1436.5536,null,1193.3622,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21452,null,"See CPT",null,1423.4724000000001,null,874.06200000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21453,null,"See CPT",null,2048.3970000000004,null,1737.4212,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21454,null,"See CPT",null,869.89980000000003,null,869.89980000000003,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[21461,null,"See CPT",null,3448.68,null,1950.2879999999998,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[21462,null,"See CPT",null,3769.1694000000002,null,2170.8845999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21465,null,"See CPT",null,1417.5264,null,1417.5264,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21470,null,"See CPT",null,2075.154,null,2075.154,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21480,null,"See CPT",null,262.21860000000004,null,54.108600000000003,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[21485,null,"See CPT",null,1834.3410000000001,null,1492.4460000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21490,null,"See CPT",null,1396.1208000000001,null,1396.1208000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21497,null,"See CPT",null,1327.1472000000001,null,1098.8208,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21499,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,null,"N"]
[21501,null,"See CPT",null,894.87300000000005,null,600.54599999999994,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21502,null,"See CPT",null,907.95420000000001,null,907.95420000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21510,null,"See CPT",null,812.22360000000003,null,812.22360000000003,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21550,null,"See CPT",null,494.7072,null,279.46199999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[21552,null,"See CPT",null,799.73699999999997,null,799.73699999999997,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21554,null,"See CPT",null,1303.9577999999999,null,1303.9577999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21555,null,"See CPT",null,800.92619999999999,null,551.78879999999992,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[21556,null,"See CPT",null,951.95460000000014,null,951.95460000000014,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[21557,null,"See CPT",null,1698.7722000000001,null,1698.7722000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21558,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"X"]
[21600,null,"See CPT",null,1004.8739999999999,null,1004.8739999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21601,null,"See CPT",null,2042.451,null,2042.451,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[21602,null,"See CPT",null,2762.5116000000003,null,2762.5116000000003,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[21603,null,"See CPT",null,2995.5948000000003,null,2995.5948000000003,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[21610,null,"See CPT",null,2126.2896000000001,null,2126.2896000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21615,null,"See CPT",null,1082.172,null,1082.172,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[21616,null,"See CPT",null,1249.8491999999999,null,1249.8491999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[21620,null,"See CPT",null,903.19740000000002,null,903.19740000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21627,null,"See CPT",null,972.17100000000005,null,972.17100000000005,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21630,null,"See CPT",null,2342.1294000000003,null,2342.1294000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21632,null,"See CPT",null,2139.9654,null,2139.9654,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21685,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X"]
[21700,null,"See CPT",null,624.33000000000004,null,624.33000000000004,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[21705,null,"See CPT",null,931.73820000000001,null,931.73820000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[21720,null,"See CPT",null,947.19780000000003,null,947.19780000000003,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21725,null,"See CPT",null,975.14399999999989,null,975.14399999999989,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21740,null,"See CPT",null,1801.6380000000001,null,1801.6380000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[21742,null,"See CPT",null," By Report ",null," By Report ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"N",null,"Y-CM"]
[21743,null,"See CPT",null," By Report ",null," By Report ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"N",null,"Y-CM"]
[21750,null,"See CPT",null,1192.7675999999999,null,1192.7675999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21811,null,"See CPT",null,1039.3607999999999,null,1039.3607999999999,null,"000",0,0,0,0,2,1,2,0,0,null,"R"]
[21812,null,"See CPT",null,1261.1466,null,1261.1466,null,"000",0,0,0,0,2,1,2,0,0,null,"R"]
[21813,null,"See CPT",null,1724.34,null,1724.34,null,"000",0,0,0,0,2,1,2,0,0,null,"R"]
[21820,null,"See CPT",null,272.32679999999999,null,266.97540000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21825,null,"See CPT",null,982.27919999999995,null,982.27919999999995,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21899,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,null,"N",null,"Y-UR"]
[21920,null,"See CPT",null,478.05839999999995,null,278.86740000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[21925,null,"See CPT",null,906.17039999999997,null,678.43860000000006,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21930,null,"See CPT",null,922.81920000000002,null,652.27620000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21931,null,"See CPT",null,840.16980000000001,null,840.16980000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[21932,null,"See CPT",null,1185.0378000000001,null,1185.0378000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21933,null,"See CPT",null,1318.2282,null,1318.2282,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21935,null,"See CPT",null,1824.2328,null,1824.2328,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-CM"]
[21936,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"X"]
[22010,null,"See CPT",null,1723.1508000000001,null,1723.1508000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[22015,null,"See CPT",null,1694.0154,null,1694.0154,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[22100,null,"See CPT",null,1542.9870000000001,null,1542.9870000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22101,null,"See CPT",null,1534.068,null,1534.068,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22102,null,"See CPT",null,1392.5532000000001,null,1392.5532000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22103,null,"See CPT",null,236.6508,null,236.6508,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[22110,null,"See CPT",null,1873.5846000000001,null,1873.5846000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22112,null,"See CPT",null,2009.7479999999998,null,2009.7479999999998,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22114,null,"See CPT",null,2009.7479999999998,null,2009.7479999999998,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22116,null,"See CPT",null,246.16439999999997,null,246.16439999999997,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[22206,null,"See CPT",null,4309.0662000000002,null,4309.0662000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22207,null,"See CPT",null,4224.0384000000004,null,4224.0384000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22208,null,"See CPT",null,1025.6849999999999,null,1025.6849999999999,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22210,null,"See CPT",null,3162.0828000000001,null,3162.0828000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22212,null,"See CPT",null,2678.6729999999998,null,2678.6729999999998,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22214,null,"See CPT",null,2679.8622,null,2679.8622,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22216,null,"See CPT",null,632.65440000000001,null,632.65440000000001,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[22220,null,"See CPT",null,2868.9450000000002,null,2868.9450000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22222,null,"See CPT",null,3100.8389999999999,null,3100.8389999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22224,null,"See CPT",null,2820.7824000000001,null,2820.7824000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22226,null,"See CPT",null,629.08680000000004,null,629.08680000000004,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[22310,null,"See CPT",null,562.49160000000006,null,535.7346,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[22315,null,"See CPT",null,1587.5819999999999,null,1378.8774000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[22318,null,"See CPT",null,2896.2966000000001,null,2896.2966000000001,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[22319,null,"See CPT",null,3220.9482000000003,null,3220.9482000000003,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[22325,null,"See CPT",null,2603.1588000000002,null,2603.1588000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22326,null,"See CPT",null,2664.9972000000002,null,2664.9972000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22327,null,"See CPT",null,2709.5922,null,2709.5922,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22328,null,"See CPT",null,488.16660000000007,null,488.16660000000007,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[22505,null,"See CPT",null,230.11020000000002,null,230.11020000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[22510,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[22511,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[22512,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,1,0,0,null,"X"]
[22513,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[22514,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[22515,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,1,0,0,null,"X"]
[22526,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,9,9,9,9,9,9,null,"X"]
[22527,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[22532,null,"See CPT",null,3181.11,null,3181.11,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22533,null,"See CPT",null,2931.9726000000001,null,2931.9726000000001,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22534,null,"See CPT",null,626.70839999999998,null,626.70839999999998,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22548,null,"See CPT",null,3451.6529999999998,null,3451.6529999999998,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22551,null,"See CPT",null,2998.5677999999998,null,2998.5677999999998,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22552,null,"See CPT",null,689.73599999999999,null,689.73599999999999,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22554,null,"See CPT",null,2226.777,null,2226.777,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22556,null,"See CPT",null,2940.297,null,2940.297,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22558,null,"See CPT",null,2700.0785999999998,null,2700.0785999999998,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22585,null,"See CPT",null,567.24839999999995,null,567.24839999999995,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22586,null,"See CPT",null,3570.5729999999999,null,3570.5729999999999,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22590,null,"See CPT",null,2799.3768,null,2799.3768,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22595,null,"See CPT",null,2677.4838,null,2677.4838,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22600,null,"See CPT",null,2301.1020000000003,null,2301.1020000000003,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22610,null,"See CPT",null,2263.6422000000002,null,2263.6422000000002,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22612,null,"See CPT",null,2804.7282,null,2804.7282,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22614,null,"See CPT",null,680.81700000000001,null,680.81700000000001,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22630,null,"See CPT",null,2791.0524,null,2791.0524,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22632,null,"See CPT",null,557.14019999999994,null,557.14019999999994,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22633,null,"See CPT",null,3261.3810000000003,null,3261.3810000000003,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22634,null,"See CPT",null,863.9538,null,863.9538,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22800,null,"See CPT",null,2408.7246,null,2408.7246,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22802,null,"See CPT",null,3735.2772,null,3735.2772,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22804,null,"See CPT",null,4284.6876000000002,null,4284.6876000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22808,null,"See CPT",null,3226.2995999999998,null,3226.2995999999998,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22810,null,"See CPT",null,3560.4648000000002,null,3560.4648000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22812,null,"See CPT",null,3901.7652000000003,null,3901.7652000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22818,null,"See CPT",null,3807.2238000000002,null,3807.2238000000002,null,"090",0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22819,null,"See CPT",null,4382.7965999999997,null,4382.7965999999997,null,"090",0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22830,null,"See CPT",null,1460.9322,null,1460.9322,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22840,null,"See CPT",null,1321.7958000000001,null,1321.7958000000001,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22841,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled",null,"Y-UR"]
[22842,null,"See CPT",null,1328.3363999999999,null,1328.3363999999999,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22843,null,"See CPT",null,1420.4994000000002,null,1420.4994000000002,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22844,null,"See CPT",null,1717.7994000000001,null,1717.7994000000001,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22845,null,"See CPT",null,1265.9033999999999,null,1265.9033999999999,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22846,null,"See CPT",null,1315.8498,null,1315.8498,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22847,null,"See CPT",null,1406.8235999999999,null,1406.8235999999999,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22848,null,"See CPT",null,627.303,null,627.303,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22849,null,"See CPT",null,2310.6156000000001,null,2310.6156000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22850,null,"See CPT",null,1311.6876,null,1311.6876,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22852,null,"See CPT",null,1260.5519999999999,null,1260.5519999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22853,null,"See CPT",null,448.923,null,448.923,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22854,null,"See CPT",null,582.70800000000008,null,582.70800000000008,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22855,null,"See CPT",null,1961.5854000000002,null,1961.5854000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22856,null,"See CPT",null,2874.8910000000001,null,2874.8910000000001,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22857,null,"See CPT",null,3134.1366000000003,null,3134.1366000000003,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22858,null,"See CPT",null,882.38639999999998,null,882.38639999999998,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22859,null,"See CPT",null,579.73500000000001,null,579.73500000000001,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22861,null,"See CPT",null,4058.145,null,4058.145,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22862,null,"See CPT",null,4061.7126000000003,null,4061.7126000000003,null,"090",0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22864,null,"See CPT",null,3626.4654,null,3626.4654,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22865,null,"See CPT",null,3965.9820000000004,null,3965.9820000000004,null,"090",0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22867,null,"See CPT",null,1902.1253999999999,null,1902.1253999999999,null,"090",0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[22868,null,"See CPT",null,423.35520000000002,null,423.35520000000002,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22869,null,"See CPT",null,776.54759999999999,null,776.54759999999999,null,"090",0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[22870,null,"See CPT",null,209.8938,null,209.8938,null,"000",0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22899,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,2,1,1,null,"N",null,"Y-UR"]
[22900,null,"See CPT",null,1010.82,null,1010.82,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22901,null,"See CPT",null,1192.7675999999999,null,1192.7675999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22902,null,"See CPT",null,871.08900000000006,null,599.35680000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22903,null,"See CPT",null,788.43960000000004,null,788.43960000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[22904,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,1,1,null,"X"]
[22905,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,1,1,null,"X"]
[22999,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,null,"N",null,"Y-CM"]
[23000,null,"See CPT",null,1063.7394000000002,null,667.14120000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23020,null,"See CPT",null,1240.3355999999999,null,1240.3355999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[23030,null,"See CPT",null,818.16959999999995,null,457.84200000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[23031,null,"See CPT",null,789.62879999999996,null,393.62520000000001,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[23035,null,"See CPT",null,1228.4436000000001,null,1228.4436000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[23040,null,"See CPT",null,1293.2550000000001,null,1293.2550000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23044,null,"See CPT",null,1020.3336,null,1020.3336,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[23065,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"X"]
[23066,null,"See CPT",null,1041.1446000000001,null,658.22220000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[23071,null,"See CPT",null,753.35820000000001,null,753.35820000000001,null,"090",0.1,0.8,0.1,0,2,1,2,0,0,null,"R"]
[23073,null,"See CPT",null,1245.6869999999999,null,1245.6869999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[23075,null,"See CPT",null,962.65740000000005,null,592.81620000000009,null,"090",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23076,null,"See CPT",null,975.73860000000002,null,975.73860000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23077,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[23078,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[23100,null,"See CPT",null,915.68400000000008,null,915.68400000000008,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23101,null,"See CPT",null,827.08860000000004,null,827.08860000000004,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23105,null,"See CPT",null,1152.9294,null,1152.9294,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23106,null,"See CPT",null,909.14339999999993,null,909.14339999999993,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23107,null,"See CPT",null,1189.2,null,1189.2,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23120,null,"See CPT",null,1060.1717999999998,null,1060.1717999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23125,null,"See CPT",null,1276.6061999999999,null,1276.6061999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23130,null,"See CPT",null,1118.4425999999999,null,1118.4425999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23140,null,"See CPT",null,1002.4956,null,1002.4956,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[23145,null,"See CPT",null,1252.8222000000001,null,1252.8222000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23146,null,"See CPT",null,1124.3886,null,1124.3886,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[23150,null,"See CPT",null,1191.5783999999999,null,1191.5783999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23155,null,"See CPT",null,1432.9860000000001,null,1432.9860000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23156,null,"See CPT",null,1221.903,null,1221.903,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[23170,null,"See CPT",null,1019.1444,null,1019.1444,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[23172,null,"See CPT",null,1029.2526,null,1029.2526,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[23174,null,"See CPT",null,1374.7152000000001,null,1374.7152000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23180,null,"See CPT",null,1196.3352,null,1196.3352,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[23182,null,"See CPT",null,1211.7947999999999,null,1211.7947999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[23184,null,"See CPT",null,1328.931,null,1328.931,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23190,null,"See CPT",null,1037.577,null,1037.577,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23195,null,"See CPT",null,1333.0932,null,1333.0932,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23200,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[23210,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[23220,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[23330,null,"See CPT",null,559.51859999999999,null,300.86759999999998,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[23333,null,"See CPT",null,852.06180000000006,null,852.06180000000006,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[23334,null,"See CPT",null,1893.8010000000002,null,1893.8010000000002,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23335,null,"See CPT",null,2255.3177999999998,null,2255.3177999999998,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23350,null,"See CPT",null,314.54340000000002,null,88.000799999999998,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[23395,null,"See CPT",null,2281.4802,null,2281.4802,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[23397,null,"See CPT",null,2028.1805999999999,null,2028.1805999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[23400,null,"See CPT",null,1739.7996000000001,null,1739.7996000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23405,null,"See CPT",null,1114.2803999999999,null,1114.2803999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[23406,null,"See CPT",null,1335.4716000000001,null,1335.4716000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[23410,null,"See CPT",null,1469.8512000000001,null,1469.8512000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23412,null,"See CPT",null,1526.3382000000001,null,1526.3382000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23415,null,"See CPT",null,1257.579,null,1257.579,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23420,null,"See CPT",null,1744.5563999999999,null,1744.5563999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23430,null,"See CPT",null,1337.2554,null,1337.2554,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23440,null,"See CPT",null,1356.2826,null,1356.2826,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23450,null,"See CPT",null,1691.6369999999999,null,1691.6369999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23455,null,"See CPT",null,1773.0971999999999,null,1773.0971999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23460,null,"See CPT",null,1947.3150000000001,null,1947.3150000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23462,null,"See CPT",null,1904.5038000000002,null,1904.5038000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23465,null,"See CPT",null,1997.2614000000003,null,1997.2614000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23466,null,"See CPT",null,2002.6128000000001,null,2002.6128000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23470,null,"See CPT",null,2136.3978000000002,null,2136.3978000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23472,null,"See CPT",null,2571.0504000000001,null,2571.0504000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23473,null,"See CPT",null,2862.4043999999999,null,2862.4043999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23474,null,"See CPT",null,3087.1632,null,3087.1632,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23480,null,"See CPT",null,1469.8512000000001,null,1469.8512000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[23485,null,"See CPT",null,1698.7722000000001,null,1698.7722000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23490,null,"See CPT",null,1541.2032000000002,null,1541.2032000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[23491,null,"See CPT",null,1816.5030000000002,null,1816.5030000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23500,null,"See CPT",null,408.49020000000002,null,417.4092,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23505,null,"See CPT",null,660.00599999999997,null,611.24879999999996,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23515,null,"See CPT",null,1293.8496,null,1293.8496,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23520,null,"See CPT",null,443.57159999999999,null,437.03100000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23525,null,"See CPT",null,727.79039999999998,null,664.16819999999996,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23530,null,"See CPT",null,1039.3607999999999,null,1039.3607999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[23532,null,"See CPT",null,1129.1453999999999,null,1129.1453999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[23540,null,"See CPT",null,439.40940000000001,null,432.27420000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23545,null,"See CPT",null,645.73559999999998,null,577.95120000000009,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23550,null,"See CPT",null,1032.2256,null,1032.2256,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23552,null,"See CPT",null,1177.9025999999999,null,1177.9025999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23570,null,"See CPT",null,431.67959999999999,null,444.76080000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23575,null,"See CPT",null,753.35820000000001,null,693.89819999999997,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23585,null,"See CPT",null,1748.7185999999999,null,1748.7185999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23600,null,"See CPT",null,614.81640000000004,null,581.51879999999994,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23605,null,"See CPT",null,859.79160000000002,null,778.33140000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23615,null,"See CPT",null,1582.8252,null,1582.8252,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23616,null,"See CPT",null,2199.4254000000001,null,2199.4254000000001,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[23620,null,"See CPT",null,498.86940000000004,null,478.65300000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23625,null,"See CPT",null,704.601,null,642.76260000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23630,null,"See CPT",null,1397.9046000000001,null,1397.9046000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23650,null,"See CPT",null,598.76220000000001,null,539.30219999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23655,null,"See CPT",null,745.03379999999993,null,745.03379999999993,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23660,null,"See CPT",null,1053.6312,null,1053.6312,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23665,null,"See CPT",null,793.79099999999994,null,728.9796,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23670,null,"See CPT",null,1556.6628000000001,null,1556.6628000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23675,null,"See CPT",null,1006.0632000000002,null,908.54880000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23680,null,"See CPT",null,1658.934,null,1658.934,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23700,null,"See CPT",null,352.59780000000001,null,352.59780000000001,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23800,null,"See CPT",null,1834.9356,null,1834.9356,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23802,null,"See CPT",null,2286.8316,null,2286.8316,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23900,null,"See CPT",null,2463.4277999999999,null,2463.4277999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[23920,null,"See CPT",null,2002.6128000000001,null,2002.6128000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[23921,null,"See CPT",null,851.46720000000005,null,851.46720000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[23929,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,0,2,0,2,1,1,null,"Bundled",null,"Y-UR"]
[23930,null,"See CPT",null,669.51959999999997,null,385.30080000000004,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23931,null,"See CPT",null,566.05920000000003,null,289.5702,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23935,null,"See CPT",null,921.63,null,921.63,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24000,null,"See CPT",null,855.03480000000002,null,855.03480000000002,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,"Y-UR"]
[24006,null,"See CPT",null,1280.7683999999999,null,1280.7683999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,"Y-UR"]
[24065,null,"See CPT",null,482.81519999999995,null,294.327,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[24066,null,"See CPT",null,1141.6320000000001,null,754.54739999999993,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24071,null,"See CPT",null,727.79039999999998,null,727.79039999999998,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24073,null,"See CPT",null,1238.5518,null,1238.5518,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24075,null,"See CPT",null,"994.1+E7712",null,594.00540000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24076,null,"See CPT",null,979.9008,null,979.9008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24077,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"X"]
[24079,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[24100,null,"See CPT",null,760.49339999999995,null,760.49339999999995,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24101,null,"See CPT",null,912.1164,null,912.1164,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24102,null,"See CPT",null,1115.4696000000001,null,1115.4696000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24105,null,"See CPT",null,655.24919999999997,null,655.24919999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24110,null,"See CPT",null,1065.5232000000001,null,1065.5232000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24115,null,"See CPT",null,1324.7688000000001,null,1324.7688000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24116,null,"See CPT",null,1540.6086,null,1540.6086,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24120,null,"See CPT",null,963.25199999999995,null,963.25199999999995,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24125,null,"See CPT",null,1123.7939999999999,null,1123.7939999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24126,null,"See CPT",null,1172.5511999999999,null,1172.5511999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24130,null,"See CPT",null,922.22460000000001,null,922.22460000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[24134,null,"See CPT",null,1342.6068,null,1342.6068,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24136,null,"See CPT",null,1139.8482000000001,null,1139.8482000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24138,null,"See CPT",null,1242.1194,null,1242.1194,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24140,null,"See CPT",null,1265.3088,null,1265.3088,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24145,null,"See CPT",null,1072.6584,null,1072.6584,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24147,null,"See CPT",null,1136.8752000000002,null,1136.8752000000002,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24149,null,"See CPT",null,2108.4515999999999,null,2108.4515999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24150,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[24152,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[24155,null,"See CPT",null,1526.3382000000001,null,1526.3382000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24160,null,"See CPT",null,2229.75,null,2229.75,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24164,null,"See CPT",null,1300.3902,null,1300.3902,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24200,null,"See CPT",null,404.92259999999999,null,254.48880000000003,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[24201,null,"See CPT",null,1009.6308,null,659.41139999999996,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24220,null,"See CPT",null,361.51679999999999,null,116.5416,null,"000",0,0,0,0,2,1,0,0,0,null,"R"]
[24300,null,"See CPT",null,796.76400000000001,null,796.76400000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24301,null,"See CPT",null,1346.769,null,1346.769,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[24305,null,"See CPT",null,1045.3067999999998,null,1045.3067999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[24310,null,"See CPT",null,860.98080000000004,null,860.98080000000004,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[24320,null,"See CPT",null,1399.6884,null,1399.6884,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[24330,null,"See CPT",null,1290.8766000000001,null,1290.8766000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24331,null,"See CPT",null,1409.202,null,1409.202,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24332,null,"See CPT",null,1110.7128,null,1110.7128,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[24340,null,"See CPT",null,1114.875,null,1114.875,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24341,null,"See CPT",null,1340.8230000000001,null,1340.8230000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24342,null,"See CPT",null,1390.7694000000001,null,1390.7694000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24343,null,"See CPT",null,1287.309,null,1287.309,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24344,null,"See CPT",null,1959.8016,null,1959.8016,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24345,null,"See CPT",null,1280.7683999999999,null,1280.7683999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24346,null,"See CPT",null,1976.4504000000002,null,1976.4504000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24357,null,"See CPT",null,760.49339999999995,null,760.49339999999995,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24358,null,"See CPT",null,956.71140000000003,null,956.71140000000003,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24359,null,"See CPT",null,1192.173,null,1192.173,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24360,null,"See CPT",null,1618.5011999999999,null,1618.5011999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24361,null,"See CPT",null,1802.8271999999999,null,1802.8271999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24362,null,"See CPT",null,1895.5847999999999,null,1895.5847999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24363,null,"See CPT",null,2572.2395999999999,null,2572.2395999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24365,null,"See CPT",null,1155.3078,null,1155.3078,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24366,null,"See CPT",null,1225.4705999999999,null,1225.4705999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24370,null,"See CPT",null,2732.1870000000004,null,2732.1870000000004,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24371,null,"See CPT",null,3136.5149999999999,null,3136.5149999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24400,null,"See CPT",null,1481.1486,null,1481.1486,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24410,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[24420,null,"See CPT",null,1924.7202,null,1924.7202,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24430,null,"See CPT",null,1883.6928,null,1883.6928,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24435,null,"See CPT",null,1932.45,null,1932.45,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24470,null,"See CPT",null,1211.2002,null,1211.2002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[24495,null,"See CPT",null,1475.2025999999998,null,1475.2025999999998,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24498,null,"See CPT",null,1551.9060000000002,null,1551.9060000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24500,null,"See CPT",null,665.952,null,613.0326,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24505,null,"See CPT",null,922.22460000000001,null,824.71019999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24515,null,"See CPT",null,1580.4467999999999,null,1580.4467999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24516,null,"See CPT",null,1538.2302,null,1538.2302,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[24530,null,"See CPT",null,702.81720000000007,null,643.95180000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24535,null,"See CPT",null,1126.1724000000002,null,1031.6310000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24538,null,"See CPT",null,1431.7967999999998,null,1431.7967999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24545,null,"See CPT",null,1660.7177999999999,null,1660.7177999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24546,null,"See CPT",null,1852.1789999999999,null,1852.1789999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[24560,null,"See CPT",null,614.22180000000003,null,541.68060000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24565,null,"See CPT",null,989.4144,null,900.22440000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24566,null,"See CPT",null,1299.7955999999999,null,1299.7955999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24575,null,"See CPT",null,1317.039,null,1317.039,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24576,null,"See CPT",null,648.70860000000005,null,576.16739999999993,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24577,null,"See CPT",null,1016.7660000000001,null,924.60300000000007,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24579,null,"See CPT",null,1495.4189999999999,null,1495.4189999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24582,null,"See CPT",null,1472.2296000000001,null,1472.2296000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24586,null,"See CPT",null,1940.7744,null,1940.7744,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24587,null,"See CPT",null,1943.7474,null,1943.7474,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24600,null,"See CPT",null,684.38459999999998,null,616.60019999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24605,null,"See CPT",null,869.89980000000003,null,869.89980000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24615,null,"See CPT",null,1281.9576,null,1281.9576,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24620,null,"See CPT",null,1020.3336,null,1020.3336,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24635,null,"See CPT",null,1215.3624000000002,null,1215.3624000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24640,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"X"]
[24650,null,"See CPT",null,486.38279999999997,null,451.3014,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24655,null,"See CPT",null,819.95339999999999,null,737.30400000000009,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24665,null,"See CPT",null,1187.4161999999999,null,1187.4161999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24666,null,"See CPT",null,1315.8498,null,1315.8498,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24670,null,"See CPT",null,539.89679999999998,null,492.32879999999994,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24675,null,"See CPT",null,850.87260000000003,null,768.22320000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24685,null,"See CPT",null,1178.4972,null,1178.4972,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24800,null,"See CPT",null,1496.0136,null,1496.0136,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24802,null,"See CPT",null,1793.9082000000001,null,1793.9082000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24900,null,"See CPT",null,1324.7688000000001,null,1324.7688000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24920,null,"See CPT",null,1315.8498,null,1315.8498,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24925,null,"See CPT",null,1027.4688000000001,null,1027.4688000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24930,null,"See CPT",null,1387.7963999999999,null,1387.7963999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24931,null,"See CPT",null,1664.2854,null,1664.2854,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24935,null,"See CPT",null,2201.8038000000001,null,2201.8038000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24940,null,"See CPT",null,2003.7910155120003,null,2003.7910155120003,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"F",null,"Y-UR"]
[24999,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,0,1,1,null,"N",null,"Y-UR"]
[25000,null,"See CPT",null,628.49220000000003,null,628.49220000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25001,null,"See CPT",null,630.27599999999995,null,630.27599999999995,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25020,null,"See CPT",null,1384.8234,null,1384.8234,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25023,null,"See CPT",null,2417.049,null,2417.049,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[25024,null,"See CPT",null,1403.8506,null,1403.8506,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25025,null,"See CPT",null,2101.3164000000002,null,2101.3164000000002,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[25028,null,"See CPT",null,1300.3902,null,1300.3902,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25031,null,"See CPT",null,669.51959999999997,null,669.51959999999997,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25035,null,"See CPT",null,1057.1988000000001,null,1057.1988000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25040,null,"See CPT",null,1007.847,null,1007.847,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25065,null,"See CPT",null,475.68,null,284.8134,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[25066,null,"See CPT",null,662.97900000000004,null,662.97900000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25071,null,"See CPT",null,761.08800000000008,null,761.08800000000008,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25073,null,"See CPT",null,962.06280000000004,null,962.06280000000004,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25075,null,"See CPT",null,969.19800000000009,null,569.03219999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25076,null,"See CPT",null,931.73820000000001,null,931.73820000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25077,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"X"]
[25078,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"X"]
[25085,null,"See CPT",null,811.03440000000001,null,811.03440000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25100,null,"See CPT",null,636.81660000000011,null,636.81660000000011,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25101,null,"See CPT",null,734.92560000000003,null,734.92560000000003,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25105,null,"See CPT",null,880.60260000000005,null,880.60260000000005,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25107,null,"See CPT",null,1113.6858,null,1113.6858,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25109,null,"See CPT",null,966.81960000000015,null,966.81960000000015,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25110,null,"See CPT",null,630.27599999999995,null,630.27599999999995,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25111,null,"See CPT",null,589.84320000000002,null,589.84320000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25112,null,"See CPT",null,707.57400000000007,null,707.57400000000007,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25115,null,"See CPT",null,1357.4718,null,1357.4718,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25116,null,"See CPT",null,1088.1180000000002,null,1088.1180000000002,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25118,null,"See CPT",null,694.49279999999999,null,694.49279999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25119,null,"See CPT",null,909.73800000000006,null,909.73800000000006,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25120,null,"See CPT",null,907.3596,null,907.3596,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25125,null,"See CPT",null,1075.0367999999999,null,1075.0367999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25126,null,"See CPT",null,1082.7666000000002,null,1082.7666000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25130,null,"See CPT",null,818.16959999999995,null,818.16959999999995,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25135,null,"See CPT",null,1013.793,null,1013.793,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25136,null,"See CPT",null,902.6028,null,902.6028,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25145,null,"See CPT",null,943.03559999999993,null,943.03559999999993,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25150,null,"See CPT",null,1025.0903999999998,null,1025.0903999999998,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25151,null,"See CPT",null,1054.2257999999999,null,1054.2257999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25170,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[25210,null,"See CPT",null,890.71080000000006,null,890.71080000000006,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[25215,null,"See CPT",null,1115.4696000000001,null,1115.4696000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25230,null,"See CPT",null,783.68280000000004,null,783.68280000000004,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25240,null,"See CPT",null,777.73680000000002,null,777.73680000000002,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25246,null,"See CPT",null,372.21960000000001,null,128.43360000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[25248,null,"See CPT",null,759.30420000000004,null,759.30420000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25250,null,"See CPT",null,966.22500000000002,null,966.22500000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25251,null,"See CPT",null,1293.2550000000001,null,1293.2550000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25259,null,"See CPT",null,787.84500000000003,null,787.84500000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25260,null,"See CPT",null,1145.7942,null,1145.7942,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[25263,null,"See CPT",null,1145.7942,null,1145.7942,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[25265,null,"See CPT",null,1350.3366000000001,null,1350.3366000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[25270,null,"See CPT",null,893.68380000000002,null,893.68380000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[25272,null,"See CPT",null,1011.4146000000001,null,1011.4146000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[25274,null,"See CPT",null,1196.9297999999999,null,1196.9297999999999,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[25275,null,"See CPT",null,1210.0110000000002,null,1210.0110000000002,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25280,null,"See CPT",null,1022.712,null,1022.712,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[25290,null,"See CPT",null,789.62879999999996,null,789.62879999999996,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[25295,null,"See CPT",null,952.54920000000004,null,952.54920000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[25300,null,"See CPT",null,1244.4978000000001,null,1244.4978000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25301,null,"See CPT",null,1157.6861999999999,null,1157.6861999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25310,null,"See CPT",null,1118.4425999999999,null,1118.4425999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[25312,null,"See CPT",null,1286.1197999999999,null,1286.1197999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[25315,null,"See CPT",null,1381.8504,null,1381.8504,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25316,null,"See CPT",null,1642.2852,null,1642.2852,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25320,null,"See CPT",null,1768.3404,null,1768.3404,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[25332,null,"See CPT",null,1515.0408,null,1515.0408,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25335,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"X"]
[25337,null,"See CPT",null,1590.5550000000001,null,1590.5550000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25350,null,"See CPT",null,1214.1732000000002,null,1214.1732000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25355,null,"See CPT",null,1374.7152000000001,null,1374.7152000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25360,null,"See CPT",null,1180.2810000000002,null,1180.2810000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25365,null,"See CPT",null,1644.069,null,1644.069,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25370,null,"See CPT",null,1814.1246000000001,null,1814.1246000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25375,null,"See CPT",null,1708.8804,null,1708.8804,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25390,null,"See CPT",null,1380.0666000000001,null,1380.0666000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25391,null,"See CPT",null,1782.6108000000002,null,1782.6108000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25392,null,"See CPT",null,1813.53,null,1813.53,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25393,null,"See CPT",null,2015.694,null,2015.694,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25394,null,"See CPT",null,1408.0128,null,1408.0128,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25400,null,"See CPT",null,1438.932,null,1438.932,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25405,null,"See CPT",null,1855.7466000000002,null,1855.7466000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25415,null,"See CPT",null,1733.8536000000001,null,1733.8536000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25420,null,"See CPT",null,2081.6945999999998,null,2081.6945999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25425,null,"See CPT",null,1726.7184,null,1726.7184,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25426,null,"See CPT",null,2004.3966,null,2004.3966,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25430,null,"See CPT",null,1315.8498,null,1315.8498,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25431,null,"See CPT",null,1413.3642,null,1413.3642,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25440,null,"See CPT",null,1378.2828,null,1378.2828,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25441,null,"See CPT",null,1680.3396,null,1680.3396,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25442,null,"See CPT",null,1454.3916000000002,null,1454.3916000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25443,null,"See CPT",null,1410.9858000000002,null,1410.9858000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25444,null,"See CPT",null,1487.6892,null,1487.6892,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25445,null,"See CPT",null,1292.0658000000001,null,1292.0658000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25446,null,"See CPT",null,2087.6406000000002,null,2087.6406000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25447,null,"See CPT",null,1492.4460000000001,null,1492.4460000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25449,null,"See CPT",null,1848.0167999999999,null,1848.0167999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25450,null,"See CPT",null,1114.875,null,1114.875,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[25455,null,"See CPT",null,1315.8498,null,1315.8498,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[25490,null,"See CPT",null,1292.6604,null,1292.6604,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25491,null,"See CPT",null,1328.3363999999999,null,1328.3363999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25492,null,"See CPT",null,1625.6364000000001,null,1625.6364000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25500,null,"See CPT",null,525.03179999999998,null,472.70699999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25505,null,"See CPT",null,924.60300000000007,null,836.00760000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25515,null,"See CPT",null,1206.4433999999999,null,1206.4433999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25520,null,"See CPT",null,1053.6312,null,990.60360000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25525,null,"See CPT",null,1416.9317999999998,null,1416.9317999999998,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[25526,null,"See CPT",null,1714.2318,null,1714.2318,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[25530,null,"See CPT",null,486.97739999999999,null,445.95,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25535,null,"See CPT",null,907.95420000000001,null,834.22379999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25545,null,"See CPT",null,1127.3616000000002,null,1127.3616000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25560,null,"See CPT",null,535.14,null,475.68,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25565,null,"See CPT",null,949.57620000000009,null,846.71040000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25574,null,"See CPT",null,1215.3624000000002,null,1215.3624000000002,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[25575,null,"See CPT",null,1622.0688,null,1622.0688,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25600,null,"See CPT",null,625.51919999999996,null,597.57300000000009,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25605,null,"See CPT",null,985.84679999999992,null,929.95440000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25606,null,"See CPT",null,1205.8488,null,1205.8488,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25607,null,"See CPT",null,1330.1202000000001,null,1330.1202000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25608,null,"See CPT",null,1485.9053999999999,null,1485.9053999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25609,null,"See CPT",null,1884.8820000000001,null,1884.8820000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25622,null,"See CPT",null,567.24839999999995,null,522.65339999999992,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25624,null,"See CPT",null,902.00819999999999,null,814.60199999999998,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25628,null,"See CPT",null,1295.6333999999999,null,1295.6333999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25630,null,"See CPT",null,562.49160000000006,null,521.46420000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25635,null,"See CPT",null,855.62940000000003,null,774.16919999999993,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25645,null,"See CPT",null,1032.2256,null,1032.2256,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25650,null,"See CPT",null,608.2758,null,561.30240000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25651,null,"See CPT",null,886.54859999999996,null,886.54859999999996,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25652,null,"See CPT",null,1123.7939999999999,null,1123.7939999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25660,null,"See CPT",null,818.76419999999996,null,818.76419999999996,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25670,null,"See CPT",null,1097.6316000000002,null,1097.6316000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25671,null,"See CPT",null,959.6844000000001,null,959.6844000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25675,null,"See CPT",null,822.92640000000006,null,740.27699999999993,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25676,null,"See CPT",null,1137.4697999999999,null,1137.4697999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25680,null,"See CPT",null,963.84660000000008,null,963.84660000000008,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25685,null,"See CPT",null,1321.2012,null,1321.2012,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25690,null,"See CPT",null,894.87300000000005,null,894.87300000000005,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25695,null,"See CPT",null,1144.0103999999999,null,1144.0103999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25800,null,"See CPT",null,1314.6605999999999,null,1314.6605999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25805,null,"See CPT",null,1521.5814,null,1521.5814,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25810,null,"See CPT",null,1550.1222,null,1550.1222,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25820,null,"See CPT",null,1180.8756000000001,null,1180.8756000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25825,null,"See CPT",null,1438.3374000000001,null,1438.3374000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25830,null,"See CPT",null,1894.3956000000001,null,1894.3956000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25900,null,"See CPT",null,1287.9036000000001,null,1287.9036000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25905,null,"See CPT",null,1262.9304,null,1262.9304,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25907,null,"See CPT",null,1108.3344,null,1108.3344,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25909,null,"See CPT",null,1233.7950000000001,null,1233.7950000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25915,null,"See CPT",null,2078.1270000000004,null,2078.1270000000004,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25920,null,"See CPT",null,1325.9580000000001,null,1325.9580000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25922,null,"See CPT",null,1177.9025999999999,null,1177.9025999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25924,null,"See CPT",null,1296.2280000000001,null,1296.2280000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25927,null,"See CPT",null,1590.5550000000001,null,1590.5550000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25929,null,"See CPT",null,1081.5774000000001,null,1081.5774000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25931,null,"See CPT",null,1476.9864,null,1476.9864,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25999,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,0,1,1,null,"N"]
[26010,null,"See CPT",null,655.24919999999997,null,254.48880000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[26011,null,"See CPT",null,914.49480000000005,null,334.75979999999998,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[26020,null,"See CPT",null,1006.0632000000002,null,1006.0632000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26025,null,"See CPT",null,762.27719999999999,null,762.27719999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26030,null,"See CPT",null,886.54859999999996,null,886.54859999999996,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26034,null,"See CPT",null,999.5225999999999,null,999.5225999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26035,null,"See CPT",null,1546.5546000000002,null,1546.5546000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26037,null,"See CPT",null,1009.0361999999999,null,1009.0361999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26040,null,"See CPT",null,574.97820000000002,null,574.97820000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26045,null,"See CPT",null,855.62940000000003,null,855.62940000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26055,null,"See CPT",null,1111.902,null,529.78859999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26060,null,"See CPT",null,467.35560000000004,null,467.35560000000004,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26070,null,"See CPT",null,582.70800000000008,null,582.70800000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26075,null,"See CPT",null,613.62720000000002,null,613.62720000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26080,null,"See CPT",null,724.81740000000002,null,724.81740000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26100,null,"See CPT",null,617.7894,null,617.7894,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26105,null,"See CPT",null,621.9516000000001,null,621.9516000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26110,null,"See CPT",null,592.22160000000008,null,592.22160000000008,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26111,null,"See CPT",null,747.41219999999998,null,747.41219999999998,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26113,null,"See CPT",null,982.87380000000007,null,982.87380000000007,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26115,null,"See CPT",null,1020.9282000000001,null,598.16759999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26116,null,"See CPT",null,945.41399999999999,null,945.41399999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26117,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"X"]
[26118,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"X"]
[26121,null,"See CPT",null,1080.9828,null,1080.9828,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26123,null,"See CPT",null,1504.9325999999999,null,1504.9325999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26125,null,"See CPT",null,473.89619999999996,null,473.89619999999996,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[26130,null,"See CPT",null,851.46720000000005,null,851.46720000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26135,null,"See CPT",null,1001.9010000000001,null,1001.9010000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26140,null,"See CPT",null,919.25160000000005,null,919.25160000000005,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26145,null,"See CPT",null,932.33280000000002,null,932.33280000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26160,null,"See CPT",null,1155.3078,null,572.59980000000007,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26170,null,"See CPT",null,740.27699999999993,null,740.27699999999993,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26180,null,"See CPT",null,814.60199999999998,null,814.60199999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26185,null,"See CPT",null,1007.847,null,1007.847,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26200,null,"See CPT",null,812.81820000000005,null,812.81820000000005,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26205,null,"See CPT",null,1093.4694,null,1093.4694,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26210,null,"See CPT",null,811.03440000000001,null,811.03440000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26215,null,"See CPT",null,1025.0903999999998,null,1025.0903999999998,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26230,null,"See CPT",null,903.19740000000002,null,903.19740000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26235,null,"See CPT",null,888.92700000000002,null,888.92700000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26236,null,"See CPT",null,799.73699999999997,null,799.73699999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26250,null,"See CPT",null,1900.3416,null,1900.3416,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26260,null,"See CPT",null,1427.04,null,1427.04,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26262,null,"See CPT",null,1133.3075999999999,null,1133.3075999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26320,null,"See CPT",null,635.62739999999997,null,635.62739999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26340,null,"See CPT",null,647.51940000000002,null,647.51940000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26341,null,"See CPT",null,215.24520000000001,null,141.51480000000001,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[26350,null,"See CPT",null,1392.5532000000001,null,1392.5532000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26352,null,"See CPT",null,1545.96,null,1545.96,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26356,null,"See CPT",null,1438.3374000000001,null,1438.3374000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26357,null,"See CPT",null,1610.1768,null,1610.1768,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26358,null,"See CPT",null,1775.4756,null,1775.4756,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26370,null,"See CPT",null,1460.3375999999998,null,1460.3375999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26372,null,"See CPT",null,1696.9884,null,1696.9884,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26373,null,"See CPT",null,1635.7446000000002,null,1635.7446000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26390,null,"See CPT",null,1618.5011999999999,null,1618.5011999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26392,null,"See CPT",null,1850.3952000000002,null,1850.3952000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26410,null,"See CPT",null,1124.9832000000001,null,1124.9832000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26412,null,"See CPT",null,1334.2824000000001,null,1334.2824000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26415,null,"See CPT",null,1577.4738,null,1577.4738,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26416,null,"See CPT",null,1701.7452000000001,null,1701.7452000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26418,null,"See CPT",null,1168.9836,null,1168.9836,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26420,null,"See CPT",null,1384.2288000000001,null,1384.2288000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26426,null,"See CPT",null,910.33260000000007,null,910.33260000000007,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26428,null,"See CPT",null,1480.5539999999999,null,1480.5539999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26432,null,"See CPT",null,1019.1444,null,1019.1444,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26433,null,"See CPT",null,1069.6853999999998,null,1069.6853999999998,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26434,null,"See CPT",null,1295.6333999999999,null,1295.6333999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26437,null,"See CPT",null,1240.3355999999999,null,1240.3355999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26440,null,"See CPT",null,1218.93,null,1218.93,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26442,null,"See CPT",null,1824.8274000000001,null,1824.8274000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26445,null,"See CPT",null,1141.6320000000001,null,1141.6320000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26449,null,"See CPT",null,1257.579,null,1257.579,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26450,null,"See CPT",null,865.73760000000004,null,865.73760000000004,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26455,null,"See CPT",null,856.22400000000005,null,856.22400000000005,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26460,null,"See CPT",null,843.14279999999997,null,843.14279999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26471,null,"See CPT",null,1228.4436000000001,null,1228.4436000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26474,null,"See CPT",null,1215.9569999999999,null,1215.9569999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26476,null,"See CPT",null,1202.2811999999999,null,1202.2811999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26477,null,"See CPT",null,1166.0106000000001,null,1166.0106000000001,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[26478,null,"See CPT",null,1234.3896000000002,null,1234.3896000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26479,null,"See CPT",null,1259.3628000000001,null,1259.3628000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26480,null,"See CPT",null,1461.5267999999999,null,1461.5267999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26483,null,"See CPT",null,1612.5552,null,1612.5552,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26485,null,"See CPT",null,1548.3383999999999,null,1548.3383999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26489,null,"See CPT",null,1784.9892,null,1784.9892,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26490,null,"See CPT",null,1550.7167999999999,null,1550.7167999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26492,null,"See CPT",null,1709.4750000000001,null,1709.4750000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26494,null,"See CPT",null,1556.0682000000002,null,1556.0682000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26496,null,"See CPT",null,1670.826,null,1670.826,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26497,null,"See CPT",null,1669.0422000000001,null,1669.0422000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26498,null,"See CPT",null,2156.6142000000004,null,2156.6142000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26499,null,"See CPT",null,1607.7983999999999,null,1607.7983999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26500,null,"See CPT",null,1243.3086000000001,null,1243.3086000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26502,null,"See CPT",null,1402.0667999999998,null,1402.0667999999998,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26508,null,"See CPT",null,1257.579,null,1257.579,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26510,null,"See CPT",null,1195.7406000000001,null,1195.7406000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26516,null,"See CPT",null,1378.2828,null,1378.2828,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26517,null,"See CPT",null,1599.4739999999999,null,1599.4739999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26518,null,"See CPT",null,1619.6904,null,1619.6904,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26520,null,"See CPT",null,1277.2008000000001,null,1277.2008000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26525,null,"See CPT",null,1281.3630000000001,null,1281.3630000000001,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[26530,null,"See CPT",null,978.11699999999996,null,978.11699999999996,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26531,null,"See CPT",null,1138.6589999999999,null,1138.6589999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26535,null,"See CPT",null,790.8180000000001,null,790.8180000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26536,null,"See CPT",null,1394.337,null,1394.337,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26540,null,"See CPT",null,1299.201,null,1299.201,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[26541,null,"See CPT",null,1538.2302,null,1538.2302,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26542,null,"See CPT",null,1340.2284,null,1340.2284,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26545,null,"See CPT",null,1356.2826,null,1356.2826,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26546,null,"See CPT",null,1902.1253999999999,null,1902.1253999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26548,null,"See CPT",null,1475.2025999999998,null,1475.2025999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26550,null,"See CPT",null,3002.73,null,3002.73,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26551,null,"See CPT",null,5901.9996000000001,null,5901.9996000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26553,null,"See CPT",null,5862.1614,null,5862.1614,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26554,null,"See CPT",null,6814.116,null,6814.116,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26555,null,"See CPT",null,2533.5906,null,2533.5906,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26556,null,"See CPT",null,6097.0284000000001,null,6097.0284000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26560,null,"See CPT",null,1186.2269999999999,null,1186.2269999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26561,null,"See CPT",null,1805.8002000000001,null,1805.8002000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26562,null,"See CPT",null,2505.6444000000001,null,2505.6444000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26565,null,"See CPT",null,1331.3094000000001,null,1331.3094000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26567,null,"See CPT",null,1334.877,null,1334.877,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26568,null,"See CPT",null,1725.5291999999999,null,1725.5291999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26580,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"X"]
[26587,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"X"]
[26590,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"X"]
[26591,null,"See CPT",null,913.30560000000003,null,913.30560000000003,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26593,null,"See CPT",null,1201.6866,null,1201.6866,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26596,null,"See CPT",null,1500.1758,null,1500.1758,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26600,null,"See CPT",null,555.95100000000002,null,528.00480000000005,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26605,null,"See CPT",null,610.65419999999995,null,548.22120000000007,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26607,null,"See CPT",null,934.71120000000008,null,934.71120000000008,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26608,null,"See CPT",null,877.03499999999997,null,877.03499999999997,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26615,null,"See CPT",null,1040.55,null,1040.55,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26641,null,"See CPT",null,771.19620000000009,null,700.43880000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26645,null,"See CPT",null,795.5748000000001,null,721.84440000000006,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26650,null,"See CPT",null,877.62959999999998,null,877.62959999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26665,null,"See CPT",null,1128.5508,null,1128.5508,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[26670,null,"See CPT",null,640.97879999999998,null,570.22140000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26675,null,"See CPT",null,847.30500000000006,null,770.60160000000008,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26676,null,"See CPT",null,926.98140000000001,null,926.98140000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26685,null,"See CPT",null,1042.3338000000001,null,1042.3338000000001,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[26686,null,"See CPT",null,1124.9832000000001,null,1124.9832000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26700,null,"See CPT",null,619.57320000000004,null,567.84300000000007,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26705,null,"See CPT",null,778.92600000000004,null,704.00639999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26706,null,"See CPT",null,812.22360000000003,null,812.22360000000003,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26715,null,"See CPT",null,1036.9824000000001,null,1036.9824000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26720,null,"See CPT",null,369.2466,null,346.65180000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26725,null,"See CPT",null,629.08680000000004,null,557.14019999999994,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26727,null,"See CPT",null,863.35919999999999,null,863.35919999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26735,null,"See CPT",null,1074.4422,null,1074.4422,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26740,null,"See CPT",null,429.30119999999999,null,405.5172,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26742,null,"See CPT",null,687.35760000000005,null,614.22180000000003,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26746,null,"See CPT",null,1336.6608000000001,null,1336.6608000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26750,null,"See CPT",null,344.27339999999998,null,346.65180000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26755,null,"See CPT",null,588.654,null,502.43699999999995,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26756,null,"See CPT",null,775.95300000000009,null,775.95300000000009,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26765,null,"See CPT",null,910.92720000000008,null,910.92720000000008,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26770,null,"See CPT",null,523.84260000000006,null,474.49080000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26775,null,"See CPT",null,722.43900000000008,null,645.73559999999998,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26776,null,"See CPT",null,821.14260000000002,null,821.14260000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26785,null,"See CPT",null,988.81979999999999,null,988.81979999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26820,null,"See CPT",null,1534.6625999999999,null,1534.6625999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26841,null,"See CPT",null,1432.3914,null,1432.3914,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[26842,null,"See CPT",null,1538.8247999999999,null,1538.8247999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26843,null,"See CPT",null,1450.8239999999998,null,1450.8239999999998,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26844,null,"See CPT",null,1589.3658,null,1589.3658,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26850,null,"See CPT",null,1361.634,null,1361.634,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26852,null,"See CPT",null,1535.8517999999999,null,1535.8517999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26860,null,"See CPT",null,1142.8211999999999,null,1142.8211999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26861,null,"See CPT",null,179.5692,null,179.5692,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[26862,null,"See CPT",null,1418.1210000000001,null,1418.1210000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26863,null,"See CPT",null,400.16580000000005,null,400.16580000000005,null,"000",0,0,0,0,0,0,2,0,0,null,"R"]
[26910,null,"See CPT",null,1408.0128,null,1408.0128,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26951,null,"See CPT",null,1298.6064000000001,null,1298.6064000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26952,null,"See CPT",null,1268.2818,null,1268.2818,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26989,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,1,1,1,null,"N"]
[26990,null,"See CPT",null,1240.3355999999999,null,1240.3355999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26991,null,"See CPT",null,1294.4441999999999,null,941.84640000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26992,null,"See CPT",null,1814.7192,null,1814.7192,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[27000,null,"See CPT",null,727.19580000000008,null,727.19580000000008,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27001,null,"See CPT",null,973.36020000000008,null,973.36020000000008,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27003,null,"See CPT",null,1080.3882000000001,null,1080.3882000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27005,null,"See CPT",null,1297.4172000000001,null,1297.4172000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27006,null,"See CPT",null,1288.4982000000002,null,1288.4982000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27025,null,"See CPT",null,1651.7988,null,1651.7988,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[27027,null,"See CPT",null,1581.0414000000001,null,1581.0414000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27030,null,"See CPT",null,1673.2044000000001,null,1673.2044000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27033,null,"See CPT",null,1735.6374000000001,null,1735.6374000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27035,null,"See CPT",null,2069.8026,null,2069.8026,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27036,null,"See CPT",null,1820.6652000000001,null,1820.6652000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27040,null,"See CPT",null,626.70839999999998,null,353.19240000000002,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27041,null,"See CPT",null,1268.8764000000001,null,1268.8764000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27043,null,"See CPT",null,838.38599999999997,null,838.38599999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27045,null,"See CPT",null,1309.9038,null,1309.9038,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27047,null,"See CPT",null,910.92720000000008,null,647.51940000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27048,null,"See CPT",null,1089.9017999999999,null,1089.9017999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27049,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[27050,null,"See CPT",null,734.92560000000003,null,734.92560000000003,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[27052,null,"See CPT",null,1041.7392,null,1041.7392,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27054,null,"See CPT",null,1236.768,null,1236.768,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27057,null,"See CPT",null,1801.0434,null,1801.0434,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27059,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[27060,null,"See CPT",null,841.35900000000004,null,841.35900000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27062,null,"See CPT",null,822.33180000000004,null,822.33180000000004,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27065,null,"See CPT",null,950.17079999999999,null,950.17079999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27066,null,"See CPT",null,1462.1214,null,1462.1214,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27067,null,"See CPT",null,1850.9898000000001,null,1850.9898000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27070,null,"See CPT",null,1606.0146000000002,null,1606.0146000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27071,null,"See CPT",null,1760.0160000000001,null,1760.0160000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27075,null,"See CPT",null,3687.7092000000002,null,3687.7092000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27076,null,"See CPT",null,4452.3647999999994,null,4452.3647999999994,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27077,null,"See CPT",null,4963.7208000000001,null,4963.7208000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27078,null,"See CPT",null,3635.9789999999998,null,3635.9789999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27080,null,"See CPT",null,918.06240000000003,null,918.06240000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27086,null,"See CPT",null,579.1404,null,303.84060000000005,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27087,null,"See CPT",null,1099.4153999999999,null,1099.4153999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27090,null,"See CPT",null,1487.6892,null,1487.6892,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27091,null,"See CPT",null,2827.9176000000002,null,2827.9176000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27093,null,"See CPT",null,449.51759999999996,null,118.92,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[27095,null,"See CPT",null,605.89739999999995,null,145.67700000000002,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[27096,null,"See CPT",null,299.0838,null,145.67700000000002,null,"000",0,0,0,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27097,null,"See CPT",null,1229.6328000000001,null,1229.6328000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27098,null,"See CPT",null,1251.633,null,1251.633,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27100,null,"See CPT",null,1490.0675999999999,null,1490.0675999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27105,null,"See CPT",null,1561.4196000000002,null,1561.4196000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27110,null,"See CPT",null,1738.0158000000001,null,1738.0158000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27111,null,"See CPT",null,1619.0958000000001,null,1619.0958000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27120,null,"See CPT",null,2312.3994000000002,null,2312.3994000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27122,null,"See CPT",null,1969.3151999999998,null,1969.3151999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27125,null,"See CPT",null,2015.694,null,2015.694,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27130,null,"See CPT",null,2280.8856000000001,null,2280.8856000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27132,null,"See CPT",null,2963.4864000000002,null,2963.4864000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27134,null,"See CPT",null,3371.3820000000001,null,3371.3820000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27137,null,"See CPT",null,2598.9965999999999,null,2598.9965999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27138,null,"See CPT",null,2700.6732000000002,null,2700.6732000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27140,null,"See CPT",null,1598.2847999999999,null,1598.2847999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27146,null,"See CPT",null,2279.1017999999999,null,2279.1017999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27147,null,"See CPT",null,2598.9965999999999,null,2598.9965999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27151,null,"See CPT",null,2807.1066000000001,null,2807.1066000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27156,null,"See CPT",null,3022.9464000000003,null,3022.9464000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27158,null,"See CPT",null,2488.9956000000002,null,2488.9956000000002,null,"090",0.1,0.69,0.21,0,2,2,2,0,0,null,"R"]
[27161,null,"See CPT",null,2175.6414000000004,null,2175.6414000000004,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27165,null,"See CPT",null,2455.1034,null,2455.1034,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27170,null,"See CPT",null,2074.5594000000001,null,2074.5594000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27175,null,"See CPT",null,1193.9567999999999,null,1193.9567999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27176,null,"See CPT",null,1651.2041999999999,null,1651.2041999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27177,null,"See CPT",null,1991.3154000000002,null,1991.3154000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27178,null,"See CPT",null,1651.2041999999999,null,1651.2041999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27179,null,"See CPT",null,1751.097,null,1751.097,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27181,null,"See CPT",null,1997.2614000000003,null,1997.2614000000003,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27185,null,"See CPT",null,1290.8766000000001,null,1290.8766000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27187,null,"See CPT",null,1782.6108000000002,null,1782.6108000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27197,null,"See CPT",null,242.5968,null,242.5968,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[27198,null,"See CPT",null,569.6268,null,569.6268,null,"000",0,0,0,0,2,0,0,2,0,null,"R"]
[27200,null,"See CPT",null,344.27339999999998,null,345.46260000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[27202,null,"See CPT",null,946.60320000000002,null,946.60320000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[27215,null,"See CPT",null,1076.2260000000001,null,1076.2260000000001,null,"090",0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27216,null,"See CPT",null,1589.9603999999999,null,1589.9603999999999,null,"090",0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27217,null,"See CPT",null,1494.8244,null,1494.8244,null,"090",0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27218,null,"See CPT",null,2048.3970000000004,null,2048.3970000000004,null,"090",0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27220,null,"See CPT",null,756.33120000000008,null,743.84460000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27222,null,"See CPT",null,1760.0160000000001,null,1760.0160000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27226,null,"See CPT",null,1881.3144,null,1881.3144,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27227,null,"See CPT",null,2927.8104000000003,null,2927.8104000000003,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27228,null,"See CPT",null,3325.0032000000001,null,3325.0032000000001,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27230,null,"See CPT",null,883.57560000000001,null,865.73760000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27232,null,"See CPT",null,1314.066,null,1314.066,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27235,null,"See CPT",null,1622.6633999999999,null,1622.6633999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27236,null,"See CPT",null,2125.1004000000003,null,2125.1004000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27238,null,"See CPT",null,846.71040000000005,null,846.71040000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27240,null,"See CPT",null,1714.8263999999999,null,1714.8263999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27244,null,"See CPT",null,2185.7496000000001,null,2185.7496000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27245,null,"See CPT",null,2183.9657999999999,null,2183.9657999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27246,null,"See CPT",null,709.3578,null,699.8442,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27248,null,"See CPT",null,1335.4716000000001,null,1335.4716000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27250,null,"See CPT",null,313.94880000000001,null,313.94880000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[27252,null,"See CPT",null,1352.1204,null,1352.1204,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27253,null,"See CPT",null,1681.5288,null,1681.5288,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27254,null,"See CPT",null,2264.8314,null,2264.8314,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27256,null,"See CPT",null,551.19420000000002,null,420.38220000000001,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27257,null,"See CPT",null,642.16800000000001,null,642.16800000000001,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27258,null,"See CPT",null,1984.1801999999998,null,1984.1801999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27259,null,"See CPT",null,2741.1060000000002,null,2741.1060000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27265,null,"See CPT",null,742.65539999999999,null,742.65539999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27266,null,"See CPT",null,1054.2257999999999,null,1054.2257999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27267,null,"See CPT",null,798.54779999999994,null,798.54779999999994,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27268,null,"See CPT",null,981.68460000000016,null,981.68460000000016,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27269,null,"See CPT",null,2204.1822000000002,null,2204.1822000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27275,null,"See CPT",null,329.40840000000003,null,329.40840000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[27279,null,"See CPT",null,1490.6622,null,1490.6622,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27280,null,"See CPT",null,2408.13,null,2408.13,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27282,null,"See CPT",null,1542.3924000000002,null,1542.3924000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27284,null,"See CPT",null,2843.3771999999999,null,2843.3771999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27286,null,"See CPT",null,2914.1345999999999,null,2914.1345999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27290,null,"See CPT",null,2887.3776000000003,null,2887.3776000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27295,null,"See CPT",null,2242.2366000000002,null,2242.2366000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27299,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,1,1,null,"N"]
[27301,null,"See CPT",null,1231.4166,null,910.92720000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27303,null,"See CPT",null,1147.578,null,1147.578,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27305,null,"See CPT",null,872.87279999999998,null,872.87279999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27306,null,"See CPT",null,613.0326,null,613.0326,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27307,null,"See CPT",null,755.14199999999994,null,755.14199999999994,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[27310,null,"See CPT",null,1315.2552000000001,null,1315.2552000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27323,null,"See CPT",null,503.62620000000004,null,311.57040000000001,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27324,null,"See CPT",null,733.7364,null,733.7364,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27325,null,"See CPT",null,1020.3336,null,1020.3336,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[27326,null,"See CPT",null,946.0086,null,946.0086,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27327,null,"See CPT",null,934.71120000000008,null,566.65379999999993,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27328,null,"See CPT",null,1114.2803999999999,null,1114.2803999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27329,null,"See CPT",null,1851.5844,null,1851.5844,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27330,null,"See CPT",null,764.65559999999994,null,764.65559999999994,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27331,null,"See CPT",null,860.98080000000004,null,860.98080000000004,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27332,null,"See CPT",null,1163.0375999999999,null,1163.0375999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27333,null,"See CPT",null,1063.1448,null,1063.1448,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27334,null,"See CPT",null,1233.7950000000001,null,1233.7950000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27335,null,"See CPT",null,1375.3098,null,1375.3098,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27337,null,"See CPT",null,752.16899999999998,null,752.16899999999998,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27339,null,"See CPT",null,1347.9582,null,1347.9582,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27340,null,"See CPT",null,680.81700000000001,null,680.81700000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27345,null,"See CPT",null,878.2242,null,878.2242,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27347,null,"See CPT",null,949.57620000000009,null,949.57620000000009,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27350,null,"See CPT",null,1179.0917999999999,null,1179.0917999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27355,null,"See CPT",null,1097.037,null,1097.037,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27356,null,"See CPT",null,1329.5255999999999,null,1329.5255999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27357,null,"See CPT",null,1472.2296000000001,null,1472.2296000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27358,null,"See CPT",null,483.40980000000008,null,483.40980000000008,null,"000",0,0,0,0,0,0,2,0,0,null,"R",null,"Y-UR"]
[27360,null,"See CPT",null,1636.9338,null,1636.9338,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27364,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[27365,null,"See CPT",null,3633.6006000000002,null,3633.6006000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27369,null,"See CPT",null,330.5976,null,70.162800000000004,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[27372,null,"See CPT",null,1093.4694,null,724.22280000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27380,null,"See CPT",null,1133.9022,null,1133.9022,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27381,null,"See CPT",null,1485.3108,null,1485.3108,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27385,null,"See CPT",null,1106.5506,null,1106.5506,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27386,null,"See CPT",null,1551.9060000000002,null,1551.9060000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27390,null,"See CPT",null,812.81820000000005,null,812.81820000000005,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27391,null,"See CPT",null,1003.6848,null,1003.6848,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR"]
[27392,null,"See CPT",null,1281.9576,null,1281.9576,null,"090",0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR"]
[27393,null,"See CPT",null,906.17039999999997,null,906.17039999999997,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27394,null,"See CPT",null,1178.4972,null,1178.4972,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[27395,null,"See CPT",null,1580.4467999999999,null,1580.4467999999999,null,"090",0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR"]
[27396,null,"See CPT",null,1114.2803999999999,null,1114.2803999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27397,null,"See CPT",null,1638.123,null,1638.123,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27400,null,"See CPT",null,1252.2275999999999,null,1252.2275999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27403,null,"See CPT",null,1161.2538000000002,null,1161.2538000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27405,null,"See CPT",null,1218.3353999999999,null,1218.3353999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27407,null,"See CPT",null,1431.7967999999998,null,1431.7967999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27409,null,"See CPT",null,1731.4752000000001,null,1731.4752000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27412,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[27415,null,"See CPT",null,2444.4005999999999,null,2444.4005999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27416,null,"See CPT",null,1751.097,null,1751.097,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[27418,null,"See CPT",null,1491.2567999999999,null,1491.2567999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27420,null,"See CPT",null,1333.6877999999999,null,1333.6877999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27422,null,"See CPT",null,1334.2824000000001,null,1334.2824000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27424,null,"See CPT",null,1344.9852000000001,null,1344.9852000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27425,null,"See CPT",null,822.33180000000004,null,822.33180000000004,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27427,null,"See CPT",null,1277.2008000000001,null,1277.2008000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27428,null,"See CPT",null,1997.8560000000002,null,1997.8560000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27429,null,"See CPT",null,2248.7772,null,2248.7772,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27430,null,"See CPT",null,1334.2824000000001,null,1334.2824000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27435,null,"See CPT",null,1446.0672,null,1446.0672,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27437,null,"See CPT",null,1187.4161999999999,null,1187.4161999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27438,null,"See CPT",null,1504.9325999999999,null,1504.9325999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27440,null,"See CPT",null,1430.6076,null,1430.6076,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27441,null,"See CPT",null,1476.3917999999999,null,1476.3917999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27442,null,"See CPT",null,1558.4466,null,1558.4466,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27443,null,"See CPT",null,1462.7160000000001,null,1462.7160000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27445,null,"See CPT",null,2233.3176000000003,null,2233.3176000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27446,null,"See CPT",null,2051.37,null,2051.37,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27447,null,"See CPT",null,2278.5072,null,2278.5072,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27448,null,"See CPT",null,1449.6348,null,1449.6348,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27450,null,"See CPT",null,1808.7732000000001,null,1808.7732000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27454,null,"See CPT",null,2301.6966000000002,null,2301.6966000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27455,null,"See CPT",null,1724.9346,null,1724.9346,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27457,null,"See CPT",null,1716.0155999999999,null,1716.0155999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27465,null,"See CPT",null,2221.4256,null,2221.4256,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27466,null,"See CPT",null,2112.6138000000001,null,2112.6138000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27468,null,"See CPT",null,2387.319,null,2387.319,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27470,null,"See CPT",null,2103.1001999999999,null,2103.1001999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27472,null,"See CPT",null,2250.5610000000001,null,2250.5610000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27475,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"X"]
[27477,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"X"]
[27479,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"X"]
[27485,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"X"]
[27486,null,"See CPT",null,2494.9416000000001,null,2494.9416000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27487,null,"See CPT",null,3107.9742000000001,null,3107.9742000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27488,null,"See CPT",null,2136.9924000000001,null,2136.9924000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27495,null,"See CPT",null,2015.694,null,2015.694,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27496,null,"See CPT",null,991.19820000000016,null,991.19820000000016,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27497,null,"See CPT",null,1045.3067999999998,null,1045.3067999999998,null,"090",0.1,0.69,0.21,0,2,1,0,2,0,null,"R"]
[27498,null,"See CPT",null,1183.2539999999999,null,1183.2539999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27499,null,"See CPT",null,1261.1466,null,1261.1466,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27500,null,"See CPT",null,946.60320000000002,null,867.52139999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27501,null,"See CPT",null,918.06240000000003,null,899.62980000000005,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27502,null,"See CPT",null,1357.4718,null,1357.4718,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27503,null,"See CPT",null,1432.3914,null,1432.3914,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27506,null,"See CPT",null,2381.373,null,2381.373,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27507,null,"See CPT",null,1724.9346,null,1724.9346,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27508,null,"See CPT",null,956.1167999999999,null,904.38660000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27509,null,"See CPT",null,1229.6328000000001,null,1229.6328000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27510,null,"See CPT",null,1216.5516,null,1216.5516,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27511,null,"See CPT",null,1773.0971999999999,null,1773.0971999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27513,null,"See CPT",null,2196.4523999999997,null,2196.4523999999997,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27514,null,"See CPT",null,1721.9616000000001,null,1721.9616000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27516,null,"See CPT",null,946.0086,null,881.79179999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27517,null,"See CPT",null,1240.3355999999999,null,1240.3355999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27519,null,"See CPT",null,1589.3658,null,1589.3658,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27520,null,"See CPT",null,599.35680000000002,null,552.97800000000007,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27524,null,"See CPT",null,1352.7149999999999,null,1352.7149999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27530,null,"See CPT",null,569.03219999999999,null,533.35620000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27532,null,"See CPT",null,1124.9832000000001,null,1046.4960000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27535,null,"See CPT",null,1599.4739999999999,null,1599.4739999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27536,null,"See CPT",null,2114.3976000000002,null,2114.3976000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27538,null,"See CPT",null,890.71080000000006,null,825.30480000000011,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27540,null,"See CPT",null,1459.1484,null,1459.1484,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27550,null,"See CPT",null,938.27879999999993,null,859.197,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27552,null,"See CPT",null,1144.605,null,1144.605,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27556,null,"See CPT",null,1564.3925999999999,null,1564.3925999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27557,null,"See CPT",null,1861.6925999999999,null,1861.6925999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27558,null,"See CPT",null,2114.3976000000002,null,2114.3976000000002,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27560,null,"See CPT",null,676.06020000000001,null,614.22180000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27562,null,"See CPT",null,888.92700000000002,null,888.92700000000002,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27566,null,"See CPT",null,1597.0955999999999,null,1597.0955999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27570,null,"See CPT",null,275.2998,null,275.2998,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27580,null,"See CPT",null,2639.4294,null,2639.4294,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27590,null,"See CPT",null,1387.7963999999999,null,1387.7963999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27591,null,"See CPT",null,1723.1508000000001,null,1723.1508000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27592,null,"See CPT",null,1185.0378000000001,null,1185.0378000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27594,null,"See CPT",null,906.76499999999999,null,906.76499999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27596,null,"See CPT",null,1267.0925999999999,null,1267.0925999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27598,null,"See CPT",null,1242.1194,null,1242.1194,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27599,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,1,1,null,"N",null,"Y-UR"]
[27600,null,"See CPT",null,721.84440000000006,null,721.84440000000006,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27601,null,"See CPT",null,803.89919999999995,null,803.89919999999995,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27602,null,"See CPT",null,849.68340000000001,null,849.68340000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27603,null,"See CPT",null,973.95479999999998,null,705.79019999999991,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27604,null,"See CPT",null,819.95339999999999,null,576.16739999999993,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27605,null,"See CPT",null,610.05960000000005,null,326.43540000000002,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27606,null,"See CPT",null,487.57199999999995,null,487.57199999999995,null,"010",0.1,0.8,0.1,0,2,1,1,1,0,null,"R"]
[27607,null,"See CPT",null,1069.6853999999998,null,1069.6853999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27610,null,"See CPT",null,1162.443,null,1162.443,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27612,null,"See CPT",null,1003.0902000000001,null,1003.0902000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27613,null,"See CPT",null,464.38259999999997,null,287.1918,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27614,null,"See CPT",null,1064.9286,null,739.68240000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27615,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"X"]
[27616,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"X"]
[27618,null,"See CPT",null,906.76499999999999,null,550.59960000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27619,null,"See CPT",null,825.89940000000001,null,825.89940000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27620,null,"See CPT",null,810.4398000000001,null,810.4398000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27625,null,"See CPT",null,1029.2526,null,1029.2526,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27626,null,"See CPT",null,1079.1989999999998,null,1079.1989999999998,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27630,null,"See CPT",null,993.5766000000001,null,645.14099999999996,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27632,null,"See CPT",null,737.89859999999999,null,737.89859999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27634,null,"See CPT",null,1205.8488,null,1205.8488,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27635,null,"See CPT",null,1041.1446000000001,null,1041.1446000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27637,null,"See CPT",null,1318.2282,null,1318.2282,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27638,null,"See CPT",null,1344.3905999999999,null,1344.3905999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27640,null,"See CPT",null,1488.2838000000002,null,1488.2838000000002,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27641,null,"See CPT",null,1167.1997999999999,null,1167.1997999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27645,null,"See CPT",null,3132.3528000000001,null,3132.3528000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27646,null,"See CPT",null,2725.0517999999997,null,2725.0517999999997,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27647,null,"See CPT",null,1760.6106,null,1760.6106,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27648,null,"See CPT",null,412.65240000000006,null,89.784599999999998,null,"000",0,0,0,0,2,1,0,0,0,null,"R"]
[27650,null,"See CPT",null,1183.8486,null,1183.8486,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27652,null,"See CPT",null,1178.4972,null,1178.4972,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27654,null,"See CPT",null,1277.2008000000001,null,1277.2008000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27656,null,"See CPT",null,1008.4416000000001,null,634.43820000000005,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27658,null,"See CPT",null,662.97900000000004,null,662.97900000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[27659,null,"See CPT",null,842.54819999999995,null,842.54819999999995,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[27664,null,"See CPT",null,657.62760000000003,null,657.62760000000003,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[27665,null,"See CPT",null,759.89879999999994,null,759.89879999999994,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[27675,null,"See CPT",null,882.38639999999998,null,882.38639999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27676,null,"See CPT",null,1090.4964,null,1090.4964,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27680,null,"See CPT",null,750.97980000000007,null,750.97980000000007,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[27681,null,"See CPT",null,913.30560000000003,null,913.30560000000003,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27685,null,"See CPT",null,1195.7406000000001,null,833.03459999999995,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27686,null,"See CPT",null,954.33300000000008,null,954.33300000000008,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27687,null,"See CPT",null,814.60199999999998,null,814.60199999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27690,null,"See CPT",null,1149.9564,null,1149.9564,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27691,null,"See CPT",null,1334.2824000000001,null,1334.2824000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27692,null,"See CPT",null,177.1908,null,177.1908,null,"000",0,0,0,0,0,0,2,1,0,null,"R"]
[27695,null,"See CPT",null,862.17,null,862.17,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27696,null,"See CPT",null,982.27919999999995,null,982.27919999999995,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27698,null,"See CPT",null,1140.4428,null,1140.4428,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27700,null,"See CPT",null,1097.037,null,1097.037,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27702,null,"See CPT",null,1718.394,null,1718.394,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27703,null,"See CPT",null,1975.2611999999999,null,1975.2611999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27704,null,"See CPT",null,1025.0903999999998,null,1025.0903999999998,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27705,null,"See CPT",null,1359.2556,null,1359.2556,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27707,null,"See CPT",null,730.76339999999993,null,730.76339999999993,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27709,null,"See CPT",null,2035.9104000000002,null,2035.9104000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27712,null,"See CPT",null,1966.3422,null,1966.3422,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27715,null,"See CPT",null,1915.8011999999999,null,1915.8011999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27720,null,"See CPT",null,1566.1764000000001,null,1566.1764000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27722,null,"See CPT",null,1603.0416,null,1603.0416,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27724,null,"See CPT",null,2228.5607999999997,null,2228.5607999999997,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27725,null,"See CPT",null,2166.7224000000001,null,2166.7224000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27726,null,"See CPT",null,1711.2588000000001,null,1711.2588000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27727,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[27730,null,"See CPT",null,1061.3610000000001,null,1061.3610000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[27732,null,"See CPT",null,821.14260000000002,null,821.14260000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[27734,null,"See CPT",null,1184.4432000000002,null,1184.4432000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[27740,null,"See CPT",null,1272.444,null,1272.444,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[27742,null,"See CPT",null,1394.337,null,1394.337,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27745,null,"See CPT",null,1358.0663999999999,null,1358.0663999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27750,null,"See CPT",null,638.60040000000004,null,591.62699999999995,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27752,null,"See CPT",null,974.54939999999999,null,889.52160000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27756,null,"See CPT",null,1045.9014,null,1045.9014,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27758,null,"See CPT",null,1605.42,null,1605.42,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27759,null,"See CPT",null,1780.827,null,1780.827,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27760,null,"See CPT",null,611.84339999999997,null,564.27539999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27762,null,"See CPT",null,881.19720000000007,null,794.98019999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27766,null,"See CPT",null,1089.9017999999999,null,1089.9017999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27767,null,"See CPT",null,538.70760000000007,null,533.35620000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27768,null,"See CPT",null,814.00739999999996,null,814.00739999999996,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27769,null,"See CPT",null,1307.5254,null,1307.5254,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27780,null,"See CPT",null,571.41059999999993,null,524.43720000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27781,null,"See CPT",null,797.95320000000004,null,732.54719999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27784,null,"See CPT",null,1271.2547999999999,null,1271.2547999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27786,null,"See CPT",null,578.54579999999999,null,529.78859999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27788,null,"See CPT",null,777.73680000000002,null,701.62800000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27792,null,"See CPT",null,1161.2538000000002,null,1161.2538000000002,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27808,null,"See CPT",null,618.97860000000003,null,563.08620000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27810,null,"See CPT",null,861.57540000000006,null,773.57460000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27814,null,"See CPT",null,1372.3367999999998,null,1372.3367999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27816,null,"See CPT",null,609.46500000000003,null,539.89679999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27818,null,"See CPT",null,891.9,null,793.19640000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27822,null,"See CPT",null,1584.6089999999999,null,1584.6089999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27823,null,"See CPT",null,1776.6648,null,1776.6648,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27824,null,"See CPT",null,582.70800000000008,null,557.73480000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27825,null,"See CPT",null,985.25220000000002,null,885.95400000000006,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27826,null,"See CPT",null,1546.5546000000002,null,1546.5546000000002,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27827,null,"See CPT",null,2019.2616,null,2019.2616,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27828,null,"See CPT",null,2388.5082000000002,null,2388.5082000000002,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27829,null,"See CPT",null,1283.1468,null,1283.1468,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27830,null,"See CPT",null,717.08760000000007,null,659.41139999999996,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27831,null,"See CPT",null,745.03379999999993,null,745.03379999999993,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27832,null,"See CPT",null,1360.4448,null,1360.4448,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27840,null,"See CPT",null,694.49279999999999,null,694.49279999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27842,null,"See CPT",null,897.846,null,897.846,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27846,null,"See CPT",null,1297.4172000000001,null,1297.4172000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27848,null,"See CPT",null,1415.1480000000001,null,1415.1480000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27860,null,"See CPT",null,297.3,null,297.3,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27870,null,"See CPT",null,1804.6110000000001,null,1804.6110000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27871,null,"See CPT",null,1238.5518,null,1238.5518,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27880,null,"See CPT",null,1586.9874000000002,null,1586.9874000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27881,null,"See CPT",null,1515.0408,null,1515.0408,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27882,null,"See CPT",null,1045.9014,null,1045.9014,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[27884,null,"See CPT",null,1027.4688000000001,null,1027.4688000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27886,null,"See CPT",null,1154.7132000000001,null,1154.7132000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27888,null,"See CPT",null,1155.3078,null,1155.3078,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27889,null,"See CPT",null,1124.3886,null,1124.3886,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27892,null,"See CPT",null,958.49520000000007,null,958.49520000000007,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27893,null,"See CPT",null,1105.9560000000001,null,1105.9560000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27894,null,"See CPT",null,1457.9592,null,1457.9592,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27899,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,0,1,1,null,"N"]
[28001,null,"See CPT",null,316.92180000000002,null,170.65020000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[28002,null,"See CPT",null,455.46360000000004,null,249.73200000000003,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[28003,null,"See CPT",null,692.11440000000005,null,461.40960000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[28005,null,"See CPT",null,1021.5228,null,1021.5228,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28008,null,"See CPT",null,778.33140000000003,null,525.03179999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28010,null,"See CPT",null,419.19299999999998,null,370.43580000000003,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28011,null,"See CPT",null,564.27539999999999,null,498.86940000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28020,null,"See CPT",null,1003.6848,null,662.97900000000004,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[28022,null,"See CPT",null,885.35940000000005,null,583.30259999999998,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28024,null,"See CPT",null,828.27779999999996,null,542.86980000000005,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28035,null,"See CPT",null,952.54920000000004,null,635.03279999999995,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28039,null,"See CPT",null,888.33240000000001,null,617.7894,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28041,null,"See CPT",null,801.52080000000001,null,801.52080000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28043,null,"See CPT",null,696.87120000000004,null,463.1934,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28045,null,"See CPT",null,865.14300000000003,null,614.81640000000004,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28046,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"X"]
[28047,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[28050,null,"See CPT",null,754.54739999999993,null,495.30180000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28052,null,"See CPT",null,708.16859999999997,null,454.86900000000003,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28054,null,"See CPT",null,667.14120000000003,null,416.81459999999998,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28055,null,"See CPT",null,680.22239999999999,null,680.22239999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28060,null,"See CPT",null,944.81940000000009,null,645.14099999999996,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28062,null,"See CPT",null,1029.8471999999999,null,712.92539999999997,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28070,null,"See CPT",null,935.90039999999999,null,620.16779999999994,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28072,null,"See CPT",null,893.08920000000001,null,580.32960000000003,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28080,null,"See CPT",null,968.00880000000006,null,674.87099999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28086,null,"See CPT",null,978.11699999999996,null,638.00580000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28088,null,"See CPT",null,831.25080000000003,null,515.51819999999998,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28090,null,"See CPT",null,844.33199999999999,null,548.22120000000007,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28092,null,"See CPT",null,761.68260000000009,null,481.62599999999998,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28100,null,"See CPT",null,1119.0372,null,752.16899999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28102,null,"See CPT",null,1101.1992,null,1101.1992,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28103,null,"See CPT",null,689.73599999999999,null,689.73599999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28104,null,"See CPT",null,951.95460000000014,null,629.68140000000005,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[28106,null,"See CPT",null,757.5204,null,757.5204,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[28107,null,"See CPT",null,913.30560000000003,null,615.41099999999994,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[28108,null,"See CPT",null,789.03419999999994,null,513.73440000000005,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28110,null,"See CPT",null,837.19680000000005,null,519.08580000000006,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28111,null,"See CPT",null,872.87279999999998,null,572.59980000000007,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28112,null,"See CPT",null,879.41339999999991,null,558.32940000000008,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28113,null,"See CPT",null,1058.9826,null,759.30420000000004,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[28114,null,"See CPT",null,1926.5039999999999,null,1494.8244,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28116,null,"See CPT",null,1395.5262,null,1041.1446000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28118,null,"See CPT",null,1094.6586,null,752.16899999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28119,null,"See CPT",null,954.33300000000008,null,649.30320000000006,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28120,null,"See CPT",null,1220.7138,null,888.33240000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28122,null,"See CPT",null,1068.4962,null,780.11519999999996,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28124,null,"See CPT",null,863.35919999999999,null,594.00540000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28126,null,"See CPT",null,708.16859999999997,null,441.7878,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28130,null,"See CPT",null,1094.6586,null,1094.6586,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28140,null,"See CPT",null,1039.3607999999999,null,764.06100000000004,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[28150,null,"See CPT",null,757.5204,null,495.30180000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28153,null,"See CPT",null,741.46620000000007,null,472.70699999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28160,null,"See CPT",null,748.60140000000001,null,478.05839999999995,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28171,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"X"]
[28173,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"X"]
[28175,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"X"]
[28190,null,"See CPT",null,446.5446,null,236.05620000000002,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[28192,null,"See CPT",null,836.60220000000004,null,554.16719999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28193,null,"See CPT",null,946.0086,null,652.27620000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28200,null,"See CPT",null,903.19740000000002,null,585.68100000000004,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[28202,null,"See CPT",null,1076.2260000000001,null,761.08800000000008,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[28208,null,"See CPT",null,878.81880000000001,null,571.41059999999993,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[28210,null,"See CPT",null,1060.7664,null,746.22300000000007,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[28220,null,"See CPT",null,817.57500000000005,null,542.86980000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28222,null,"See CPT",null,943.03559999999993,null,641.57339999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28225,null,"See CPT",null,755.14199999999994,null,472.11240000000004,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28226,null,"See CPT",null,1133.3075999999999,null,718.87139999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28230,null,"See CPT",null,785.46660000000008,null,506.00459999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28232,null,"See CPT",null,689.14139999999998,null,429.89580000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28234,null,"See CPT",null,743.84460000000001,null,478.05839999999995,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28238,null,"See CPT",null,1212.9839999999999,null,871.08900000000006,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28240,null,"See CPT",null,808.65599999999995,null,523.84260000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28250,null,"See CPT",null,1051.8474000000001,null,723.62819999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28260,null,"See CPT",null,1283.1468,null,939.46800000000007,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28261,null,"See CPT",null,2173.2629999999999,null,1676.1774,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28262,null,"See CPT",null,2515.1579999999999,null,2005.5857999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28264,null,"See CPT",null,1632.7716,null,1236.768,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28270,null,"See CPT",null,883.57560000000001,null,595.19460000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28272,null,"See CPT",null,696.87120000000004,null,446.5446,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28280,null,"See CPT",null,927.57600000000002,null,620.16779999999994,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28285,null,"See CPT",null,973.36020000000008,null,684.97919999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28286,null,"See CPT",null,802.11540000000002,null,528.59940000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28288,null,"See CPT",null,1097.6316000000002,null,776.54759999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28289,null,"See CPT",null,1248.6600000000001,null,818.16959999999995,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28291,null,"See CPT",null,1282.5522000000001,null,872.27819999999997,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28292,null,"See CPT",null,1258.7682000000002,null,857.41319999999996,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28295,null,"See CPT",null,2002.0182000000002,null,1102.9829999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28296,null,"See CPT",null,1625.0418,null,911.52179999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28297,null,"See CPT",null,1896.1794,null,1077.4152000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28298,null,"See CPT",null,1518.0138000000002,null,894.87300000000005,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28299,null,"See CPT",null,1839.0978,null,1047.6852000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28300,null,"See CPT",null,1160.6592000000001,null,1160.6592000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28302,null,"See CPT",null,1286.1197999999999,null,1286.1197999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28304,null,"See CPT",null,1494.8244,null,1090.4964,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28305,null,"See CPT",null,1210.0110000000002,null,1210.0110000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28306,null,"See CPT",null,1099.4153999999999,null,719.46600000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28307,null,"See CPT",null,1437.1482000000001,null,930.54899999999998,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28308,null,"See CPT",null,1035.7932000000001,null,688.54679999999996,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28309,null,"See CPT",null,1586.9874000000002,null,1586.9874000000002,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28310,null,"See CPT",null,988.81979999999999,null,643.95180000000005,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28312,null,"See CPT",null,943.03559999999993,null,586.87019999999995,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[28313,null,"See CPT",null,957.90059999999994,null,641.57339999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28315,null,"See CPT",null,872.27819999999997,null,583.30259999999998,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28320,null,"See CPT",null,1089.3072,null,1089.3072,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28322,null,"See CPT",null,1420.4994000000002,null,1029.8471999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[28340,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"X"]
[28341,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"X"]
[28344,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"X"]
[28345,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"X"]
[28360,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,0,0,null,"X"]
[28400,null,"See CPT",null,453.08519999999999,null,419.19299999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28405,null,"See CPT",null,708.16859999999997,null,635.62739999999997,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28406,null,"See CPT",null,1024.4958000000001,null,1024.4958000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28415,null,"See CPT",null,2020.4507999999998,null,2020.4507999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28420,null,"See CPT",null,2332.0212000000001,null,2332.0212000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28430,null,"See CPT",null,441.19319999999999,null,385.30080000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28435,null,"See CPT",null,676.65480000000002,null,597.57300000000009,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28436,null,"See CPT",null,909.14339999999993,null,909.14339999999993,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28445,null,"See CPT",null,1825.422,null,1825.422,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28446,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[28450,null,"See CPT",null,387.08459999999997,null,349.03020000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28455,null,"See CPT",null,530.38319999999999,null,470.32859999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28456,null,"See CPT",null,684.97919999999999,null,684.97919999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28465,null,"See CPT",null,1145.7942,null,1145.7942,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28470,null,"See CPT",null,399.57119999999998,null,375.19259999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28475,null,"See CPT",null,464.97720000000004,null,407.30099999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28476,null,"See CPT",null,712.92539999999997,null,712.92539999999997,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28485,null,"See CPT",null,1012.6038000000001,null,1012.6038000000001,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[28490,null,"See CPT",null,258.65100000000001,null,226.54259999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28495,null,"See CPT",null,326.43540000000002,null,269.94839999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28496,null,"See CPT",null,830.65620000000001,null,443.57159999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28505,null,"See CPT",null,1195.7406000000001,null,891.9,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28510,null,"See CPT",null,218.81280000000001,null,216.43440000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28515,null,"See CPT",null,297.89459999999997,null,258.65100000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28525,null,"See CPT",null,1034.604,null,726.60120000000006,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28530,null,"See CPT",null,206.92080000000001,null,178.38,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28531,null,"See CPT",null,603.51900000000001,null,322.86779999999999,null,"090",0.1,0.69,0.21,0,2,1,1,2,0,null,"R"]
[28540,null,"See CPT",null,354.38159999999999,null,316.92180000000002,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28545,null,"See CPT",null,567.84300000000007,null,494.7072,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28546,null,"See CPT",null,1086.3342,null,638.60040000000004,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28555,null,"See CPT",null,1556.6628000000001,null,1176.7133999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28570,null,"See CPT",null,431.08499999999998,null,358.54380000000003,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28575,null,"See CPT",null,692.70900000000006,null,618.38400000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28576,null,"See CPT",null,694.49279999999999,null,694.49279999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28585,null,"See CPT",null,1597.0955999999999,null,1243.9032000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28600,null,"See CPT",null,395.40900000000005,null,335.3544,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28605,null,"See CPT",null,627.303,null,556.54559999999992,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28606,null,"See CPT",null,683.79,null,683.79,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28615,null,"See CPT",null,1489.473,null,1489.473,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[28630,null,"See CPT",null,277.6782,null,196.8126,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[28635,null,"See CPT",null,315.13799999999998,null,237.24540000000002,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[28636,null,"See CPT",null,572.59980000000007,null,356.76,null,"010",0.1,0.8,0.1,0,2,0,1,2,0,null,"R"]
[28645,null,"See CPT",null,1176.7133999999999,null,865.73760000000004,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[28660,null,"See CPT",null,222.97499999999999,null,165.89340000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[28665,null,"See CPT",null,271.73220000000003,null,225.35339999999999,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[28666,null,"See CPT",null,320.48939999999999,null,320.48939999999999,null,"010",0.1,0.8,0.1,0,2,0,1,2,0,null,"R"]
[28675,null,"See CPT",null,1048.8744000000002,null,737.30400000000009,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28705,null,"See CPT",null,2172.6684,null,2172.6684,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28715,null,"See CPT",null,1681.5288,null,1681.5288,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28725,null,"See CPT",null,1390.1748,null,1390.1748,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28730,null,"See CPT",null,1309.3091999999999,null,1309.3091999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28735,null,"See CPT",null,1395.5262,null,1395.5262,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28737,null,"See CPT",null,1224.8760000000002,null,1224.8760000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28740,null,"See CPT",null,1498.9866000000002,null,1102.9829999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28750,null,"See CPT",null,1422.2832000000001,null,1035.1985999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[28755,null,"See CPT",null,922.81920000000002,null,598.16759999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28760,null,"See CPT",null,1378.2828,null,1011.4146000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28800,null,"See CPT",null,942.44100000000003,null,942.44100000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28805,null,"See CPT",null,1258.1736000000001,null,1258.1736000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[28810,null,"See CPT",null,755.14199999999994,null,755.14199999999994,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28820,null,"See CPT",null,545.2482,null,314.54340000000002,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[28825,null,"See CPT",null,535.14,null,305.62439999999998,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[28890,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,null,"X"]
[28899,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,null,"N"]
[29000,null,"See CPT",null,630.87059999999997,null,346.05720000000002,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29010,null,"See CPT",null,488.76120000000003,null,283.02960000000002,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29015,null,"See CPT",null,525.03179999999998,null,318.7056,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29035,null,"See CPT",null,459.62580000000003,null,253.2996,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29040,null,"See CPT",null,523.84260000000006,null,304.43520000000001,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29044,null,"See CPT",null,513.73440000000005,null,294.327,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29046,null,"See CPT",null,563.08620000000008,null,331.78680000000003,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29049,null,"See CPT",null,177.78540000000001,null,123.6768,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29055,null,"See CPT",null,398.97660000000002,null,242.5968,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29058,null,"See CPT",null,220.00200000000001,null,165.2988,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29065,null,"See CPT",null,173.02860000000001,null,121.2984,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29075,null,"See CPT",null,155.7852,null,110.001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29085,null,"See CPT",null,171.2448,null,119.51459999999999,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29086,null,"See CPT",null,137.3526,null,88.000799999999998,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29105,null,"See CPT",null,146.27160000000001,null,72.541200000000003,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29125,null,"See CPT",null,118.3254,null,70.757400000000004,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29126,null,"See CPT",null,139.13639999999998,null,87.406199999999998,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29130,null,"See CPT",null,73.730400000000003,null,51.730200000000004,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29131,null,"See CPT",null,94.54140000000001,null,60.6492,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29200,null,"See CPT",null,60.054600000000001,null,33.297600000000003,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[29240,null,"See CPT",null,54.703200000000002,null,32.703000000000003,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29260,null,"See CPT",null,53.514000000000003,null,33.892199999999995,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29280,null,"See CPT",null,52.919400000000003,null,35.081400000000002,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29305,null,"See CPT",null,442.38240000000002,null,279.46199999999999,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29325,null,"See CPT",null,488.16660000000007,null,312.75959999999998,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[29345,null,"See CPT",null,242.00220000000002,null,176.0016,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29355,null,"See CPT",null,253.2996,null,187.89360000000002,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29358,null,"See CPT",null,286.59720000000004,null,181.94759999999999,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29365,null,"See CPT",null,220.00200000000001,null,154.596,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29405,null,"See CPT",null,142.70400000000001,null,102.86580000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29425,null,"See CPT",null,134.9742,null,95.73060000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29435,null,"See CPT",null,200.97479999999999,null,140.92020000000002,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29440,null,"See CPT",null,75.514200000000002,null,49.351799999999997,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29445,null,"See CPT",null,229.51560000000001,null,175.40700000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29450,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,1,0,0,null,"X"]
[29505,null,"See CPT",null,156.9744,null,90.973799999999997,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29515,null,"See CPT",null,127.24440000000001,null,86.811599999999999,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29520,null,"See CPT",null,64.216800000000006,null,32.703000000000003,null,"000",0,0,0,0,2,1,0,0,0,null,"R"]
[29530,null,"See CPT",null,54.703200000000002,null,32.108400000000003,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29540,null,"See CPT",null,49.946399999999997,null,30.9192,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29550,null,"See CPT",null,34.486799999999995,null,19.6218,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29580,null,"See CPT",null,117.1362,null,46.973400000000005,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29581,null,"See CPT",null,165.2988,null,48.162600000000005,null,"000",0,0,0,0,2,1,0,0,0,null,"R"]
[29584,null,"See CPT",null,153.4068,null,27.946199999999997,null,"000",0,0,0,0,2,1,0,0,0,null,"R"]
[29700,null,"See CPT",null,110.5956,null,58.270800000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[29705,null,"See CPT",null,112.97399999999999,null,78.487200000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[29710,null,"See CPT",null,217.029,null,145.08240000000001,null,"000",0,0,0,0,2,1,0,0,0,null,"R"]
[29720,null,"See CPT",null,151.62299999999999,null,75.514200000000002,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[29730,null,"See CPT",null,113.5686,null,77.892600000000002,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[29740,null,"See CPT",null,176.0016,null,121.89299999999999,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[29750,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,null,"X"]
[29799,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,null,"N"]
[29800,null,"See CPT",null,954.33300000000008,null,954.33300000000008,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[29804,null,"See CPT",null,1079.7936,null,1079.7936,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[29806,null,"See CPT",null,1893.2064,null,1893.2064,null,"090",0.1,0.69,0.21,0,3,1,1,1,0,null,"R",null,"Y-UR"]
[29828,null,"See CPT",null,1638.7175999999999,null,1638.7175999999999,null,"090",0.1,0.69,0.21,0,3,1,2,1,0,null,"R",null,"Y-UR"]
[29847,null,"See CPT",null,978.71160000000009,null,978.71160000000009,null,"090",0.1,0.69,0.21,0,3,1,2,0,0,null,"R"]
[29860,null,"See CPT",null,1153.5239999999999,null,1153.5239999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[29876,null,"See CPT",null,1172.5511999999999,null,1172.5511999999999,null,"090",0.1,0.69,0.21,0,3,1,1,0,0,null,"R",null,"Y-UR"]
[29880,null,"See CPT",null,1010.82,null,1010.82,null,"090",0.1,0.69,0.21,0,3,1,0,1,0,null,"R",null,"Y-UR"]
[29887,null,"See CPT",null,1350.9312,null,1350.9312,null,"090",0.1,0.69,0.21,0,3,1,2,1,0,null,"R",null,"Y-UR"]
[29898,null,"See CPT",null,1004.2794,null,1004.2794,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[29914,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,3,1,2,1,0,null,"X"]
[30124,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.76,0.14000000000000001,0,2,0,1,0,0,null,"X"]
[30400,null,"See CPT",null,2283.2640000000001,null,2283.2640000000001,null,"090",0.1,0.76,0.14000000000000001,0,2,0,0,0,0,null,"R"]
[30460,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,2,0,null,"X"]
[30801,null,"See CPT",null,411.46320000000003,null,284.21880000000004,null,"010",0.1,0.8,0.1,0,2,2,1,0,0,null,"R"]
[30903,null,"See CPT",null,460.815,null,134.9742,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[31000,null,"See CPT",null,341.30040000000002,null,197.40719999999999,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[31075,null,"See CPT",null,1523.9597999999999,null,1523.9597999999999,null,"090",0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"R"]
[31201,null,"See CPT",null,1470.4458,null,1470.4458,null,"090",0.1,0.76,0.14000000000000001,0,2,1,1,0,0,null,"R"]
[31253,null,"See CPT",null,881.79179999999997,null,881.79179999999997,null,"000",0,0,0,0,3,1,1,0,0,null,"R",null,"Y-CM"]
[31292,null,"See CPT",null,1780.827,null,1780.827,null,"010",0.1,0.8,0.1,0,3,1,0,0,0,null,"R"]
[31298,null,"See CPT",null,6123.1908000000003,null,450.70679999999999,null,"000",0,0,0,0,3,1,0,0,0,null,"R",null,"Y-CM"]
[31395,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X"]
[31511,null,"See CPT",null,388.27379999999999,null,233.08320000000001,null,"000",0,0,0,0,3,0,1,0,0,null,"R"]
[31515,null,"See CPT",null,394.81439999999998,null,196.8126,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[31535,null,"See CPT",null,332.38139999999999,null,332.38139999999999,null,"000",0,0,0,0,3,0,1,0,0,null,"R"]
[31554,null,"See CPT",null,3057.4331999999999,null,3057.4331999999999,null,"090",0.1,0.76,0.14000000000000001,0,2,0,0,1,0,null,"R",null,"Y-UR"]
[31579,null,"See CPT",null,362.70599999999996,null,210.48840000000001,null,"000",0,0,0,0,3,0,1,0,0,null,"R"]
[31610,null,"See CPT",null,1743.9617999999998,null,1743.9617999999998,null,"090",0.1,0.76,0.14000000000000001,0,2,0,1,0,0,null,"R"]
[31622,null,"See CPT",null,454.86900000000003,null,231.29940000000002,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[31634,null,"See CPT",null,3034.8384000000001,null,335.3544,null,"000",0,0,0,0,3,0,2,0,0,null,"R"]
[31643,null,"See CPT",null,308.00279999999998,null,308.00279999999998,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[31647,null,"See CPT",null,362.1114,null,362.1114,null,"000",0,0,0,0,3,0,1,0,0,null,"R"]
[31717,null,"See CPT",null,548.22120000000007,null,187.89360000000002,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[31775,null,"See CPT",null,2436.0762,null,2436.0762,null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,0,0,null,"R"]
[32036,null,"See CPT",null,1396.7153999999998,null,1396.7153999999998,null,"090",0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"R"]
[32160,null,"See CPT",null,1396.7153999999998,null,1396.7153999999998,null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R"]
[32320,null,"See CPT",null,2804.1335999999997,null,2804.1335999999997,null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[32501,null,"See CPT",null,418.00380000000001,null,418.00380000000001,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[32550,null,"See CPT",null,1531.6896000000002,null,357.94919999999996,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[32553,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,2,0,0,null,"X"]
[32604,null,"See CPT",null,829.46699999999998,null,829.46699999999998,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[32654,null,"See CPT",null,2035.9104000000002,null,2035.9104000000002,null,"090",0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[32668,null,"See CPT",null,271.73220000000003,null,271.73220000000003,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[32701,null,"See CPT",null,369.84120000000001,null,369.84120000000001,null,"000",0,0,0,2,0,0,0,1,0,null,"R"]
[32856,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,2,1,0,null,"N",null,"Y-CM"]
[33018,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,1,0,0,null,"X"]
[33120,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[33211,null,"See CPT",null,294.92160000000001,null,294.92160000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33215,null,"See CPT",null,547.62660000000005,null,547.62660000000005,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33223,null,"See CPT",null,726.60120000000006,null,726.60120000000006,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[33236,null,"See CPT",null,1375.9044000000001,null,1375.9044000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,0,2,0,null,"R",null,"Y-CM"]
[33250,null,"See CPT",null,2534.1851999999999,null,2534.1851999999999,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33263,null,"See CPT",null,687.95220000000006,null,687.95220000000006,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33285,null,"See CPT",null,8616.9431999999997,null,153.4068,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[33320,null,"See CPT",null,1839.6924000000001,null,1839.6924000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33365,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,2,1,null,"X"]
[33404,null,"See CPT",null,3040.7844,null,3040.7844,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33410,null,"See CPT",null,4404.7968000000001,null,4404.7968000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33425,null,"See CPT",null,4735.3944000000001,null,4735.3944000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33465,null,"See CPT",null,4771.665,null,4771.665,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33501,null,"See CPT",null,1947.3150000000001,null,1947.3150000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[33513,null,"See CPT",null,4302.5255999999999,null,4302.5255999999999,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[33522,null,"See CPT",null,1263.5250000000001,null,1263.5250000000001,null,"000",0,0,0,0,0,0,2,0,0,null,"R",null,"Y-CM"]
[33572,null,"See CPT",null,397.19279999999998,null,397.19279999999998,null,"000",0,0,0,0,0,0,2,0,0,null,"R",null,"Y-CM"]
[33615,null,"See CPT",null,3468.8964000000001,null,3468.8964000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33620,null,"See CPT",null,2857.6476000000002,null,2857.6476000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33681,null,"See CPT",null,3209.0562,null,3209.0562,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33710,null,"See CPT",null,3553.3296,null,3553.3296,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[33745,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,2,0,0,null,"X"]
[33775,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"X"]
[33782,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[33822,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[33859,null,"See CPT",null,4223.4438,null,4223.4438,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[33866,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,0,0,1,null,"X",null,"Y-CM"]
[33895,null,"See CPT",null,1344.3905999999999,null,1344.3905999999999,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[33924,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,2,1,0,null,"X"]
[33944,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,2,1,0,null,"X"]
[33952,null,"See CPT",null,740.27699999999993,null,740.27699999999993,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[33966,null,"See CPT",null,409.08479999999997,null,409.08479999999997,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[33977,null,"See CPT",null,1937.8014000000003,null,1937.8014000000003,null,"000",0,0,0,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[33985,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,1,1,null,"X"]
[33988,null,"See CPT",null,1340.2284,null,1340.2284,null,"000",0,0,0,0,2,0,0,1,1,null,"R",null,"Y-CM"]
[34111,null,"See CPT",null,1041.1446000000001,null,1041.1446000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[34490,null,"See CPT",null,1136.2806,null,1136.2806,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[34705,null,"See CPT",null,2632.8888000000002,null,2632.8888000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[34712,null,"See CPT",null,1133.3075999999999,null,1133.3075999999999,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[34831,null,"See CPT",null,3310.7328000000002,null,3310.7328000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[34846,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,2,2,0,null,"N"]
[35021,null,"See CPT",null,2197.6415999999999,null,2197.6415999999999,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35081,null,"See CPT",null,2980.1351999999997,null,2980.1351999999997,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[35141,null,"See CPT",null,1893.2064,null,1893.2064,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35189,null,"See CPT",null,2592.4560000000001,null,2592.4560000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[35236,null,"See CPT",null,1740.9888000000001,null,1740.9888000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R"]
[35271,null,"See CPT",null,2406.9407999999999,null,2406.9407999999999,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R"]
[35331,null,"See CPT",null,2502.6714000000002,null,2502.6714000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35351,null,"See CPT",null,2221.4256,null,2221.4256,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35515,null,"See CPT",null,2281.4802,null,2281.4802,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35521,null,"See CPT",null,2112.0192000000002,null,2112.0192000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35538,null,"See CPT",null,4005.2256000000002,null,4005.2256000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[35566,null,"See CPT",null,2870.1342000000004,null,2870.1342000000004,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35621,null,"See CPT",null,1893.2064,null,1893.2064,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35636,null,"See CPT",null,2739.3222000000001,null,2739.3222000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35665,null,"See CPT",null,2021.64,null,2021.64,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35671,null,"See CPT",null,1969.3151999999998,null,1969.3151999999998,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35820,null,"See CPT",null,3490.3020000000001,null,3490.3020000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[35870,null,"See CPT",null,2147.1006000000002,null,2147.1006000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[35907,null,"See CPT",null,3283.3811999999998,null,3283.3811999999998,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[36014,null,"See CPT",null,1525.7436,null,262.21860000000004,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[36223,null,"See CPT",null,3049.7033999999999,null,557.73480000000006,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[36246,null,"See CPT",null,1593.528,null,435.24720000000002,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[36405,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,1,0,0,null,"X"]
[36425,null,"See CPT",null,70.757400000000004,null,70.757400000000004,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[36473,null,"See CPT",null,2368.2918,null,310.38119999999998,null,"000",0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[36476,null,"See CPT",null,531.57240000000002,null,232.48860000000002,null,"000",0,0,0,0,0,1,1,0,0,null,"R",null,"Y-CM"]
[36513,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,1,0,0,null,"X"]
[36560,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"X"]
[36576,null,"See CPT",null,651.68160000000012,null,325.84080000000006,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[36585,null,"See CPT",null,2256.5070000000001,null,499.46400000000006,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[36625,null,"See CPT",null,184.32600000000002,null,184.32600000000002,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[36815,null,"See CPT",null,232.48860000000002,null,232.48860000000002,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[36838,null,"See CPT",null,1973.4774,null,1973.4774,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[36901,null,"See CPT",null,1353.3096,null,292.54320000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[37145,null,"See CPT",null,3800.0886,null,3800.0886,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[37186,null,"See CPT",null,2298.7235999999998,null,419.7876,null,"000",0,0,0,0,0,2,1,2,0,null,"R"]
[37214,null,"See CPT",null,209.8938,null,209.8938,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[37222,null,"See CPT",null,1167.7944,null,319.30020000000002,null,"000",0,0,0,0,0,1,0,0,0,null,"R",null,"Y-CM"]
[37234,null,"See CPT",null,7094.1725999999999,null,487.57199999999995,null,"000",0,0,0,0,0,1,0,0,0,null,"R",null,"Y-CM"]
[37241,null,"See CPT",null,9144.9480000000003,null,744.43920000000003,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[37565,null,"See CPT",null,1285.5252,null,1285.5252,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,0,1,0,null,"R"]
[37606,null,"See CPT",null,1292.6604,null,1292.6604,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"R"]
[37700,null,"See CPT",null,431.67959999999999,null,431.67959999999999,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[37780,null,"See CPT",null,411.46320000000003,null,411.46320000000003,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[38102,null,"See CPT",null,457.24740000000003,null,457.24740000000003,null,"000",0,0,0,0,0,0,2,1,0,null,"R"]
[38211,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[38242,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,null,"X"]
[38381,null,"See CPT",null,1406.8235999999999,null,1406.8235999999999,null,"090",0.11,0.73,0.16,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[38562,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.73,0.16,0,2,2,2,1,0,null,"X"]
[38571,null,"See CPT",null,1166.0106000000001,null,1166.0106000000001,null,"010",0.1,0.8,0.1,0,3,2,2,2,0,null,"R",null,"Y-CM"]
[38790,null,"See CPT",null,143.29860000000002,null,143.29860000000002,null,"000",0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[38900,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,1,2,1,0,null,"X"]
[39402,null,"See CPT",null,699.8442,null,699.8442,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[40525,null,"See CPT",null,988.81979999999999,null,988.81979999999999,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[40720,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,1,0,0,0,null,"X"]
[40806,null,"See CPT",null,186.10980000000001,null,50.540999999999997,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[40842,null,"See CPT",null,1698.7722000000001,null,1211.7947999999999,null,"090",0.09,0.81,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[40845,null,"See CPT",null,2691.7542000000003,null,2159.5871999999999,null,"090",0.09,0.81,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[41105,null,"See CPT",null,346.65180000000004,null,196.8126,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[41112,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,1,0,0,null,"X"]
[41135,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[41800,null,"See CPT",null,545.2482,null,279.46199999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[41827,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,1,0,0,null,"X"]
[41899,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,null,"N"]
[42200,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,0,0,null,"X"]
[42215,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,0,0,null,"X"]
[42335,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,1,0,0,null,"X"]
[42405,null,"See CPT",null,552.97800000000007,null,404.92259999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[42426,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,1,2,1,0,null,"X"]
[42700,null,"See CPT",null,354.38159999999999,null,243.19139999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[42815,null,"See CPT",null,973.95479999999998,null,973.95479999999998,null,"090",0.09,0.81,0.1,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[42835,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,0,0,0,null,"X"]
[42953,null,"See CPT",null,1753.4754,null,1753.4754,null,"090",0.09,0.81,0.1,0,2,0,2,0,0,null,"R"]
[42961,null,"See CPT",null,753.95280000000002,null,753.95280000000002,null,"090",0.09,0.81,0.1,0,2,0,2,0,0,null,"R"]
[43113,null,"See CPT",null,7535.9603999999999,null,7535.9603999999999,null,"090",0.09,0.81,0.1,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[43118,null,"See CPT",null,6289.0842000000002,null,6289.0842000000002,null,"090",0.09,0.81,0.1,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[43180,null,"See CPT",null,972.76559999999995,null,972.76559999999995,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[43206,null,"See CPT",null,571.41059999999993,null,234.86700000000002,null,"000",0,0,0,0,3,0,1,0,0,null,"R",null,"Y-CM"]
[43213,null,"See CPT",null,2407.5354000000002,null,455.46360000000004,null,"000",0,0,0,0,3,0,1,0,0,null,"R"]
[43235,null,"See CPT",null,562.49160000000006,null,216.43440000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[43247,null,"See CPT",null,724.81740000000002,null,311.57040000000001,null,"000",0,0,0,0,3,0,1,0,0,null,"R"]
[43250,null,"See CPT",null,864.54840000000002,null,299.0838,null,"000",0,0,0,0,3,0,1,0,0,null,"R"]
[43270,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,3,0,1,0,0,null,"X"]
[43275,null,"See CPT",null,661.78980000000001,null,661.78980000000001,null,"000",0,0,0,0,3,0,1,0,0,null,"R"]
[43282,null,"See CPT",null,3052.6764000000003,null,3052.6764000000003,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43320,null,"See CPT",null,2477.6982000000003,null,2477.6982000000003,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43330,null,"See CPT",null,2371.2648000000004,null,2371.2648000000004,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43352,null,"See CPT",null,1872.3953999999999,null,1872.3953999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43496,null,"See CPT",null," By Report ",null," By Report ",null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"N",null,"Y-CM"]
[43500,null,"See CPT",null,1398.4992,null,1398.4992,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[43635,null,"See CPT",null,196.8126,null,196.8126,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[43644,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[43659,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,1,1,null,"N"]
[43774,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[43820,null,"See CPT",null,2381.9675999999999,null,2381.9675999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43860,null,"See CPT",null,2897.4857999999999,null,2897.4857999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43882,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,2,1,0,null,"X"]
[44100,null,"See CPT",null,187.89360000000002,null,187.89360000000002,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[44135,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,0,0,0,0,0,null,"N"]
[44144,null,"See CPT",null,3116.2985999999996,null,3116.2985999999996,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[44156,null,"See CPT",null,4087.2803999999996,null,4087.2803999999996,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[44188,null,"See CPT",null,2160.1817999999998,null,2160.1817999999998,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[44208,null,"See CPT",null,3477.8154,null,3477.8154,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[44320,null,"See CPT",null,2126.2896000000001,null,2126.2896000000001,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[44360,null,"See CPT",null,252.70500000000001,null,252.70500000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[44379,null,"See CPT",null,720.65519999999992,null,720.65519999999992,null,"000",0,0,0,0,3,0,0,0,0,null,"R",null,"Y-CM"]
[44394,null,"See CPT",null,823.52099999999996,null,397.19279999999998,null,"000",0,0,0,0,3,0,1,0,0,null,"R",null,"Y-CM"]
[44407,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,3,0,1,0,0,null,"X"]
[44615,null,"See CPT",null,1898.5578,null,1898.5578,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[44661,null,"See CPT",null,2721.4842000000003,null,2721.4842000000003,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[44721,null,"See CPT",null,671.30340000000001,null,671.30340000000001,null,"000",0,0,0,0,2,0,2,1,0,null,"R"]
[45000,null,"See CPT",null,767.03399999999999,null,767.03399999999999,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,null,"R"]
[45110,null,"See CPT",null,3223.3265999999999,null,3223.3265999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[45136,null,"See CPT",null,3155.5421999999999,null,3155.5421999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[45315,null,"See CPT",null,429.89580000000001,null,186.70440000000002,null,"000",0,0,0,0,3,0,1,0,0,null,"R",null,"Y-CM"]
[45332,null,"See CPT",null,526.221,null,185.51520000000002,null,"000",0,0,0,0,3,0,1,0,0,null,"R",null,"Y-CM"]
[45341,null,"See CPT",null,218.81280000000001,null,218.81280000000001,null,"000",0,0,0,0,3,0,1,0,0,null,"R",null,"Y-CM"]
[45378,53,"See CPT",null,316.92180000000002,null,162.32580000000002,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[45386,null,"See CPT",null,1171.9566,null,371.625,null,"000",0,0,0,0,3,0,1,0,0,null,"R",null,"Y-CM"]
[45402,null,"See CPT",null,2669.1594,null,2669.1594,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[45540,null,"See CPT",null,1867.6386,null,1867.6386,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[45915,null,"See CPT",null,654.65459999999996,null,413.84160000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[46200,null,"See CPT",null,883.57560000000001,null,614.22180000000003,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,null,"R"]
[46258,null,"See CPT",null,868.11599999999999,null,868.11599999999999,null,"090",0.09,0.81,0.1,0,2,0,0,0,0,null,"R"]
[46285,null,"See CPT",null,1038.7662,null,763.46640000000002,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,null,"R"]
[46604,null,"See CPT",null,1311.6876,null,117.7308,null,"000",0,0,0,0,3,0,1,0,0,null,"R",null,"Y-CM"]
[46614,null,"See CPT",null,318.11099999999999,null,112.37939999999999,null,"000",0,0,0,0,3,0,1,0,0,null,"R",null,"Y-CM"]
[46740,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[46750,null,"See CPT",null,1340.2284,null,1340.2284,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[46940,null,"See CPT",null,491.73419999999999,null,256.86720000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[47120,null,"See CPT",null,4128.3078000000005,null,4128.3078000000005,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[47141,null,"See CPT",null,7535.3658000000005,null,7535.3658000000005,null,"090",0.09,0.81,0.1,0,2,0,2,1,2,null,"R",null,"Y-CM"]
[47300,null,"See CPT",null,2016.8832000000002,null,2016.8832000000002,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[47383,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[47420,null,"See CPT",null,2367.6972000000001,null,2367.6972000000001,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[47538,null,"See CPT",null,7439.0406000000003,null,406.11180000000002,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[47543,null,"See CPT",null,743.25,null,247.94819999999999,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[47600,null,"See CPT",null,1900.3416,null,1900.3416,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[47740,null,"See CPT",null,2340.9402,null,2340.9402,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[47801,null,"See CPT",null,1992.5046,null,1992.5046,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[48100,null,"See CPT",null,1562.6088000000002,null,1562.6088000000002,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[48154,null,"See CPT",null,5141.5061999999998,null,5141.5061999999998,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[48400,null,"See CPT",null,187.89360000000002,null,187.89360000000002,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[49002,null,"See CPT",null,1846.8275999999998,null,1846.8275999999998,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[49014,null,"See CPT",null,666.54660000000001,null,666.54660000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[49205,null,"See CPT",null,3080.0279999999998,null,3080.0279999999998,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[49329,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,1,1,null,"N"]
[49406,null,"See CPT",null,1707.0966000000001,null,338.92200000000003,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[49419,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,1,0,0,null,"X"]
[49450,null,"See CPT",null,1160.6592000000001,null,113.5686,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[49460,null,"See CPT",null,1303.9577999999999,null,85.027799999999999,null,"000",0,0,0,0,2,0,0,0,0,null,"R"]
[49553,null,"See CPT",null,1130.3346000000001,null,1130.3346000000001,null,"090",0.09,0.81,0.1,0,2,1,2,1,0,null,"R"]
[49560,null,"See CPT",null,1313.4713999999999,null,1313.4713999999999,null,"090",0.09,0.81,0.1,0,2,1,2,1,0,null,"R"]
[49600,null,"See CPT",null,1313.4713999999999,null,1313.4713999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[49652,null,"See CPT",null,1324.7688000000001,null,1324.7688000000001,null,"090",0.09,0.81,0.1,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[49905,null,"See CPT",null,616.60019999999997,null,616.60019999999997,null,"000",0,0,0,0,0,0,2,2,0,null,"R"]
[50040,null,"See CPT",null,1625.6364000000001,null,1625.6364000000001,null,"090",0.08,0.83,0.09,0,2,1,1,1,0,null,"R"]
[50225,null,"See CPT",null,2109.0461999999998,null,2109.0461999999998,null,"090",0.08,0.83,0.09,0,2,1,2,1,0,null,"R"]
[50236,null,"See CPT",null,2568.672,null,2568.672,null,"090",0.08,0.83,0.09,0,2,1,2,1,0,null,"R"]
[50370,null,"See CPT",null,2158.9926,null,2158.9926,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[50384,null,"See CPT",null,1655.3664000000001,null,393.03060000000005,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[50432,null,"See CPT",null,1745.7456,null,355.57080000000002,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[50520,null,"See CPT",null,2061.4782,null,2061.4782,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[50546,null,"See CPT",null,2110.83,null,2110.83,null,"090",0.08,0.83,0.09,0,2,1,2,1,0,null,"R"]
[50553,null,"See CPT",null,687.35760000000005,null,545.84280000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[50606,null,"See CPT",null,916.8732,null,237.84,null,"000",0,0,0,0,0,1,1,0,0,null,"R",null,"Y-CM"]
[50630,null,"See CPT",null,1566.7710000000002,null,1566.7710000000002,null,"090",0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[50725,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.08,0.83,0.09,0,2,0,2,1,0,null,"X"]
[50740,null,"See CPT",null,2175.6414000000004,null,2175.6414000000004,null,"090",0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[50825,null,"See CPT",null,2882.0261999999998,null,2882.0261999999998,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[50930,null,"See CPT",null,1930.0716,null,1930.0716,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[50957,null,"See CPT",null,764.06100000000004,null,614.22180000000003,null,"000",0,0,0,0,3,1,0,0,0,null,"R",null,"Y-CM"]
[50976,null,"See CPT",null,808.65599999999995,null,808.65599999999995,null,"000",0,0,0,0,3,1,0,0,0,null,"R",null,"Y-CM"]
[51530,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.08,0.83,0.09,0,2,0,2,1,0,null,"X"]
[51555,null,"See CPT",null,2213.1012000000001,null,2213.1012000000001,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,null,"R"]
[51702,null,"See CPT",null,114.1632,null,44.594999999999999,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[51710,null,"See CPT",null,249.13740000000001,null,139.73099999999999,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[51728,null,"See CPT",null,687.95220000000006,null,687.95220000000006,null,"000",0,0,0,1,2,0,0,0,0,null,"R"]
[51736,26,"See CPT",null,14.2704,null,14.2704,null,"000",0,0,0,1,2,0,0,0,0,null,"R"]
[51785,"TC","See CPT",null,674.27639999999997,null,674.27639999999997,null,"000",0,0,0,1,2,0,0,0,0,null,"R"]
[51797,null,"See CPT",null,369.2466,null,369.2466,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[51960,null,"See CPT",null,2427.7518,null,2427.7518,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[51992,null,"See CPT",null,1477.5810000000001,null,1477.5810000000001,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[52265,null,"See CPT",null,702.81720000000007,null,283.02960000000002,null,"000",0,0,0,0,3,0,1,0,0,null,"R"]
[52276,null,"See CPT",null,459.03120000000001,null,459.03120000000001,null,"000",0,0,0,0,3,0,1,0,0,null,"R"]
[52315,null,"See CPT",null,863.35919999999999,null,476.86919999999998,null,"000",0,0,0,0,3,0,1,0,0,null,"R"]
[52330,null,"See CPT",null,1130.9292,null,457.24740000000003,null,"000",0,0,0,0,3,1,1,0,0,null,"R"]
[52354,null,"See CPT",null,723.62819999999999,null,723.62819999999999,null,"000",0,0,0,0,3,1,1,0,0,null,"R",null,"Y-CM"]
[52450,null,"See CPT",null,838.38599999999997,null,838.38599999999997,null,"090",0.08,0.83,0.09,0,2,0,1,0,0,null,"R"]
[53025,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,null,"X"]
[53220,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.08,0.83,0.09,0,2,0,0,0,0,null,"X"]
[53405,null,"See CPT",null,1534.6625999999999,null,1534.6625999999999,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[53420,null,"See CPT",null,1478.7702000000002,null,1478.7702000000002,null,"090",0.08,0.83,0.09,0,2,0,1,1,0,null,"R",null,"Y-CM"]
[53450,null,"See CPT",null,724.81740000000002,null,724.81740000000002,null,"090",0.08,0.83,0.09,0,2,0,1,0,0,null,"R"]
[53500,null,"See CPT",null,1321.7958000000001,null,1321.7958000000001,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[53661,null,"See CPT",null,134.37959999999998,null,70.162800000000004,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[54000,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"X"]
[54111,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,0,2,1,0,null,"X"]
[54160,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[54235,null,"See CPT",null,156.9744,null,127.839,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
[54240,"TC","See CPT",null,74.919600000000003,null,74.919600000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[54312,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,0,2,1,0,null,"X"]
[54348,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,0,2,1,0,null,"X"]
[54411,null,"See CPT",null,1810.557,null,1810.557,null,"090",0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[54437,null,"See CPT",null,1196.9297999999999,null,1196.9297999999999,null,"090",0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[54560,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,1,2,1,0,null,"X"]
[54690,null,"See CPT",null,1154.7132000000001,null,1154.7132000000001,null,"090",0.1,0.8,0.1,0,2,1,2,1,0,null,"R"]
[54900,null,"See CPT",null,1409.7966000000001,null,1409.7966000000001,null,"090",0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[55040,null,"See CPT",null,601.14059999999995,null,601.14059999999995,null,"090",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[55175,null,"See CPT",null,647.51940000000002,null,647.51940000000002,null,"090",0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[55550,null,"See CPT",null,760.49339999999995,null,760.49339999999995,null,"090",0.1,0.8,0.1,0,2,1,2,1,0,null,"R"]
[55810,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,0,2,1,0,null,"X"]
[55845,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,2,2,1,0,null,"X"]
[55920,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,null,"X"]
[56501,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[56634,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,2,0,null,"X"]
[56700,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,2,1,0,null,"X"]
[57000,null,"See CPT",null,364.4898,null,364.4898,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[57109,null,"See CPT",null,3083.0010000000002,null,3083.0010000000002,null,"090",0.12,0.74,0.14000000000000001,0,2,2,2,1,0,null,"R",null,"Y-CM"]
[57200,null,"See CPT",null,603.51900000000001,null,603.51900000000001,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R"]
[57265,null,"See CPT",null,1557.2574000000002,null,1557.2574000000002,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[57291,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,0,0,null,"X"]
[57310,null,"See CPT",null,883.57560000000001,null,883.57560000000001,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[57423,null,"See CPT",null,1657.1502,null,1657.1502,null,"090",0.08,0.83,0.09,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[57452,null,"See CPT",null,230.70480000000001,null,160.542,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[57500,null,"See CPT",null,289.5702,null,132.5958,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[57550,null,"See CPT",null,779.52059999999994,null,779.52059999999994,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[58146,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"X"]
[58260,null,"See CPT",null,1500.7703999999999,null,1500.7703999999999,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[58300,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[58350,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"X"]
[58544,null,"See CPT",null,1617.3119999999999,null,1617.3119999999999,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[58548,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,2,2,2,0,null,"X"]
[58560,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,3,0,2,2,0,null,"X"]
[58578,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,1,1,null,"N"]
[58673,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,3,1,2,0,0,null,"X"]
[58752,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,1,2,0,0,null,"X"]
[58925,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,2,2,1,0,null,"X"]
[58956,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,2,2,1,0,null,"X"]
[59020,null,"See CPT",null,126.6498,null,126.6498,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[59025,null,"See CPT",null,86.216999999999999,null,86.216999999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[59074,null,"See CPT",null,678.43860000000006,null,535.7346,null,"000",0,0,0,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[59160,null,"See CPT",null,503.62620000000004,null,335.94900000000001,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[59409,null,"See CPT",null,1400.8776,null,1400.8776,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[59612,null,"See CPT",null,1576.2846000000002,null,1576.2846000000002,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[59841,null,"See CPT",null,767.62860000000001,null,660.60059999999999,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[59870,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.17,0.6,0.23,0,2,0,2,0,0,null,"X"]
[60240,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.82,0.09,0,2,0,2,1,0,null,"X"]
[60260,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.82,0.09,0,2,1,2,1,0,null,"X"]
[60505,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.82,0.09,0,2,0,2,1,0,null,"X"]
[60659,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,0,0,null,"N"]
[61055,null,"See CPT",null,206.32620000000003,null,206.32620000000003,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[61215,null,"See CPT",null,918.06240000000003,null,918.06240000000003,null,"090",0.11,0.76,0.13,0,2,0,1,1,0,null,"R"]
[61320,null,"See CPT",null,3319.6518000000001,null,3319.6518000000001,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[61345,null,"See CPT",null,3583.6542000000004,null,3583.6542000000004,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[61519,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"X"]
[61531,null,"See CPT",null,2163.7494000000002,null,2163.7494000000002,null,"090",0.11,0.76,0.13,0,2,0,2,2,0,null,"R"]
[61536,null,"See CPT",null,4509.4464000000007,null,4509.4464000000007,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[61548,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,0,2,2,0,null,"X"]
[61563,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"X"]
[61584,null,"See CPT",null,5131.9926000000005,null,5131.9926000000005,null,"090",0.11,0.76,0.13,0,2,1,2,1,2,null,"R",null,"Y-CM"]
[61600,null,"See CPT",null,3835.17,null,3835.17,null,"090",0.11,0.76,0.13,0,2,0,2,1,2,null,"R",null,"Y-CM"]
[61615,null,"See CPT",null,5020.8023999999996,null,5020.8023999999996,null,"090",0.11,0.76,0.13,0,2,0,2,1,2,null,"R",null,"Y-CM"]
[61645,null,"See CPT",null,1457.9592,null,1457.9592,null,"000",0,0,0,0,0,1,0,0,0,null,"R",null,"Y-CM"]
[61690,null,"See CPT",null,3821.4941999999996,null,3821.4941999999996,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[61700,null,"See CPT",null,5937.6756000000005,null,5937.6756000000005,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[61737,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,1,0,0,0,null,"X"]
[61783,null,"See CPT",null,402.54419999999999,null,402.54419999999999,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[61867,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,1,2,1,0,null,"X"]
[62115,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"X"]
[62145,null,"See CPT",null,2471.1576,null,2471.1576,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[62194,null,"See CPT",null,880.60260000000005,null,880.60260000000005,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[62252,null,"See CPT",null,148.05540000000002,null,148.05540000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[62258,null,"See CPT",null,1966.3422,null,1966.3422,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[62281,null,"See CPT",null,436.43639999999999,null,280.65120000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[62294,null,"See CPT",null,1680.3396,null,1680.3396,null,"090",0.11,0.76,0.13,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[62327,null,"See CPT",null,494.7072,null,184.92060000000001,null,"000",0,0,0,0,2,9,1,0,0,null,"R",null,"Y-UR"]
[62360,null,"See CPT",null,577.95120000000009,null,577.95120000000009,null,"010",0.1,0.8,0.1,0,2,0,0,1,0,null,"R",null,"Y-UR"]
[63011,null,"See CPT",null,1944.9366,null,1944.9366,null,"090",0.11,0.76,0.13,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[63045,null,"See CPT",null,2274.9395999999997,null,2274.9395999999997,null,"090",0.11,0.76,0.13,0,2,2,2,2,0,null,"R",null,"Y-UR"]
[63046,null,"See CPT",null,2171.4792000000002,null,2171.4792000000002,null,"090",0.11,0.76,0.13,0,2,2,2,2,0,null,"R",null,"Y-UR"]
[63056,null,"See CPT",null,2632.2942000000003,null,2632.2942000000003,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63087,null,"See CPT",null,4227.6059999999998,null,4227.6059999999998,null,"090",0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[63170,null,"See CPT",null,2805.9173999999998,null,2805.9173999999998,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63266,null,"See CPT",null,3030.0816,null,3030.0816,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63273,null,"See CPT",null,3283.3811999999998,null,3283.3811999999998,null,"090",0.11,0.76,0.13,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[63290,null,"See CPT",null,4878.6930000000002,null,4878.6930000000002,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63610,null,"See CPT",null,1006.6578,null,1006.6578,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[63620,null,"See CPT",null,1978.2342000000001,null,1978.2342000000001,null,"090",0.11,0.76,0.13,0,0,0,2,0,0,null,"R",null,"Y-CM"]
[63685,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,"Y-UR"]
[64415,null,"See CPT",null,205.137,null,110.5956,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[64418,null,"See CPT",null,159.94739999999999,null,98.703599999999994,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[64451,null,"See CPT",null,429.89580000000001,null,143.89320000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[64479,null,"See CPT",null,493.51800000000003,null,231.89400000000001,null,"000",0,0,0,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[64494,null,"See CPT",null,165.89340000000001,null,90.379199999999997,null,"000",0,0,0,0,0,1,2,0,0,null,"R",null,"Y-UR"]
[64569,null,"See CPT",null,1360.4448,null,1360.4448,null,"090",0.11,0.76,0.13,0,2,1,0,1,1,null,"R",null,"Y-UR"]
[64570,null,"See CPT",null,1305.1469999999999,null,1305.1469999999999,null,"090",0.11,0.76,0.13,0,2,1,0,1,1,null,"R",null,"Y-UR"]
[64590,null,"See CPT",null,485.1936,null,286.00259999999997,null,"010",0.1,0.8,0.1,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[64632,null,"See CPT",null,162.32580000000002,null,117.7308,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[64635,null,"See CPT",null,827.68320000000006,null,339.51659999999998,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[64681,null,"See CPT",null,877.03499999999997,null,398.97660000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[64714,null,"See CPT",null,1351.5258000000001,null,1351.5258000000001,null,"090",0.11,0.76,0.13,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[64740,null,"See CPT",null,829.46699999999998,null,829.46699999999998,null,"090",0.11,0.76,0.13,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[64778,null,"See CPT",null,316.92180000000002,null,316.92180000000002,null,"000",0,0,0,0,0,0,1,0,0,null,"R"]
[64782,null,"See CPT",null,815.7912,null,815.7912,null,"090",0.11,0.76,0.13,0,2,0,1,1,0,null,"R"]
[64795,null,"See CPT",null,335.3544,null,335.3544,null,"000",0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[64856,null,"See CPT",null,1798.665,null,1798.665,null,"090",0.11,0.76,0.13,0,2,0,1,1,0,null,"R"]
[64859,null,"See CPT",null,434.05799999999999,null,434.05799999999999,null,"000",0,0,0,0,0,0,2,1,0,null,"R"]
[64890,null,"See CPT",null,1919.9633999999999,null,1919.9633999999999,null,"090",0.11,0.76,0.13,0,2,0,2,0,0,null,"R"]
[64897,null,"See CPT",null,2246.9933999999998,null,2246.9933999999998,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[65093,null,"See CPT",null,1354.4988000000001,null,1354.4988000000001,null,"090",0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[65125,null,"See CPT",null,836.60220000000004,null,521.46420000000001,null,"090",0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[65175,null,"See CPT",null,1429.4184,null,1429.4184,null,"090",0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[65270,null,"See CPT",null,526.81560000000002,null,248.5428,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[65600,null,"See CPT",null,793.19640000000004,null,601.14059999999995,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[65750,null,"See CPT",null,2242.2366000000002,null,2242.2366000000002,null,"090",0.1,0.7,0.2,0,2,1,2,1,0,null,"R"]
[65779,null,"See CPT",null,2215.4796000000001,null,260.4348,null,"000",0,0,0,0,2,1,0,0,0,null,"R"]
[65810,null,"See CPT",null,821.73720000000003,null,821.73720000000003,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[65930,null,"See CPT",null,1139.8482000000001,null,1139.8482000000001,null,"090",0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[66170,null,"See CPT",null,1937.2067999999999,null,1937.2067999999999,null,"090",0.1,0.7,0.2,0,2,1,2,1,0,null,"R"]
[66183,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,1,2,0,0,null,"X"]
[66605,null,"See CPT",null,1942.5582000000002,null,1942.5582000000002,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[66825,null,"See CPT",null,1506.1217999999999,null,1506.1217999999999,null,"090",0.1,0.7,0.2,0,2,1,0,0,0,null,"R"]
[66920,null,"See CPT",null,1322.3904,null,1322.3904,null,"090",0.1,0.7,0.2,0,2,1,0,1,0,null,"R"]
[66988,null,"See CPT",null," By Report ",null," By Report ",null,"090",0.1,0.7,0.2,0,2,1,0,1,1,null,"N",null,"Y-CM"]
[67015,null,"See CPT",null,1081.5774000000001,null,1081.5774000000001,null,"090",0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[67101,null,"See CPT",null,599.35680000000002,null,502.43699999999995,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[67208,null,"See CPT",null,1070.28,null,1020.3336,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[67228,null,"See CPT",null,603.51900000000001,null,534.54539999999997,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[67255,null,"See CPT",null,1221.903,null,1221.903,null,"090",0.1,0.7,0.2,0,2,1,2,1,0,null,"R"]
[67399,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,1,1,null,"N"]
[67414,null,"See CPT",null,2646.5645999999997,null,2646.5645999999997,null,"090",0.1,0.7,0.2,0,2,1,2,1,0,null,"R"]
[67599,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,1,1,null,"N"]
[67715,null,"See CPT",null,494.11260000000004,null,191.46120000000002,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[67875,null,"See CPT",null,335.94900000000001,null,167.6772,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[67911,null,"See CPT",null,987.03600000000006,null,987.03600000000006,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[67922,null,"See CPT",null,566.65379999999993,null,354.38159999999999,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[67930,null,"See CPT",null,674.27639999999997,null,415.03080000000006,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[68130,null,"See CPT",null,1006.0632000000002,null,730.16879999999992,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[68326,null,"See CPT",null,1136.8752000000002,null,1136.8752000000002,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[68505,null,"See CPT",null,1899.1524000000002,null,1899.1524000000002,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[68525,null,"See CPT",null,453.08519999999999,null,453.08519999999999,null,"000",0,0,0,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[68801,null,"See CPT",null,174.8124,null,139.73099999999999,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[69020,null,"See CPT",null,438.22020000000003,null,261.02940000000001,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[69145,null,"See CPT",null,768.81780000000003,null,469.13939999999997,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R"]
[69220,null,"See CPT",null,140.32560000000001,null,89.784599999999998,null,"000",0,0,0,0,2,1,1,0,0,null,"R"]
[69450,null,"See CPT",null,1010.82,null,1010.82,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,null,"R"]
[69530,null,"See CPT",null,3068.136,null,3068.136,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[69632,null,"See CPT",null,1987.1532000000002,null,1987.1532000000002,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R"]
[69636,null,"See CPT",null,2593.6451999999999,null,2593.6451999999999,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,null,"R"]
[69666,null,"See CPT",null,1476.9864,null,1476.9864,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,null,"R"]
[69717,null,"See CPT",null,1177.9025999999999,null,1177.9025999999999,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[69745,null,"See CPT",null,2242.8312000000001,null,2242.8312000000001,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,0,0,null,"R"]
[69915,null,"See CPT",null,2705.43,null,2705.43,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[70015,26,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[70100,"TC","See CPT",null,55.892399999999995,null,55.892399999999995,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[70134,26,"See CPT",null,30.9192,null,30.9192,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[70140,26,"See CPT",null,17.838000000000001,null,17.838000000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[70190,26,"See CPT",null,19.6218,null,19.6218,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[70240,"TC","See CPT",null,45.189599999999999,null,45.189599999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[70260,26,"See CPT",null,24.378599999999999,null,24.378599999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[70320,null,"See CPT",null,101.67659999999999,null,101.67659999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[70336,null,"See CPT",null,523.84260000000006,null,523.84260000000006,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[70350,"TC","See CPT",null,14.2704,null,14.2704,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[70380,null,"See CPT",null,70.162800000000004,null,70.162800000000004,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[70390,null,"See CPT",null,225.35339999999999,null,225.35339999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[70460,"TC","See CPT",null,189.08280000000002,null,189.08280000000002,null,"000",0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[70486,26,"See CPT",null,72.541200000000003,null,72.541200000000003,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[70490,null,"See CPT",null,288.38099999999997,null,288.38099999999997,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[70492,"TC","See CPT",null,291.35400000000004,null,291.35400000000004,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[70498,26,"See CPT",null,148.65,null,148.65,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[70543,null,"See CPT",null,664.76279999999997,null,664.76279999999997,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[70548,"TC","See CPT",null,351.40860000000004,null,351.40860000000004,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[70549,"TC","See CPT",null,520.86959999999999,null,520.86959999999999,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[70554,26,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,4,3,0,0,0,null,"X"]
[70557,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[71046,"TC","See CPT",null,43.405799999999999,null,43.405799999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[71048,26,"See CPT",null,26.757000000000001,null,26.757000000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[71110,null,"See CPT",null,81.460200000000015,null,81.460200000000015,null,"000",0,0,0,1,0,2,0,0,0,null,"R"]
[71120,"TC","See CPT",null,45.784199999999998,null,45.784199999999998,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[71271,26,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,4,0,0,0,0,null,"X"]
[71275,26,"See CPT",null,154.596,null,154.596,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[72020,null,"See CPT",null,45.189599999999999,null,45.189599999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[72040,26,"See CPT",null,19.6218,null,19.6218,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[72072,26,"See CPT",null,19.6218,null,19.6218,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[72081,null,"See CPT",null,79.081800000000001,null,79.081800000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[72083,"TC","See CPT",null,115.3524,null,115.3524,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[72114,null,"See CPT",null,115.3524,null,115.3524,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[72127,null,"See CPT",null,383.517,null,383.517,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[72128,null,"See CPT",null,249.13740000000001,null,249.13740000000001,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[72132,"TC","See CPT",null,221.78579999999999,null,221.78579999999999,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[72141,null,"See CPT",null,371.03040000000004,null,371.03040000000004,null,"000",0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[72148,null,"See CPT",null,371.625,null,371.625,null,"000",0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[72156,"TC","See CPT",null,430.49040000000002,null,430.49040000000002,null,"000",0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[72158,26,"See CPT",null,194.4342,null,194.4342,null,"000",0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[72191,"TC","See CPT",null,442.97700000000003,null,442.97700000000003,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[72195,"TC","See CPT",null,326.43540000000002,null,326.43540000000002,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[72196,"TC","See CPT",null,381.1386,null,381.1386,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[72202,26,"See CPT",null,19.6218,null,19.6218,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[72240,"TC","See CPT",null,135.56879999999998,null,135.56879999999998,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[72265,26,"See CPT",null,70.757400000000004,null,70.757400000000004,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[73000,26,"See CPT",null,14.2704,null,14.2704,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[73030,null,"See CPT",null,64.216800000000006,null,64.216800000000006,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[73060,26,"See CPT",null,13.675800000000001,null,13.675800000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[73090,26,"See CPT",null,13.675800000000001,null,13.675800000000001,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[73092,26,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,3,0,0,0,null,"X"]
[73130,null,"See CPT",null,67.784399999999991,null,67.784399999999991,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[73140,26,"See CPT",null,11.892000000000001,null,11.892000000000001,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[73202,null,"See CPT",null,491.73419999999999,null,491.73419999999999,null,"000",0,0,0,1,4,3,0,0,0,null,"R"]
[73220,null,"See CPT",null,813.41279999999995,null,813.41279999999995,null,"000",0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR"]
[73222,"TC","See CPT",null,481.62599999999998,null,481.62599999999998,null,"000",0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR"]
[73502,null,"See CPT",null,87.406199999999998,null,87.406199999999998,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[73523,null,"See CPT",null,114.1632,null,114.1632,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[73551,null,"See CPT",null,54.108600000000003,null,54.108600000000003,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[73552,null,"See CPT",null,65.406000000000006,null,65.406000000000006,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[73565,null,"See CPT",null,75.514200000000002,null,75.514200000000002,null,"000",0,0,0,1,0,2,0,0,0,null,"R"]
[73590,"TC","See CPT",null,44.594999999999999,null,44.594999999999999,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[73610,"TC","See CPT",null,53.514000000000003,null,53.514000000000003,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[73660,null,"See CPT",null,54.108600000000003,null,54.108600000000003,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[73701,"TC","See CPT",null,222.97499999999999,null,222.97499999999999,null,"000",0,0,0,1,4,3,0,0,0,null,"R"]
[73719,"TC","See CPT",null,377.57099999999997,null,377.57099999999997,null,"000",0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR"]
[73721,"TC","See CPT",null,276.48900000000003,null,276.48900000000003,null,"000",0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR"]
[73722,"TC","See CPT",null,482.81519999999995,null,482.81519999999995,null,"000",0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR"]
[74019,"TC","See CPT",null,48.162600000000005,null,48.162600000000005,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[74022,26,"See CPT",null,27.351600000000001,null,27.351600000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[74170,26,"See CPT",null,119.51459999999999,null,119.51459999999999,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[74178,"TC","See CPT",null,500.65320000000003,null,500.65320000000003,null,"000",0,0,0,1,4,0,9,0,0,null,"R"]
[74182,26,"See CPT",null,147.46080000000001,null,147.46080000000001,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[74210,26,"See CPT",null,50.540999999999997,null,50.540999999999997,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[74221,26,"See CPT",null,59.46,null,59.46,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[74230,26,"See CPT",null,45.784199999999998,null,45.784199999999998,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[74248,26,"See CPT",null,59.46,null,59.46,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[74261,null,"See CPT",null,823.52099999999996,null,823.52099999999996,null,"000",0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[74270,null,"See CPT",null,293.73240000000004,null,293.73240000000004,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[74290,null,"See CPT",null,165.2988,null,165.2988,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[74329,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[74360,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[74400,null,"See CPT",null,258.0564,null,258.0564,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[74410,null,"See CPT",null,266.97540000000004,null,266.97540000000004,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[74430,null,"See CPT",null,74.919600000000003,null,74.919600000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[74445,"TC","See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[74470,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[74712,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,4,0,0,0,0,null,"X"]
[74775,"TC","See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[75563,"TC","See CPT",null,592.81620000000009,null,592.81620000000009,null,"000",0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[75571,"TC","See CPT",null,140.92020000000002,null,140.92020000000002,null,"000",0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[75572,"TC","See CPT",null,288.38099999999997,null,288.38099999999997,null,"000",0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[75625,26,"See CPT",null,118.92,null,118.92,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[75705,null,"See CPT",null,444.76080000000002,null,444.76080000000002,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[75726,null,"See CPT",null,310.97580000000005,null,310.97580000000005,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[75736,null,"See CPT",null,259.24560000000002,null,259.24560000000002,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[75756,null,"See CPT",null,291.35400000000004,null,291.35400000000004,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[75805,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[75809,null,"See CPT",null,152.81219999999999,null,152.81219999999999,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[75810,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[75831,"TC","See CPT",null,128.43360000000001,null,128.43360000000001,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[75833,"TC","See CPT",null,146.86620000000002,null,146.86620000000002,null,"000",0,0,0,1,6,2,0,0,0,null,"R"]
[75860,"TC","See CPT",null,136.75799999999998,null,136.75799999999998,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[75880,"TC","See CPT",null,140.32560000000001,null,140.32560000000001,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[75891,"TC","See CPT",null,136.1634,null,136.1634,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[75898,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[75956,"TC","See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[75957,"TC","See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[75989,26,"See CPT",null,98.703599999999994,null,98.703599999999994,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76000,"TC","See CPT",null,52.324800000000003,null,52.324800000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76100,"TC","See CPT",null,117.1362,null,117.1362,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76125,26,"See CPT",null,23.189400000000003,null,23.189400000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76390,null,"See CPT",null,724.22280000000001,null,724.22280000000001,null,"000",0,0,0,1,9,9,9,9,9,null,"R",null,"Y-CM"]
[76496,"TC","See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[76506,null,"See CPT",null,215.8398,null,215.8398,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76510,null,"See CPT",null,126.6498,null,126.6498,null,"000",0,0,0,1,7,3,0,0,0,null,"R"]
[76516,"TC","See CPT",null,45.189599999999999,null,45.189599999999999,null,"000",0,0,0,1,7,2,0,0,0,null,"R"]
[76519,null,"See CPT",null,122.4876,null,122.4876,null,"000",0,0,0,1,7,2,0,0,0,null,"R"]
[76641,null,"See CPT",null,192.0558,null,192.0558,null,"000",0,0,0,1,0,1,0,0,0,null,"R",null,"Y-CM"]
[76700,"TC","See CPT",null,150.43379999999999,null,150.43379999999999,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[76775,"TC","See CPT",null,57.081600000000002,null,57.081600000000002,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[76801,null,"See CPT",null,217.62360000000001,null,217.62360000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76810,26,"See CPT",null,83.244,null,83.244,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76811,26,"See CPT",null,162.92040000000003,null,162.92040000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76816,26,"See CPT",null,73.135800000000003,null,73.135800000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[76817,"TC","See CPT",null,108.21720000000001,null,108.21720000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76821,"TC","See CPT",null,104.05500000000001,null,104.05500000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76826,26,"See CPT",null,71.352000000000004,null,71.352000000000004,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76831,26,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,4,0,0,0,0,null,"X"]
[76870,"TC","See CPT",null,133.785,null,133.785,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[76881,26,"See CPT",null,54.108600000000003,null,54.108600000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76882,26,"See CPT",null,41.0274,null,41.0274,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[76940,26,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[76940,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[76965,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[76975,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[76981,null,"See CPT",null,194.4342,null,194.4342,null,"000",0,0,0,1,4,0,0,0,0,null,"R"]
[76983,26,"See CPT",null,43.405799999999999,null,43.405799999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[77002,null,"See CPT",null,217.029,null,217.029,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[77003,null,"See CPT",null,196.21799999999999,null,196.21799999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[77021,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,9,0,0,null,"X"]
[77022,26,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,9,0,0,null,"X"]
[77053,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,9,0,0,null,"X"]
[77054,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,9,0,0,null,"X"]
[77065,"TC","See CPT",null,164.70420000000001,null,164.70420000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77071,null,"See CPT",null,101.67659999999999,null,101.67659999999999,null,"000",0,0,0,2,0,2,0,0,0,null,"R"]
[77075,null,"See CPT",null,184.92060000000001,null,184.92060000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[77076,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[77084,"TC","See CPT",null,491.13959999999997,null,491.13959999999997,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[77085,null,"See CPT",null,93.94680000000001,null,93.94680000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[77285,null,"See CPT",null,824.11559999999997,null,824.11559999999997,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77290,null,"See CPT",null,847.30500000000006,null,847.30500000000006,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77299,26,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[77306,null,"See CPT",null,264.00240000000002,null,264.00240000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77318,null,"See CPT",null,827.68320000000006,null,827.68320000000006,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77331,26,"See CPT",null,81.460200000000015,null,81.460200000000015,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77338,null,"See CPT",null,831.25080000000003,null,831.25080000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77338,26,"See CPT",null,398.97660000000002,null,398.97660000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77423,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,3,0,0,0,0,0,null,"X"]
[77427,null,"See CPT",null,337.13819999999998,null,337.13819999999998,null,"000",0,0,0,2,9,9,9,9,9,null,"R",null,"Y-CM"]
[77499,"TC","See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[77605,null,"See CPT",null,1859.3142,null,1859.3142,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77750,null,"See CPT",null,701.62800000000004,null,701.62800000000004,null,"090",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77762,26,"See CPT",null,535.7346,null,535.7346,null,"090",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77770,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[77771,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[77799,26,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[78012,"TC","See CPT",null,133.19040000000001,null,133.19040000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78015,26,"See CPT",null,57.081600000000002,null,57.081600000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78020,"TC","See CPT",null,98.703599999999994,null,98.703599999999994,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78075,"TC","See CPT",null,725.41199999999992,null,725.41199999999992,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78102,26,"See CPT",null,44.594999999999999,null,44.594999999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78111,26,"See CPT",null,16.054200000000002,null,16.054200000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78120,"TC","See CPT",null,115.3524,null,115.3524,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78185,26,"See CPT",null,29.135400000000001,null,29.135400000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78191,26,"See CPT",null,44.000399999999999,null,44.000399999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78202,null,"See CPT",null,374.59800000000001,null,374.59800000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78216,26,"See CPT",null,46.378800000000005,null,46.378800000000005,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78231,26,"See CPT",null,37.459800000000001,null,37.459800000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78261,null,"See CPT",null,363.30060000000003,null,363.30060000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78266,null,"See CPT",null,777.1422,null,777.1422,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[78266,26,"See CPT",null,86.216999999999999,null,86.216999999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[78299,26,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[78300,"TC","See CPT",null,351.40860000000004,null,351.40860000000004,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[78315,26,"See CPT",null,84.433199999999999,null,84.433199999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[78414,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[78431,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-UR"]
[78433,"TC","See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-UR"]
[78452,"TC","See CPT",null,701.62800000000004,null,701.62800000000004,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-UR"]
[78454,"TC","See CPT",null,654.06000000000006,null,654.06000000000006,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-UR"]
[78459,"TC","See CPT",null,3085.8673697280005,null,3085.8673697280005,null,"000",0,0,0,1,0,0,0,0,0,null,"F",null,"Y-UR"]
[78466,"TC","See CPT",null,284.21880000000004,null,284.21880000000004,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[78472,26,"See CPT",null,82.0548,null,82.0548,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[78483,"TC","See CPT",null,305.62439999999998,null,305.62439999999998,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[78496,26,"See CPT",null,42.2166,null,42.2166,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR"]
[78580,"TC","See CPT",null,356.16540000000003,null,356.16540000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78598,"TC","See CPT",null,467.35560000000004,null,467.35560000000004,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78600,26,"See CPT",null,37.459800000000001,null,37.459800000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[78608,null,"See CPT",null,138.48976421280003,null,138.48976421280003,null,"000",0,0,0,1,0,0,0,0,0,null,"F",null,"Y-CM"]
[78609,26,"See CPT",null,130.2174,null,130.2174,null,"000",0,0,0,1,9,9,9,9,9,null,"R",null,"Y-CM"]
[78630,26,"See CPT",null,57.081600000000002,null,57.081600000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[78660,26,"See CPT",null,44.594999999999999,null,44.594999999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[78707,26,"See CPT",null,78.487200000000001,null,78.487200000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[78725,26,"See CPT",null,31.513800000000003,null,31.513800000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[78761,26,"See CPT",null,60.6492,null,60.6492,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[78801,null,"See CPT",null,487.57199999999995,null,487.57199999999995,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78808,null,"See CPT",null,74.325000000000003,null,74.325000000000003,null,"000",0,0,0,5,0,0,0,0,0,null,"R",null,"Y-CM"]
[78811,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[78813,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[78830,26,"See CPT",null,120.70379999999999,null,120.70379999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78835,null,"See CPT",null,176.0016,null,176.0016,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[79200,"TC","See CPT",null,100.48739999999999,null,100.48739999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[79440,"TC","See CPT",null,76.108800000000002,null,76.108800000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[80047,null,"See CPT",null,19.633900000000001,null,19.633900000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[80145,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[80155,null,"See CPT",null,55.155099999999997,null,55.155099999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[80162,null,"See CPT",null,18.990399999999998,null,18.990399999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[80177,null,"See CPT",null,18.947499999999998,null,18.947499999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[80185,null,"See CPT",null,18.947499999999998,null,18.947499999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[80201,null,"See CPT",null,17.0456,null,17.0456,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[80285,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[80322,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[80334,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[80337,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[80343,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[80355,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[80362,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[80376,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[80415,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[80426,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[80506,null,"See CPT",null,75.514200000000002,null,75.514200000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[81002,null,"See CPT",null,4.9763999999999999,null,4.9763999999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[81025,null,"See CPT",null,12.312299999999999,null,12.312299999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[81121,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81167,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81182,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81191,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81203,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81218,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81221,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81227,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81239,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81250,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81257,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81264,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81276,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81284,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81297,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81300,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81312,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81323,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81330,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81337,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81349,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81355,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81376,null,"See CPT",null,174.77459999999999,null,174.77459999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[81379,null,"See CPT",null,479.59339999999997,null,479.59339999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[81407,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81420,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81432,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81439,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81479,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81504,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81521,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81525,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[81596,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[82024,null,"See CPT",null,55.226599999999991,null,55.226599999999991,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82075,null,"See CPT",null,42.9,null,42.9,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82106,null,"See CPT",null,24.31,null,24.31,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82150,null,"See CPT",null,9.2664000000000009,null,9.2664000000000009,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82164,null,"See CPT",null,20.878,null,20.878,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82271,null,"See CPT",null,7.6075999999999997,null,7.6075999999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82286,null,"See CPT",null,7.3788,null,7.3788,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82378,null,"See CPT",null,27.1128,null,27.1128,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[82390,null,"See CPT",null,15.3582,null,15.3582,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82465,null,"See CPT",null,6.2204999999999995,null,6.2204999999999995,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[82525,null,"See CPT",null,17.746299999999998,null,17.746299999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82575,null,"See CPT",null,13.527800000000001,null,13.527800000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82608,null,"See CPT",null,20.477599999999999,null,20.477599999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82658,null,"See CPT",null,62.962899999999998,null,62.962899999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82670,null,"See CPT",null,39.9542,null,39.9542,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[82746,null,"See CPT",null,21.020999999999997,null,21.020999999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82777,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[82810,null,"See CPT",null,13.971099999999998,null,13.971099999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82946,null,"See CPT",null,25.411099999999998,null,25.411099999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[82960,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[83006,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[83030,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[83037,null,"See CPT",null,13.885300000000001,null,13.885300000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[83491,null,"See CPT",null,25.596999999999998,null,25.596999999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[83516,null,"See CPT",null,16.4879,null,16.4879,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[83582,null,"See CPT",null,22.1221,null,22.1221,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[83631,null,"See CPT",null,28.070899999999998,null,28.070899999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[83664,null,"See CPT",null,27.627599999999997,null,27.627599999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[83722,null,"See CPT",null,48.891699999999993,null,48.891699999999993,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[83873,null,"See CPT",null,24.595999999999997,null,24.595999999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[83880,null,"See CPT",null,56.141799999999996,null,56.141799999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[83951,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[84030,null,"See CPT",null,7.8649999999999993,null,7.8649999999999993,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[84120,null,"See CPT",null,21.035299999999999,null,21.035299999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[84133,null,"See CPT",null,6.7639000000000005,null,6.7639000000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[84145,null,"See CPT",null,38.924599999999998,null,38.924599999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[84165,26,"See CPT",null,32.108400000000003,null,32.108400000000003,null,"000",0,0,0,6,0,0,0,0,0,null,"R"]
[84210,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[84233,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[84302,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[84375,null,"See CPT",null,55.769999999999996,null,55.769999999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[84442,null,"See CPT",null,21.135399999999997,null,21.135399999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[84446,null,"See CPT",null,20.2774,null,20.2774,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[84480,null,"See CPT",null,20.2774,null,20.2774,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[84540,null,"See CPT",null,7.9507999999999992,null,7.9507999999999992,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[84591,null,"See CPT",null,24.395799999999998,null,24.395799999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[84703,null,"See CPT",null,10.753599999999999,null,10.753599999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[85013,null,"See CPT",null,10.01,null,10.01,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[85032,null,"See CPT",null,6.1632999999999996,null,6.1632999999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[85240,null,"See CPT",null,25.596999999999998,null,25.596999999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[85246,null,"See CPT",null,32.804200000000002,null,32.804200000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[85291,null,"See CPT",null,13.027299999999999,null,13.027299999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[85337,null,"See CPT",null,24.696099999999998,null,24.696099999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[85385,null,"See CPT",null,20.677800000000001,null,20.677800000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[85415,null,"See CPT",null,24.581700000000001,null,24.581700000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[85525,null,"See CPT",null,16.9312,null,16.9312,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[85549,null,"See CPT",null,26.8125,null,26.8125,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[85675,null,"See CPT",null,9.7954999999999988,null,9.7954999999999988,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[85732,null,"See CPT",null,9.2520999999999987,null,9.2520999999999987,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86008,null,"See CPT",null,25.639899999999997,null,25.639899999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86053,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[86153,26,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,6,0,0,0,0,0,null,"X"]
[86171,null,"See CPT",null,14.314299999999999,null,14.314299999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86256,26,"See CPT",null,32.108400000000003,null,32.108400000000003,null,"000",0,0,0,6,0,0,0,0,0,null,"R"]
[86294,null,"See CPT",null,36.565100000000001,null,36.565100000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[86327,26,"See CPT",null,38.054400000000001,null,38.054400000000001,null,"000",0,0,0,6,0,0,0,0,0,null,"R"]
[86335,26,"See CPT",null,32.108400000000003,null,32.108400000000003,null,"000",0,0,0,6,0,0,0,0,0,null,"R"]
[86336,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[86360,null,"See CPT",null,67.181399999999996,null,67.181399999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86406,null,"See CPT",null,15.215199999999999,null,15.215199999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86480,null,"See CPT",null,88.631399999999985,null,88.631399999999985,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86603,null,"See CPT",null,18.4041,null,18.4041,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86611,null,"See CPT",null,14.557399999999999,null,14.557399999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86648,null,"See CPT",null,21.750299999999999,null,21.750299999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86665,null,"See CPT",null,25.940200000000001,null,25.940200000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86666,null,"See CPT",null,14.557399999999999,null,14.557399999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86695,null,"See CPT",null,18.861699999999999,null,18.861699999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86710,null,"See CPT",null,19.3765,null,19.3765,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86727,null,"See CPT",null,18.4041,null,18.4041,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86762,null,"See CPT",null,20.5777,null,20.5777,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86769,null,"See CPT",null,60.245899999999999,null,60.245899999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[86805,null,"See CPT",null,270.99929999999995,null,270.99929999999995,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86821,null,"See CPT",null,52.280799999999999,null,52.280799999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86825,null,"See CPT",null,156.57069999999999,null,156.57069999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86860,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
[86906,null,"See CPT",null,11.0825,null,11.0825,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[86923,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
[86971,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
[86999,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
[87081,null,"See CPT",null,9.4809000000000001,null,9.4809000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87107,null,"See CPT",null,14.7576,null,14.7576,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87109,null,"See CPT",null,22.0077,null,22.0077,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87158,null,"See CPT",null,11.068199999999999,null,11.068199999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87186,null,"See CPT",null,12.3695,null,12.3695,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87206,null,"See CPT",null,7.7076999999999991,null,7.7076999999999991,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87260,null,"See CPT",null,20.634899999999998,null,20.634899999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87273,null,"See CPT",null,17.131399999999999,null,17.131399999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87300,null,"See CPT",null,17.131399999999999,null,17.131399999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87332,null,"See CPT",null,17.131399999999999,null,17.131399999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87335,null,"See CPT",null,18.1038,null,18.1038,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87391,null,"See CPT",null,31.316999999999997,null,31.316999999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87430,null,"See CPT",null,24.038299999999996,null,24.038299999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87485,null,"See CPT",null,28.671499999999998,null,28.671499999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87501,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[87511,null,"See CPT",null,50.178699999999999,null,50.178699999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87530,null,"See CPT",null,61.261200000000002,null,61.261200000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87538,null,"See CPT",null,50.178699999999999,null,50.178699999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87539,null,"See CPT",null,83.826599999999999,null,83.826599999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87562,null,"See CPT",null,61.261200000000002,null,61.261200000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87592,null,"See CPT",null,61.261200000000002,null,61.261200000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[87640,null,"See CPT",null,50.178699999999999,null,50.178699999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87800,null,"See CPT",null,62.448099999999997,null,62.448099999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87808,null,"See CPT",null,21.864699999999999,null,21.864699999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87903,null,"See CPT",null,698.78380000000004,null,698.78380000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[87910,null,"See CPT",null,368.15349999999995,null,368.15349999999995,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[88014,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[88104,null,"See CPT",null,121.89299999999999,null,121.89299999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88108,26,"See CPT",null,39.243600000000001,null,39.243600000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88125,null,"See CPT",null,48.757199999999997,null,48.757199999999997,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88153,null,"See CPT",null,34.362900000000003,null,34.362900000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88161,26,"See CPT",null,44.594999999999999,null,44.594999999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88172,"TC","See CPT",null,35.676000000000002,null,35.676000000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88177,"TC","See CPT",null,13.081200000000001,null,13.081200000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88182,26,"See CPT",null,67.189799999999991,null,67.189799999999991,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88237,null,"See CPT",null,205.5625,null,205.5625,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88262,null,"See CPT",null,179.45069999999998,null,179.45069999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88280,null,"See CPT",null,47.862099999999998,null,47.862099999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88304,null,"See CPT",null,76.108800000000002,null,76.108800000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[88307,"TC","See CPT",null,378.16560000000004,null,378.16560000000004,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[88312,26,"See CPT",null,46.378800000000005,null,46.378800000000005,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[88319,"TC","See CPT",null,209.29920000000001,null,209.29920000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[88323,null,"See CPT",null,201.5694,null,201.5694,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[88333,26,"See CPT",null,108.21720000000001,null,108.21720000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[88342,null,"See CPT",null,183.73140000000001,null,183.73140000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[88348,"TC","See CPT",null,700.43880000000001,null,700.43880000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[88358,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[88361,26,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[88365,26,"See CPT",null,76.703400000000002,null,76.703400000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88368,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[88369,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[88375,null,"See CPT",null,85.027799999999999,null,85.027799999999999,null,"000",0,0,0,2,0,0,0,0,0,null,"R"]
[88381,"TC","See CPT",null,344.86799999999999,null,344.86799999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[88399,"TC","See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[89050,null,"See CPT",null,6.7495999999999992,null,6.7495999999999992,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[89251,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[89268,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[89320,null,"See CPT",null,17.603300000000001,null,17.603300000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
[89325,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[89354,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[90291,null,"See CPT",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
[90389,null,"See CPT",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
[90472,null,"See CPT",null,22.594799999999999,null,22.594799999999999,null,"000",0,0,0,5,0,0,0,0,0,null,"R"]
[90633,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[90654,null,"See CPT",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
[90664,null,"See CPT",null,0,null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
[90668,null,"See CPT",null,0,null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
[90685,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[90696,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[90732,null,"See CPT",null,133.47200000000001,null,133.47200000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
[90743,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[90833,null,"See CPT",null,124.2714,null,110.5956,null,"000",0,0,0,0,0,0,9,0,0,null,"R",null,"Y-CM"]
[90853,null,"See CPT",null,47.568000000000005,null,41.622,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[90875,null,"See CPT",null,107.02800000000001,null,105.83880000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"R",null,"Y-CM"]
[90882,null,"See CPT",null,82.955401214399998,null,82.955401214399998,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
[90940,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
[90956,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[90968,null,"See CPT",null,30.9192,null,30.9192,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[91010,null,"See CPT",null,420.97680000000003,null,420.97680000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[91030,null,"See CPT",null,271.73220000000003,null,271.73220000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[91037,26,"See CPT",null,87.406199999999998,null,87.406199999999998,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[91065,null,"See CPT",null,170.0556,null,170.0556,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[91110,null,"See CPT",null,1459.1484,null,1459.1484,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[91117,null,"See CPT",null,241.40759999999997,null,241.40759999999997,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[91132,"TC","See CPT",null,834.8184,null,834.8184,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[91301,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
[92002,null,"See CPT",null,155.7852,null,82.6494,null,"000",0,0,0,0,0,2,0,0,0,null,"R"]
[92060,26,"See CPT",null,65.406000000000006,null,65.406000000000006,null,"000",0,0,0,1,7,2,0,0,0,null,"R"]
[92072,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,2,0,0,0,null,"X"]
[92132,26,"See CPT",null,28.540800000000001,null,28.540800000000001,null,"000",0,0,0,1,7,2,0,0,0,null,"R"]
[92133,26,"See CPT",null,38.054400000000001,null,38.054400000000001,null,"000",0,0,0,1,7,2,0,0,0,null,"R"]
[92145,"TC","See CPT",null,13.081200000000001,null,13.081200000000001,null,"000",0,0,0,1,7,2,0,0,0,null,"R",null,"Y-CM"]
[92230,null,"See CPT",null,178.97459999999998,null,57.676200000000001,null,"000",0,0,0,0,0,3,0,0,0,null,"R"]
[92250,26,"See CPT",null,36.865200000000002,null,36.865200000000002,null,"000",0,0,0,1,7,2,0,0,0,null,"R"]
[92270,26,"See CPT",null,74.919600000000003,null,74.919600000000003,null,"000",0,0,0,1,7,2,0,0,0,null,"R"]
[92286,null,"See CPT",null,70.757400000000004,null,70.757400000000004,null,"000",0,0,0,1,7,2,0,0,0,null,"R"]
[92312,null,"See CPT",null,224.16419999999999,null,107.62260000000001,null,"000",0,0,0,0,0,2,0,0,0,null,"R"]
[92353,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
[92358,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
[92511,null,"See CPT",null,220.00200000000001,null,66.595200000000006,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[92522,null,"See CPT",null,200.3802,null,200.3802,null,"000",0,0,0,7,5,0,0,0,0,null,"R"]
[92540,"TC","See CPT",null,62.433000000000007,null,62.433000000000007,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[92541,"TC","See CPT",null,8.9190000000000005,null,8.9190000000000005,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[92546,26,"See CPT",null,26.757000000000001,null,26.757000000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[92549,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[92565,null,"See CPT",null,35.081400000000002,null,35.081400000000002,null,"000",0,0,0,3,0,2,0,0,0,null,"R"]
[92570,null,"See CPT",null,58.865400000000001,null,52.324800000000003,null,"000",0,0,0,7,0,2,0,0,0,null,"R"]
[92587,null,"See CPT",null,39.838200000000001,null,39.838200000000001,null,"000",0,0,0,1,0,2,0,0,0,null,"R"]
[92592,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
[92611,null,"See CPT",null,165.2988,null,165.2988,null,"000",0,0,0,7,0,0,0,0,0,null,"R",null,"Y-CM"]
[92614,null,"See CPT",null,266.97540000000004,null,117.1362,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[92640,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,0,2,0,0,0,null,"X"]
[92920,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,0,0,0,null,"X"]
[92944,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[92960,null,"See CPT",null,281.84040000000005,null,190.86660000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[92987,null,"See CPT",null,2386.7244000000001,null,2386.7244000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[92998,null,"See CPT",null,550.005,null,550.005,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[93042,null,"See CPT",null,11.892000000000001,null,11.892000000000001,null,"000",0,0,0,2,0,0,0,0,0,null,"R"]
[93227,null,"See CPT",null,32.703000000000003,null,32.703000000000003,null,"000",0,0,0,2,0,0,0,0,0,null,"R"]
[93247,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,3,6,0,0,0,0,null,"N",null,"Y-CM"]
[93261,"TC","See CPT",null,66.000600000000006,null,66.000600000000006,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93280,null,"See CPT",null,149.83920000000001,null,149.83920000000001,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93281,null,"See CPT",null,158.75819999999999,null,158.75819999999999,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93286,null,"See CPT",null,88.000799999999998,null,88.000799999999998,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93287,null,"See CPT",null,101.67659999999999,null,101.67659999999999,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93292,"TC","See CPT",null,58.270800000000001,null,58.270800000000001,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93294,null,"See CPT",null,52.919400000000003,null,52.919400000000003,null,"000",0,0,0,2,0,0,0,0,0,null,"R",null,"Y-CM"]
[93304,"TC","See CPT",null,229.51560000000001,null,229.51560000000001,null,"000",0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93307,26,"See CPT",null,77.892600000000002,null,77.892600000000002,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[93315,"TC","See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[93317,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[93325,26,"See CPT",null,5.3513999999999999,null,5.3513999999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[93350,26,"See CPT",null,122.4876,null,122.4876,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[93454,null,"See CPT",null,1736.8266000000001,null,1736.8266000000001,null,"000",0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93455,26,"See CPT",null,482.81519999999995,null,482.81519999999995,null,"000",0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93458,26,"See CPT",null,511.35599999999999,null,511.35599999999999,null,"000",0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93461,null,"See CPT",null,2617.4292,null,2617.4292,null,"000",0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93563,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[93566,null,"See CPT",null,239.62380000000002,null,80.271000000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[93592,null,"See CPT",null,686.16839999999991,null,686.16839999999991,null,"000",0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[93593,26,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[93600,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[93602,26,"See CPT",null,202.16399999999999,null,202.16399999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[93609,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[93615,26,"See CPT",null,66.000600000000006,null,66.000600000000006,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[93620,26,"See CPT",null,1089.3072,null,1089.3072,null,"000",0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93621,26,"See CPT",null,165.89340000000001,null,165.89340000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[93640,26,"See CPT",null,310.38119999999998,null,310.38119999999998,null,"000",0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93641,26,"See CPT",null,541.08600000000001,null,541.08600000000001,null,"000",0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93662,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N"]
[93702,null,"See CPT",null,262.21860000000004,null,262.21860000000004,null,"000",0,0,0,3,6,0,0,0,0,null,"R",null,"Y-CM"]
[93740,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[93797,null,"See CPT",null,30.3246,null,16.054200000000002,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[93886,"TC","See CPT",null,423.35520000000002,null,423.35520000000002,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[93888,"TC","See CPT",null,256.27259999999995,null,256.27259999999995,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[93922,"TC","See CPT",null,131.4066,null,131.4066,null,"000",0,0,0,1,6,2,0,0,0,null,"R"]
[93924,26,"See CPT",null,42.811199999999999,null,42.811199999999999,null,"000",0,0,0,1,6,2,0,0,0,null,"R"]
[93930,null,"See CPT",null,367.46280000000002,null,367.46280000000002,null,"000",0,0,0,1,6,2,0,0,0,null,"R"]
[93970,"TC","See CPT",null,293.73240000000004,null,293.73240000000004,null,"000",0,0,0,1,6,2,0,0,0,null,"R"]
[93975,26,"See CPT",null,98.108999999999995,null,98.108999999999995,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[93980,26,"See CPT",null,104.64960000000001,null,104.64960000000001,null,"000",0,0,0,1,6,0,0,0,0,null,"R"]
[93998,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,1,1,null,"N"]
[94010,null,"See CPT",null,48.757199999999997,null,48.757199999999997,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[94070,null,"See CPT",null,112.37939999999999,null,112.37939999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[94200,"TC","See CPT",null,22.594799999999999,null,22.594799999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[94450,26,"See CPT",null,31.513800000000003,null,31.513800000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[94610,null,"See CPT",null,97.514399999999995,null,97.514399999999995,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[94625,null,"See CPT",null,118.3254,null,32.703000000000003,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[94680,null,"See CPT",null,96.919799999999995,null,96.919799999999995,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[94727,"TC","See CPT",null,58.865400000000001,null,58.865400000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[94729,null,"See CPT",null,108.21720000000001,null,108.21720000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[94777,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,2,0,0,0,0,0,null,"X"]
[95012,null,"See CPT",null,35.081400000000002,null,35.081400000000002,null,"000",0,0,0,5,0,0,0,0,0,null,"R"]
[95052,null,"See CPT",null,11.892000000000001,null,11.892000000000001,null,"000",0,0,0,5,0,0,0,0,0,null,"R"]
[95115,null,"See CPT",null,17.243399999999998,null,17.243399999999998,null,"000",0,0,0,5,0,0,0,0,0,null,"R",null,"Y-CM"]
[95133,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
[95249,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,3,0,0,0,0,0,null,"X"]
[95714,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
[95719,null,"See CPT",null,278.27279999999996,null,275.89439999999996,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[95783,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
[95801,26,"See CPT",null,72.541200000000003,null,72.541200000000003,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[95806,null,"See CPT",null,166.488,null,166.488,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[95808,"TC","See CPT",null,1083.9558,null,1083.9558,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[95811,26,"See CPT",null,218.2182,null,218.2182,null,"000",0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[95819,26,"See CPT",null,101.08199999999999,null,101.08199999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[95852,null,"See CPT",null,31.513800000000003,null,9.5136000000000003,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[95861,null,"See CPT",null,302.65140000000002,null,302.65140000000002,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[95866,null,"See CPT",null,240.81299999999999,null,240.81299999999999,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[95868,"TC","See CPT",null,154.00139999999999,null,154.00139999999999,null,"000",0,0,0,1,0,2,0,0,0,null,"R"]
[95870,26,"See CPT",null,34.486799999999995,null,34.486799999999995,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[95875,"TC","See CPT",null,149.83920000000001,null,149.83920000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[95885,"TC","See CPT",null,86.811599999999999,null,86.811599999999999,null,"000",0,0,0,1,0,3,0,0,0,null,"R"]
[95907,26,"See CPT",null,93.94680000000001,null,93.94680000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[95911,"TC","See CPT",null,159.94739999999999,null,159.94739999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[95913,26,"See CPT",null,331.19220000000001,null,331.19220000000001,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[95924,26,"See CPT",null,152.81219999999999,null,152.81219999999999,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[95926,26,"See CPT",null,49.351799999999997,null,49.351799999999997,null,"000",0,0,0,1,0,2,0,0,0,null,"R"]
[95929,null,"See CPT",null,450.70679999999999,null,450.70679999999999,null,"000",0,0,0,1,0,2,0,0,0,null,"R"]
[95937,26,"See CPT",null,61.2438,null,61.2438,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[95938,26,"See CPT",null,80.865600000000001,null,80.865600000000001,null,"000",0,0,0,1,0,2,0,0,0,null,"R"]
[95957,null,"See CPT",null,478.05839999999995,null,478.05839999999995,null,"000",0,0,0,1,0,0,0,0,0,null,"R"]
[95965,"TC","See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[95967,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[95983,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[95992,null,"See CPT",null,77.892600000000002,null,64.811400000000006,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[96113,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[96132,null,"See CPT",null,231.89400000000001,null,185.51520000000002,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[96137,null,"See CPT",null,71.946600000000004,null,32.108400000000003,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[96360,null,"See CPT",null,63.027600000000007,null,63.027600000000007,null,"000",0,0,0,5,0,0,0,0,0,null,"R"]
[96366,null,"See CPT",null,38.054400000000001,null,38.054400000000001,null,"000",0,0,0,5,0,0,0,0,0,null,"R"]
[96379,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,null,"N"]
[96413,null,"See CPT",null,252.70500000000001,null,252.70500000000001,null,"000",0,0,0,5,0,0,0,0,0,null,"R"]
[96446,null,"See CPT",null,366.8682,null,45.784199999999998,null,"000",0,0,0,5,0,0,0,0,0,null,"R",null,"Y-CM"]
[96904,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,5,0,0,0,0,0,null,"X"]
[96931,null,"See CPT",null,318.7056,null,318.7056,null,"000",0,0,0,4,0,0,0,0,0,null,"R"]
[96934,null,"See CPT",null,221.19120000000001,null,221.19120000000001,null,"000",0,0,0,4,0,0,0,0,0,null,"R"]
[97034,null,"See CPT",null,26.162400000000002,null,26.162400000000002,null,"000",0,0,0,7,5,0,0,0,0,null,"R"]
[97039,null,"See CPT",null,20.725329081600002,null,20.725329081600002,null,"000",0,0,0,7,0,0,0,0,0,null,"F"]
[97152,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[97161,null,"See CPT",null,180.75839999999999,null,180.75839999999999,null,"000",0,0,0,7,5,0,0,0,0,null,"R"]
[97170,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[97606,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,0,0,0,0,0,0,null,"Bundled",null,"Y-CM"]
[97761,null,"See CPT",null,75.514200000000002,null,75.514200000000002,null,"000",0,0,0,7,5,0,0,0,0,null,"R"]
[97802,null,"See CPT",null,66.000600000000006,null,57.676200000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[98943,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[98962,null,"See CPT",null,19.027200000000001,null,19.027200000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"R"]
[99000,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
[99051,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
[99078,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
[99170,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,1,0,0,null,"X"]
[99184,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[99191,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
[99219,null,"See CPT",null,230.70480000000001,null,230.70480000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[99222,null,"See CPT",null,235.4616,null,235.4616,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[99239,null,"See CPT",null,184.32600000000002,null,184.32600000000002,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[99252,null,"See CPT",null,128.43360000000001,null,128.43360000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"R"]
[99288,null,"See CPT",null,40.109352940800001,null,40.109352940800001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
[99325,null,"See CPT",null,137.94719999999998,null,137.94719999999998,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[99337,null,"See CPT",null,337.13819999999998,null,337.13819999999998,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[99341,null,"See CPT",null,94.54140000000001,null,94.54140000000001,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
[99360,null,"See CPT",null,105.83880000000001,null,105.83880000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"R"]
[99368,null,"See CPT",null,64.216800000000006,null,64.216800000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"R"]
[99386,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[99396,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[99409,null,"See CPT",null,120.70379999999999,null,114.7578,null,"000",0,0,0,9,9,9,9,9,9,null,"R"]
[99424,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[99448,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[99451,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[99467,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[99471,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
[99485,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[99492,null,"See CPT",null,272.32679999999999,null,164.1096,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-ONC"]
[99504,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
[99512,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0005F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["0011U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0015M",null,"See CPT",null,1866.6790999999998,null,1866.6790999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-ONC"]
["0016U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0042A",null,"See CPT",null,41.2,null,41.2,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["0071T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["0084U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0092U",null,"See CPT",null,3557.8399999999997,null,3557.8399999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
["0100U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0106U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0112U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0115U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0131U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0133U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0145U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0152U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0162U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0200T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,1,0,0,0,null,"X"]
["0208T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,3,0,0,0,0,0,null,"N"]
["0210T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,3,0,0,0,0,0,null,"N"]
["0218T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,1,0,0,0,null,"N",null,"Y-UR"]
["0219T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,null,"N",null,"Y-UR"]
["0227U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0233U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0240U",null,"See CPT",null,203.96089999999998,null,203.96089999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
["0268T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["0286U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0289U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0303R",null,"Retraining, plan travel, bridge/ferry toll",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["0304R",null,"Retraining, plan travel, commercial transportation",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["0331T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0345T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0375R",null,"Retraining, relocation costs",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["0390R",null,"Vocational evaluation - non voc, ea 6 minutes, work eval",null,10.0922401008,null,10.0922401008,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["0402A",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["0403T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["0414A",null,"Claimant - taxi one way, or mileage",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["0415A",null,"Claimant - replacement of clothing",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["0426A",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["0432T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["0441T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["0449T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["0479T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,1,0,0,null,"X"]
["0483T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,0,2,1,null,"X"]
["0491T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0500T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0504T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,2,9,9,9,9,9,null,"X"]
["0515T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,0,1,0,0,null,"N",null,"Y-CM"]
["0520T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,0,1,0,0,null,"N",null,"Y-CM"]
["0526F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["0535F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["0537T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["0544T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["0555F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["0559T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["0569T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["0578T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["0583F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["0593T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["0622T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,1,0,0,0,null,"X"]
["0630T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,2,0,0,0,null,"X"]
["0671T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,1,1,0,0,null,"X"]
["0678T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,1,0,0,null,"N"]
["0690T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
["0700T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,null,"X"]
["0708T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,1,0,0,null,"X"]
["0810V",null,"Assessment services",null,10.189592899200003,null,10.189592899200003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["0830V",null,"Plan development services",null,10.189592899200003,null,10.189592899200003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["0842V",null,"Plan implementation services exception - vrc",null,10.189592899200003,null,10.189592899200003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["0896V",null,"Ferry and bridge charges (voc)",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["1004F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["1026F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["1036F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["1045M",null,"Physical capacities exam (pce)",null,276.35214372480004,null,276.35214372480004,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["1066F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["1070M",null,"Refer for assessment of impediments",null,"Contracted",null,"Contracted",null,"000",0,0,0,9,9,9,9,9,9,null,"C"]
["1074M",null,"AP response to vrc/employer request re: RTW",null,35.555405371200003,null,35.555405371200003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["1090F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["1105M",null,"Ime-physical capacities estimate",null,35.56,null,35.56,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["1123F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["1128M",null,"Ime - occupational disease hx",null,215.6,null,215.6,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["1139M",null,"IME, no show fee for missed neuropsychological testing",null,1036.71,null,1036.71,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["1152F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["1157M",null,"Omd contracted consultant claim review",null,"Contracted",null,"Contracted",null,"000",0,0,0,9,9,9,9,9,9,null,"C"]
["1159M",null,"Interest, self-insurer bills only",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["1191M",null,"Impairment rating by a/p, standard",null,700.56,null,700.56,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["1207M",null,"Ur contracted - outpatient rvw data coll",null,"Contracted",null,"Contracted",null,"000",0,0,0,9,9,9,9,9,9,null,"C"]
["1243M",null,"Ur contract:  retrospective inpatient review without bill audit",null,"Contracted",null,"Contracted",null,"000",0,0,0,9,9,9,9,9,9,null,"C"]
["1250M",null,"UR, advanced imaging goldcard providers",null,"Contracted",null,"Contracted",null,"000",0,0,0,9,9,9,9,9,9,null,"C"]
["1290M",null,"COE care mgmt initial                   ",null,"Contracted",null,"Contracted",null,"000",0,0,0,9,9,9,9,9,9,null,"C"]
["1451F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["1502F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["1729M",null,"PGAP Coach Mileage",null,"State Rate",null,"State Rate",null,"000",0,0,0,9,9,9,9,9,9,null,"S"]
["2002F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["2015F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["2027F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["2035F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["2134A",null,"Naturopathic follow up visit, extended incl eval & treatment",null,164.47214440800005,null,164.47214440800005,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["3022F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3042F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3056F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3074F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3078F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3093F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3112F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3150F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3260F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3273F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3290F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3315F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3318F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3341F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3351F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3386F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3475F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3497F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3514F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3555F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3573F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3759F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["3776F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4015F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4033F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4051F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4063F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4073F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4079F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4132F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4142F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4163F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4177F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4186F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4201F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4245F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4260F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4290F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4301F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4500F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4555F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["4562F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["5093V",null,"Hearing aid repair (manf invoice required)",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["6010F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["6045F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["8883H",null,"Nursing facility rehab - medium (per day",null,643.30999999999995,null,643.30999999999995,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["8886H",null,"Nursing facility special care (per day)",null,544.24,null,544.24,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["8916H",null,"Home modification evaluation and consultation",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["9004F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,null,"T"]
["9918M",null,"Electronic Provider Communication",null,50.807015999999997,null,48.138492000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["9996M",null,"Interpreter, ime no show fee",null,60.154997760000008,null,60.154997760000008,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A0120",null,"Noner transport mini-bus",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A0180",null,"Noner transport lodgng recip",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A0420",null,"Ambulance waiting 1/2 hr",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A0425",null,"Ground mileage",null,15.028851233373123,null,15.028851233373123,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A0888",null,"Noncovered ambulance mileage",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["A2009",null,"Symphony, per sq cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["A4207",null,"2 cc sterile syringe&needle",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4215",null,"Sterile needle",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4231",null,"Infusion insulin pump needle",null,9.2959999999999994,null,9.2959999999999994,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4236",null,"Silvr oxide batt glucose mon",null,2.9298999999999995,null,2.9298999999999995,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4258",null,"Lancet device each",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4262",null,"Temporary tear duct plug",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4283",null,"Replacement breastpump cap",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["A4312",null,"Cath w/o bag 2-way silicone",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4322",null,"Irrigation syringe",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4333",null,"Urinary cath anchor device",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4353",null,"Intermittent urinary cath",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4358",null,"Urinary leg or abdomen bag",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4375",null,"Drainable plastic pch w fcpl",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4378",null,"Drainable rubber pch w/o fp",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4391",null,"Urinary pouch w ex wear barr",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4405",null,"Nonpectin based ostomy paste",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4412",null,"Ost pouch drain high output",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4419",null,"Ost pch for bar w flange/flt",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4431",null,"Ost pch urine w barrier/tapv",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4450",null,"Non-waterproof tape",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A4481",null,"Tracheostoma filter",null,0.46350000000000002,null,0.46350000000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4495",null,"Thigh length surg stocking",null,34.162799999999997,null,34.162799999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4562",null,"Pessary, non rubber,any type",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["A4575",null,"Hyperbaric o2 chamber disps",null,756.46199999999999,null,756.46199999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4612",null,"Battery cables",null,232.36263081600001,null,232.36263081600001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4619",null,"Face tent",null,4.2661999999999995,null,4.2661999999999995,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4628",null,"Oropharyngeal suction cath",null,4.4902999999999995,null,4.4902999999999995,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4637",null,"Repl tip cane/crutch/walker",null,3.0766694927999998,null,3.0766694927999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4671",null,"Disposable cycler set",null,82.966799999999992,null,82.966799999999992,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4674",null,"Chem/antisept solution, 8oz",null,107.36880000000001,null,107.36880000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4724",null,"Dialys sol fld vol > 3999cc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A4736",null,"Topical anesthetic, per gram",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A4774",null,"Ammonia test strips",null,29.282399999999999,null,29.282399999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A4918",null,"Venous pressure clamp",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A5051",null,"Pouch clsd w barr attached",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A5072",null,"Urinary pouch w/o barrier",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A5121",null,"Solid skin barrier 6x6",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A5131",null,"Appliance cleaner",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A5514",null,"Mult den insert dir carv/cam",null,48.770500000000006,null,48.770500000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["A6022",null,"Collagen drsg>16<=48 sq in",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A6206",null,"Contact layer <= 16 sq in",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A6213",null,"Foam drg >16<=48 sq in w/bdr",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A6220",null,"Gauze >16 <=48 sq in w/bordr",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A6234",null,"Hydrocolld drg <=16 w/o bdr",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A6246",null,"Hydrogel drg >16<=48 in w/b",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A6250",null,"Skin seal protect moisturizr",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A6266",null,"Impreg gauze no h20/sal/yard",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A6410",null,"Sterile eye pad",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A6449",null,"Lt compres band >=3\" <5\"/yd",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A6456",null,"Zinc paste band w >=3\"<5\"/yd",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A6504",null,"Cmprsburngarment glove-wrist",null,183.01499999999999,null,183.01499999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A6531",null,"Compression stocking bk30-40",null,48.978299999999997,null,48.978299999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A6545",null,"Grad comp non-elastic bk",null,113.97559999999999,null,113.97559999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A7000",null,"Disposable canister for pump",null,31.191399999999998,null,31.191399999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["A7014",null,"Compressor nondispos filter",null,5.859799999999999,null,5.859799999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A7020",null,"Interface, cough stim device",null,34.527999999999999,null,34.527999999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A7031",null,"Replacement facemask interfa",null,78.825099999999992,null,78.825099999999992,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A7045",null,"Repl exhalation port for pap",null,53.122664472000004,null,53.122664472000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A7504",null,"Tracheostoma hmes filter",null,0.86519999999999997,null,0.86519999999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A7525",null,"Tracheostomy mask",null,2.5956000000000001,null,2.5956000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["A9180",null,"Lice treatment, topical",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["A9273",null,"Hot/cold botle/cap/col/wrap",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["A9286",null,"Any hygienic item, device",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["A9502",null,"Tc99m tetrofosmin",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["A9510",null,"Tc99m disofenin",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL"]
["A9529",null,"I131 iodide sol, dx",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A9539",null,"Tc99m pentetate",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A9553",null,"Cr51 chromate",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A9566",null,"Tc99m fanolesomab",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A9572",null,"Indium in-111 pentetreotide",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A9585",null,"Gadobutrol injection",null,0.32200000000000001,null,0.32200000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["A9588",null,"Fluciclovine f-18",null,757.08449999999993,null,757.08449999999993,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["A9595",null,"Piflu f-18, dia 1 millicurie",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A9700",null,"Echocardiography contrast",null,300.19439999999997,null,300.19439999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["B4100",null,"Food thickener oral",null,1.6267999999999998,null,1.6267999999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["B4152",null,"Ef calorie dense>/=1.5kcal",null,0.51500000000000001,null,0.51500000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["B4172",null,"Parenteral sol amino acid 5.",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL"]
["B4189",null,"Parenteral sol amino acid &",null,232.60490000000001,null,232.60490000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["B9002","RR","Enter nutr inf pump any type",null,106.66680000000001,null,106.66680000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["B9006","NU","Parenteral infus pump statio",null,3301.7062000000001,null,3301.7062000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["C1714",null,"Cath, trans atherectomy, dir",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C1726",null,"Cath, bal dil, non-vascular",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C1753",null,"Cath, intravas ultrasound",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C1760",null,"Closure dev, vasc",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C1772",null,"Infusion pump, programmable",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C1780",null,"Lens, intraocular (new tech)",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C1815",null,"Pros, urinary sph, imp",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C1818",null,"Integrated keratoprosthesis",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C1825",null,"Gen, neuro, carot sinus baro",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["C1874",null,"Stent, coated/cov w/del sys",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C1884",null,"Embolization protect syst",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C1897",null,"Lead, neurostim test kit",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C2619",null,"Pmkr, dual, non rate-resp",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C2625",null,"Stent, non-cor, tem w/del sy",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C2639",null,"Brachytx, non-stranded,i-125",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["C2642",null,"Brachytx, stranded, c-131",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["C5272",null,"Low cost skin substitute app",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["C8902",null,"Mra w/o fol w/cont, abd",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C8913",null,"Mra w/o cont, lwr ext",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C8928",null,"Tte w or w/o fol w/con,stres",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C9041",null,"Inj, coagulation factor xa",null,"Facility Only",null,346.69800000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C9056",null,"Injection, givosiran",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["C9094",null,"Inj., susvimo, 0.1 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["C9248",null,"Inj, clevidipine butyrate",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["C9352",null,"Neuragen nerve guide, per cm",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C9362",null,"Implnt,bon void filler-strip",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["C9484",null,"Injection, eteplirsen",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["C9606",null,"Perc d-e cor revasc w ami s",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["C9751",null,"Microwave bronch, 3d, ebus",null,"Facility Only",null,8667.9753000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR"]
["C9759",null,"Transcath intraop microinf",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-UR"]
["C9771",null,"Nsl/sins cryo post nasal tis",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC"]
["C9778",null,"Colpopexy, min/inv, ex-perit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D0140",null,"Limit oral eval problm focus",null,93.112000000000009,null,93.112000000000009,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D0170",null,"Re-eval,est pt,problem focus",null,85.696000000000012,null,85.696000000000012,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D0230",null,"Intraoral periapical ea add",null,31.312000000000005,null,31.312000000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D0322",null,"Dental tomographic survey",null,539.72,null,539.72,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D0367",null,"Cone beam ct interp both jaw",null,384.80800000000005,null,384.80800000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D0385",null,"Max mri image capture",null,617.17600000000004,null,617.17600000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D0418",null,"Analysis of saliva sample",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D0470",null,"Diagnostic casts",null,141.72800000000001,null,141.72800000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D0481",null,"Electron microscopy",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D0485",null,"Consult inc prep of slides",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D0604",null,"Antigen test pub hlth pathog",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X",null,"Y-ONC"]
["D0999",null,"Unspecified diagnostic proce",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["D1330",null,"Oral hygiene instruction",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["D1526",null,"Remove bilat space main, max",null,525.7120000000001,null,525.7120000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D1704",null,"Moderna Covid-19 vaccine administration - second dose",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D2160",null,"Amalgam three surfaces perma",null,266.15200000000004,null,266.15200000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D2394",null,"Post >=4srfc resinbase cmpst",null,399.64,null,399.64,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D2510",null,"Dental inlay metalic 1 surf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D2620",null,"Inlay porcelain/ceramic 2 su",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D2712",null,"Crown 3/4 resin-based compos",null,1170.08,null,1170.08,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D2753",null,"Crown porc fused to titanium",null,1328.2880000000002,null,1328.2880000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["D2910",null,"Recement inlay onlay or part",null,140.08000000000001,null,140.08000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D2941",null,"Int therapeutic restoration",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D2955",null,"Post removal",null,338.66400000000004,null,338.66400000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D2983",null,"Veneer repair",null,362.56,null,362.56,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D3120",null,"Pulp cap indirect",null,102.176,null,102.176,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D3320",null,"End thxpy, premolar tooth",null,1001.9840000000002,null,1001.9840000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D3356",null,"Pulpal regeneration interim",null,379.86400000000003,null,379.86400000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D3430",null,"Retrograde filling",null,355.14400000000001,null,355.14400000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D3502",null,"Surg exp root surf premolar",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC"]
["D4231",null,"Ana crown exp 1-3 per quad",null,731.7120000000001,null,731.7120000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D4263",null,"Bone replce graft first site",null,795.16,null,795.16,null,"000",0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D4276",null,"Con tissue w dble ped graft",null,1368.6640000000002,null,1368.6640000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D4342",null,"Periodontal scaling 1-3teeth",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D4381",null,"Localized delivery antimicro",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["D5214",null,"Dentures mandibl part metal",null,2172.8879999999999,null,2172.8879999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5228",null,"Immed mand part denture",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["D5512",null,"Rep broke comp dent base max",null,279.33600000000001,null,279.33600000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5710",null,"Dentures rebase cmplt maxil",null,706.16800000000001,null,706.16800000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5740",null,"Denture reln part maxil chr",null,437.54400000000004,null,437.54400000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5821",null,"Denture interm part mandbl",null,839.65600000000006,null,839.65600000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5867",null,"Replacement of precision att",null,461.44,null,461.44,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5899",null,"Removable prosthodontic proc",null,1241.7680000000003,null,1241.7680000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5926",null,"Replacement nasal prosthesis",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["D5935",null,"Mandibular denture prosth",null,5844.3805463472008,null,5844.3805463472008,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5960",null,"Modify speech aid prosthesis",null,623.39323606560004,null,623.39323606560004,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5988",null,"Surgical splint",null,798.45600000000002,null,798.45600000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6050",null,"Odontics transosteal implnt",null,6071.2320000000009,null,6071.2320000000009,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6055",null,"Implant connecting bar",null,3556.3840000000005,null,3556.3840000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6071",null,"Abutment supported retainer",null,1577.1360000000002,null,1577.1360000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6074",null,"Abutment supported retainer",null,1558.1840000000002,null,1558.1840000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6087",null,"Implant crown noble alloys",null,1774.0720000000001,null,1774.0720000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["D6096",null,"Remove broken imp ret screw",null,592.45600000000002,null,592.45600000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6113",null,"Imp/abut rem dent part mand",null,3416.3040000000001,null,3416.3040000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D6120",null,"Imp retain porc to titanium",null,1774.0720000000001,null,1774.0720000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["D6210",null,"Prosthodont high noble metal",null,1315.1040000000003,null,1315.1040000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6212",null,"Bridge noble metal cast",null,1241.7680000000003,null,1241.7680000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6602",null,"Cst hgh nble mtl inlay 2 srf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D6605",null,"Cst bse mtl inlay >= 3 surfa",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D6615",null,"Onlay cst nbl mtl >=3 surfac",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D6750",null,"Crown porcelain high noble",null,1301.92,null,1301.92,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6793",null,"Provisional retainer crown",null,650.13600000000008,null,650.13600000000008,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6985",null,"Pediatric partial denture fx",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D7261",null,"Primary closure sinus perf",null,975.6160000000001,null,975.6160000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D7272",null,"Tooth transplantation",null,888.27200000000016,null,888.27200000000016,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D7298",null,"Remove screw retained plate",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["D7310",null,"Alveoplasty w/ extraction",null,371.62400000000002,null,371.62400000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7414",null,"Excision malig lesion>1.25cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D7465",null,"Lesion destruction",null,489.45600000000007,null,489.45600000000007,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7550",null,"Removal of sloughed off bone",null,655.08000000000004,null,655.08000000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7660",null,"Clsd red simp malar/zygom fx",null,3341.32,null,3341.32,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7780",null,"Reduct compnd facial bone fx",null,9662.224000000002,null,9662.224000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7820",null,"Closed tmp manipulation",null,777.03200000000015,null,777.03200000000015,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7876",null,"Tmj arthroscopy discectomy",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["D7881",null,"Occ orthotic device adjust",null,221.65600000000003,null,221.65600000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D7943",null,"Cutting ramus open w/graft",null,9290.6,null,9290.6,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7951",null,"Sinus aug w bone or bone sub",null,3303.4160000000002,null,3303.4160000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["D7981",null,"Excision of salivary gland",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D7995",null,"Synthetic graft facial bones",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["D8210",null,"Orthodontic rem appliance tx",null,977.26400000000012,null,977.26400000000012,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D8660",null,"Preorthodontic tx visit",null,516.64800000000002,null,516.64800000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D9130",null,"Temporomandibular joint dysf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D9212",null,"Trigeminal block anesthesia",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["D9311",null,"Consult w/med hlth care prof",null,214.24,null,214.24,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D9613",null,"Infiltration thera drug",null,217.53600000000003,null,217.53600000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D9942",null,"Repair/reline occlusal guard",null,286.75200000000007,null,286.75200000000007,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D9949",null,"Repair sleep apnea appliance",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D9986",null,"Missed appointment",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["D9994",null,"Case mgmt, pt education",null,92.288000000000011,null,92.288000000000011,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0116","NU","Crutch underarm each no wood",null,30.003899999999998,null,30.003899999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0130","NU","Walker rigid adjust/fixed ht",null,65.044499999999999,null,65.044499999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0144","NU","Enclosed walker w rear seat",null,321.875,null,321.875,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0153","NU","Forearm crutch platform atta",null,86.550899999999999,null,86.550899999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0159","NU","Brake for wheeled walker",null,18.3855,null,18.3855,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0170","NU","Commode chair electric",null,1671.9802276320004,null,1671.9802276320004,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0184","NU","Dry pressure mattress",null,217.8965,null,217.8965,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0187","RR","Water pressure mattress",null,27.212600000000002,null,27.212600000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0198","RR","Water pressure pad for mattr",null,23.731200000000001,null,23.731200000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0202",null,"Phototherapy light w/ photom",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["E0239",null,"Hydrocollator unit portable",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["E0242","NU","Bath tub rail floor",null,95.9898592224,null,95.9898592224,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0249",null,"Pad water circulating heat u",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["E0265","RR","Hosp bed total electr w/ mat",null,188.27369999999999,null,188.27369999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E0273","NU","Bed board",null,107.5514,null,107.5514,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0290","NU","Hosp bed fx ht w/o rails w/m",null,743.351,null,743.351,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E0296","NU","Hosp bed total elect w/ matt",null,1513.6880000000001,null,1513.6880000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0297","RR","Hosp bed total elect w/o mat",null,131.27350000000001,null,131.27350000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0315","RR","Bed accessory brd/tbl/supprt",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["E0325","NU","Urinal male jug-type",null,11.7729,null,11.7729,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0370","RR","Air elevator for heel",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["E0439","RR","Stationary liquid 02",null,155.68450000000001,null,155.68450000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0447",null,"Port o2 cont, liq over 4 lpm",null,104.92610000000001,null,104.92610000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0462","RR","Rocking bed w/ or w/o side r",null,312.13120000000004,null,312.13120000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0480","NU","Percussor elect/pneum home m",null,553.83100000000002,null,553.83100000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0481","RR","Intrpulmnry percuss vent sys",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["E0562","NU","Humidifier heated used w pap",null,246.15970000000002,null,246.15970000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0570","RR","Nebulizer with compression",null,13.5754,null,13.5754,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0580","NU","Nebulizer for use w/ regulat",null,145.13730000000001,null,145.13730000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0615","NU","Pacemaker monitr digital/vis",null,603.34310000000005,null,603.34310000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0620","RR","Cap bld skin piercing laser",null,110.16879999999999,null,110.16879999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0629","NU","Seat lift mech, non-electric",null,362.05529999999999,null,362.05529999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0639","RR","Moveable patient lift system",null,135.00209999999998,null,135.00209999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0641","NU","Multi-position stnd fram sys",null," By Report ",null," By Report ",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["E0657","RR","Segmental pneumatic chest",null,68.402299999999997,null,68.402299999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0665","NU","Pneumatic appliance full arm",null,159.84569999999999,null,159.84569999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0668","RR","Seg pneumatic appl full arm",null,54.950500000000005,null,54.950500000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0691",null,"Uvl pnl 2 sq ft or less",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["E0730",null,"Tens four lead",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["E0747","RR","Elec osteogen stim not spine",null,490.36239999999998,null,490.36239999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["E0764","RR","Functional neuromuscularstim",null,1394.5479,null,1394.5479,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0769",null,"Electric wound treatment dev",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["E0785","NU","Replacement impl pump cathet",null,574.68438593280007,null,574.68438593280007,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0787","NU","Cgs dose adj insulin inf pmp",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["E0849","NU","Cervical pneum trac equip",null,649.41500000000008,null,649.41500000000008,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0890","RR","Traction frame attach pelvic",null,41.375100000000003,null,41.375100000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0920","NU","Fracture frame attached to b",null,537.55700000000002,null,537.55700000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0940","RR","Trapeze bar free standing",null,31.332600000000003,null,31.332600000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0946","RR","Fracture frame dual w cross",null,74.551400000000001,null,74.551400000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0956","NU","W/c lateral trunk/hip suppor",null,98.0869,null,98.0869,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0966","NU","Wheelchair head rest extensi",null,86.303700000000006,null,86.303700000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0967","RR","Man wc rim/projection rep ea",null,8.291500000000001,null,8.291500000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0974","NU","W/ch access anti-rollback",null,92.195300000000003,null,92.195300000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0981","RR","Seat upholstery, replacement",null,4.8616000000000001,null,4.8616000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0985","NU","W/c seat lift mechanism",null,253.483,null,253.483,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E0995","RR","Wc calf rest, pad replacemnt",null,3.1002999999999998,null,3.1002999999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E1004","NU","Pwr seat recline mech",null,5227.1469999999999,null,5227.1469999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1010","RR","Add pwr leg elevation",null,122.40520000000001,null,122.40520000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E1029","NU","W/c vent tray fixed",null,401.18500000000006,null,401.18500000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E1030","RR","W/c vent tray gimbaled",null,126.5664,null,126.5664,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E1050","RR","Whelchr fxd full length arms",null,128.34829999999999,null,128.34829999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1084","NU","Hemi-wheelchair detachable a",null,1236.2059999999999,null,1236.2059999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1087","RR","Wheelchair lightwt fixed arm",null,154.60300000000001,null,154.60300000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1100","RR","Whchr s-recl fxd arm leg res",null,130.7997,null,130.7997,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1140","NU","Wheelchair standard detach a",null,325.13589999999999,null,325.13589999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E1172","RR","Wheelchair amputee detach ar",null,123.46610000000001,null,123.46610000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E1222","NU","Wheelchair spec size w/ leg",null,854.07600000000002,null,854.07600000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E1225","RR","Manual semi-reclining back",null,50.47,null,50.47,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E1229",null,"Pediatric wheelchair nos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["E1236",null,"Folding ped wc adjustable",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["E1250","RR","Wheelchair lightwt fixed arm",null,106.489,null,106.489,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1295","RR","Wheelchair heavy duty fixed",null,153.05799999999999,null,153.05799999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1298","NU","Wheelchair spec seat depth/w",null,533.8696000000001,null,533.8696000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E1390","RR","Oxygen concentrator",null,1556.8,null,1556.8,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E1550","RR","Bath conductivity meter",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["E1594","RR","Cycler dialysis machine",null,844.7989,null,844.7989,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E1630","RR","Reciprocating peritoneal dia",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["E1699","NU","Dialysis equipment noc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL"]
["E1802","RR","Adjst forearm pro/sup device",null,411.82490000000001,null,411.82490000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E1830","RR","Adjust toe ext/flex device",null,159.21740000000003,null,159.21740000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2000","RR","Gastric suction pump hme mdl",null,65.312299999999993,null,65.312299999999993,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E2205","NU","Manual wc accessory, handrim",null,40.705600000000004,null,40.705600000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2212","NU","Pneumatic prop tire tube",null,7.3026999999999997,null,7.3026999999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2219","NU","Foam caster tire any size ea",null,49.8005,null,49.8005,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2227","NU","Gear reduction drive wheel",null,2357.4639999999999,null,2357.4639999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2231","RR","Solid seat support base",null,17.726300000000002,null,17.726300000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2300","RR","Pwr seat elevation sys",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["E2321","RR","Hand interface joystick",null,166.19049999999999,null,166.19049999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2324","NU","Chin cup interface",null,47.596299999999999,null,47.596299999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2330","RR","Head control proximity switc",null,370.48070000000001,null,370.48070000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2351","RR","Electronic sgd interface",null,75.911000000000001,null,75.911000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2362","RR","Gr24 nonsealed leadacid",null,11.6493,null,11.6493,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2365","NU","U1 sealed leadacid battery",null,105.4308,null,105.4308,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2369","NU","Pwr wc drivewheel gear repl",null,468.95900000000006,null,468.95900000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2373","RR","Hand/chin ctrl spec joystick",null,87.117400000000004,null,87.117400000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2383","RR","Insert, pneum wheel drive",null,15.655999999999999,null,15.655999999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2385","NU","Tube, pneumatic caster tire",null,50.583300000000001,null,50.583300000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2391","NU","Solid caster tire",null,21.362199999999998,null,21.362199999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2398","NU","Wc dynamic pos back hardware",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC"]
["E2500","RR","Sgd digitized pre-rec <=8min",null,49.285500000000006,null,49.285500000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2506","RR","Sgd prerec msg > 40 min",null,291.44880000000001,null,291.44880000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2605","NU","Position wc cush wdth <22 in",null,268.00599999999997,null,268.00599999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2608","NU","Skin pro/pos wc cus wd>=22in",null,337.63400000000001,null,337.63400000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2624","NU","Adj skin pro/pos cus<22in",null,352.63080000000002,null,352.63080000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["E2627","NU","Arm supp att to wc rancho ty",null,1201.6495000000002,null,1201.6495000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["G0010",null,"Admin hepatitis b vaccine",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["G0038",null,"Clin pt no ref",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G0042",null,"Ref to therapy",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G0047",null,"Ped blunt hd traum",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G0063",null,"Cardiology ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G0066",null,"Clinical social work ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G0085",null,"Care man h v ext pt 75 m",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["G0088",null,"Adm iv drug 1st home visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G0108",null,"Diab manage trn  per indiv",null,98.703599999999994,null,98.703599999999994,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
["G0123",null,"Screen cerv/vag thin layer",null,28.971800000000002,null,28.971800000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
["G0129",null,"Partial hosp prog service",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G0143",null,"Scr c/v cyto,thinlayer,rescr",null,38.6815,null,38.6815,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
["G0168",null,"Wound closure by adhesive",null,235.4616,null,26.757000000000001,null,"000",0,0,0,0,2,0,1,0,0,null,"R"]
["G0177",null,"Opps/php; train & educ serv",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["G0219",null,"Pet img wholbod melano nonco",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,9,9,9,9,9,null,"X"]
["G0235",null,"Pet not otherwise specified",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,9,9,9,9,9,null,"X"]
["G0252",26,"Pet imaging initial dx",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,9,9,9,9,9,null,"X"]
["G0259",null,"Inject for sacroiliac joint",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["G0279",null,"Tomosynthesis, mammo",null,95.73060000000001,null,95.73060000000001,null,"000",0,0,0,1,0,2,9,0,0,null,"R"]
["G0283",null,"Elec stim other than wound",null,22.0002,null,22.0002,null,"000",0,0,0,7,5,0,0,0,0,null,"R"]
["G0329",null,"Electromagntic tx for ulcers",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,7,5,0,0,0,0,null,"X"]
["G0339",null,"Robot lin-radsurg com, first",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["G0396",null,"Alcohol/subs interv 15-30mn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["G0399",null,"Home sleep test/type 3 porta",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
["G0412",null,"Open tx iliac spine uni/bil",null,1296.2280000000001,null,1296.2280000000001,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
["G0420",null,"Ed svc ckd ind per session",null,198.59639999999999,null,198.59639999999999,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
["G0432",null,"Eia hiv-1/hiv-2 screen",null,27.985099999999999,null,27.985099999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
["G0438",null,"Ppps, initial visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["G0460",null,"Autologous prp for ulcers",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,1,0,0,null,"X"]
["G0465",null,"AUTOLOG PRP DIAB WOUND ULCER ",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,1,0,0,null,"X"]
["G0491",null,"Dialysis acu kidney no esrd",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G0494",null,"Lpn care ea 15min hh/hospice",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G0509",null,"Crit care telehea consult 50",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,9,0,0,null,"X"]
["G0517",null,"Remove drug implant",null,406.70639999999997,null,195.6234,null,"000",0,0,0,0,2,0,0,0,0,null,"R",null,"Y-ONC"]
["G1007",null,"Cdsm aim",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G1011",null,"Cdsm qualified nos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G1027",null,"Pt hemo < 3mo",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2007",null,"Post-d/c h vst ext pt 30 m",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["G2021",null,"Hea care pract tx in place",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2024",null,"Spec coll snf/lab covid-19",null,36.407800000000002,null,36.407800000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
["G2077",null,"Periodic assessment",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2083",null,"Visit esketamine, > 56m",null,2077.5324000000001,null,63.622200000000007,null,"000",0,0,0,0,0,0,0,0,0,null,"R",null,"Y-ONC"]
["G2098",null,"Pt 66+ frailty and med dem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2101",null,"Pt 66+ frailty and adv ill",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2127",null,"Pt 66+ frailty med dem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2141",null,"Leg pain vas 6-20wk > 3",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2151",null,"Dx degen neuro",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2168",null,"Svs by pt in home health",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2180",null,"Inelig footwr eval",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2186",null,"Pt ref app rsrcs",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2198",null,"Med rsn no unhlthy etoh",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2205",null,"Preg drng adjv trtmt",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G2250",null,"Remot img sub by pt, non e/m",null,21.4056,null,16.054200000000002,null,"000",0,0,0,0,0,0,0,0,0,null,"R"]
["G4005",null,"Family medicine ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G4015",null,"Neurology ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G4018",null,"Ob/gyn ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G4030",null,"Pulmonology ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G4036",null,"Urgent care ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G6006",null,"Radiation treatment delivery",null,245.56979999999999,null,245.56979999999999,null,"000",0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM"]
["G6013",null,"Radiation treatment delivery",null,448.923,null,448.923,null,"000",0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM"]
["G8404",null,"Low extemity neur exam docum",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8420",null,"Calc bmi norm parameters",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8452",null,"Pt w/abn lvef b-bloc no rx",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8474",null,"Ace/arb not rx'd; doc reas",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8536",null,"No doc elder mal scrn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8559",null,"Pt ref doc oto eval",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8575",null,"Postop ren fail",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8601",null,"No elig tpa init w/in 3 hrs",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8658",null,"Rafscrs llfai no scor + surv",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8667",null,"Rafscrs ewh scor >= 0",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8712",null,"Not pres antibiotic",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8723",null,"Spec sit not prim tumor",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8753",null,"Sys bp > or = 140",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8815",null,"Doc reas no statin therapy",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8842",null,"Ahi or rdi initial dx",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8851",null,"Adhere pos air press therapy",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8869",null,"Doc immune hep b antitnf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8883",null,"Rev, comm, track, doc biopsy",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8914",null,"Pt trans to hosp post d/c",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8917",null,"Pt w iv ab not given on time",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8941",null,"Eld maltreatment doc as pos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G8962",null,"Csit on pt any reas 30 days",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9004",null,"Mccd, risk adj lo, initial",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9011",null,"Mccd, risk adj, level 5",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["G9055",null,"Onc visit unspecified nos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9059",null,"Onc prac mgmt pt opt alterna",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9075",null,"Onc dx brst metastic/ recur",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9079",null,"Onc dx prostate t3b-t4noprog",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9089",null,"Onc dx colon extent unknown",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9099",null,"Onc dx esophageal unknown",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9111",null,"Onc dx head/neck m1 mets rec",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9123",null,"Onc dx cml chronic phase",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9134",null,"Onc nhlstg 1-2 no relap no",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9147",null,"Outpt iv insulin tx any mea",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["G9212",null,"Doc of dsm-iv init eval",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9225",null,"Norsn no foot exam",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9243",null,"Doc viral load <200",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9276",null,"Doc of tobacco user",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9288",null,"Doc medrsn no hist type rpt",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9295",null,"Non cutaneous loc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9310",null,"Unplnd hosp readm in 30d",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9318",null,"Image std nomenclature",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9354",null,"1 or no ct sinus w/in 90d dx",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9357",null,"Pp eval/edu perf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9380",null,"Off assis eol iss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9402",null,"Recd f/u w/in 30d disch",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9409",null,"No card tamp e/in 30d",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9421",null,"Lung cx bx rpt no doc class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9431",null,"Patho rpt no pt ctg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9456",null,"Doc med pt reas no hcc scrn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9477",null,"Care coord at hospice",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9480",null,"Admission to mccm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9506",null,"Bio imm resp mod presc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9516",null,"Impr vis acuit w/in 90d",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9529",null,"Minor blunt trauma w/head ct",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9548",null,"No f/u rec image study",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9580",null,"Door to punc time <2hrs",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9599",null,"Aor ane >=6.0 cm max diam",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9614",null,"Photodoc < 2 cec lndmk",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9621",null,"Scr unheal etoh w/counsel",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9629",null,"Med rsn no rpt bowel inj",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9645",null,"Had smoke b/4 anes day surg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9656",null,"Pt trans from anest to pacu",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9676",null,"40-75y w/type 1/2 w/ldl-c rs",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9696",null,"Med rsn no presc bronchdil",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9705",null,"Ajcc br ca stg ib",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9717",null,"Doc pt dx dep/bp f/u nt req",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9718",null,"Hospice anytime msmt per",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9726",null,"Refused to participate",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9740",null,"Hosp srv to pt dur msmt per",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9753",null,"Doc no dicom, ct other fac",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9766",null,"Cva stroke dx tx transf fac",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9777",null,"Pt no antiemet pre/intraop",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9785",null,"Path report sent",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9797",null,"Pt currently on statin",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9805",null,"Pt w/hosp anytime msmt per",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9813",null,"Pt not died w/in 30d of proc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9839",null,"Anti-egfr mon anti ther",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9846",null,"Pt died from cancer",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9875",null,"9 em core sessions",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9881",null,"Em 9 percent wl",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9898",null,"Pt 66+ snp or ltc pos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9910",null,"Pt 66+ snp or ltc pos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9911",null,"Node neg pre/post syst ther",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9919",null,"Scrn nd pos nd prov of rec",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9932",null,"Doc pt rsn no tb scrn recrds",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9946",null,"Bk pain no vas",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9963",null,"Embolization not doc separat",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9974",null,"Mac exam perf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["G9995",null,"Pall serv during meas",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["H0008",null,"Alcohol and/or drug services",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["H0009",null,"Alcohol and/or drug services",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["H0017",null,"Alcohol and/or drug services",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["H0029",null,"Alcohol and/or drug preventi",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["H0036",null,"Comm psy face-face per 15min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["H0048",null,"Spec coll non-blood:a/d test",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["H1003",null,"Prenatal at risk education",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["H2015",null,"Comp comm supp svc, 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["H2027",null,"Psychoed svc, per 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["H2028",null,"Sex offend tx svc, 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["H2036",null,"A/d tx program, per diem",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["J0179",null,"Inj, brolucizumab-dbll, 1 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J0190",null,"Inj biperiden lactate/5 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J0224",null,"Inj. lumasiran, 0.5 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J0278",null,"Amikacin sulfate injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J0348",null,"Anidulafungin injection",null,0.60899999999999999,null,0.60899999999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J0470",null,"Dimecaprol injection",null,56.42,null,56.42,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J0475",null,"Baclofen 10 mg injection",null,179.649,null,179.649,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J0517",null,"Inj., benralizumab, 1 mg",null,165.57,null,165.57,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J0587",null,"Inj, rimabotulinumtoxinb",null,12.170999999999999,null,12.170999999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J0594",null,"Busulfan injection",null,1.909,null,1.909,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J0610",null,"Calcium gluconate injection",null,4.048,null,4.048,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J0641",null,"Inj levoleucovorin nos 0.5mg",null,0.104,null,0.104,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J0702",null,"Betamethasone acet&sod phosp",null,6.7869999999999999,null,6.7869999999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J0735",null,"Clonidine hydrochloride",null,26.23,null,26.23,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J0770",null,"Colistimethate sodium inj",null,15.683999999999999,null,15.683999999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J0791",null,"Inj crizanlizumab-tmca 5mg",null,124.181,null,124.181,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["J0888",null,"Epoetin beta non esrd",null,1.5620000000000001,null,1.5620000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J0897",null,"Denosumab injection",null,21.26,null,21.26,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J1096",null,"Dexametha opth insert 0.1 mg",null,134.71,null,134.71,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J1162",null,"Digoxin immune fab (ovine)",null,4296.5410000000002,null,4296.5410000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J1250",null,"Inj dobutamine hcl/250 mg",null,6.0030000000000001,null,6.0030000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J1322",null,"Elosulfase alfa, injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J1380",null,"Estradiol valerate 10 mg inj",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J1427",null,"Inj. viltolarsen",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J1451",null,"Fomepizole, 15 mg",null,9.86,null,9.86,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J1457",null,"Gallium nitrate injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J1559",null,"Hizentra injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J1570",null,"Ganciclovir sodium injection",null,44.670999999999999,null,44.670999999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J1626",null,"Granisetron hcl injection",null,0.33500000000000002,null,0.33500000000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J1652",null,"Fondaparinux sodium",null,1.244,null,1.244,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J1726",null,"Makena, 10 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J1738",null,"Inj. meloxicam 1 mg",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["J1823",null,"Inj. inebilizumab-cdon, 1 mg",null,462.86700000000002,null,462.86700000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["J1840",null,"Kanamycin sulfate 500 mg inj",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J1953",null,"Levetiracetam injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J1960",null,"Levorphanol tartrate inj",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J2182",null,"Injection, mepolizumab, 1mg",null,28.75,null,28.75,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J2280",null,"Inj, moxifloxacin 100 mg",null,9.5310000000000006,null,9.5310000000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J2326",null,"Inj, nusinersen, 0.1mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J2354",null,"Octreotide inj, non-depot",null,0.84599999999999997,null,0.84599999999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J2469",null,"Palonosetron hcl",null,1.214,null,1.214,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J2506",null,"Inj pegfilgrast ex bio 0.5mg",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["J2597",null,"Inj desmopressin acetate",null,8.2710000000000008,null,8.2710000000000008,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J2675",null,"Inj progesterone per 50 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J2770",null,"Quinupristin/dalfopristin",null,428.32799999999997,null,428.32799999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J2794",null,"Inj risperdal consta, 0.5 mg",null,11.045999999999999,null,11.045999999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J2810",null,"Inj theophylline per 40 mg",null,0.39,null,0.39,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J2850",null,"Inj secretin synthetic human",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J3032",null,"Inj. eptinezumab-jjmr 1 mg",null,16.010999999999999,null,16.010999999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["J3101",null,"Tenecteplase injection",null,134.75899999999999,null,134.75899999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J3260",null,"Tobramycin sulfate injection",null,2.19,null,2.19,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J3280",null,"Thiethylperazine maleate inj",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J3350",null,"Urea injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J3397",null,"Inj., vestronidase alfa-vjbk",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J3420",null,"Vitamin b12 injection",null,1.6120000000000001,null,1.6120000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J3475",null,"Inj magnesium sulfate",null,0.76100000000000001,null,0.76100000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J3530",null,"Nasal vaccine inhalation",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J7042",null,"5% dextrose/normal saline",null,1.0169999999999999,null,1.0169999999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J7180",null,"Factor xiii anti-hem factor",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J7183",null,"Wilate injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J7197",null,"Antithrombin iii injection",null,3.3620000000000001,null,3.3620000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J7202",null,"Factor ix idelvion inj",null,4.7030000000000003,null,4.7030000000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J7296",null,"Kyleena, 19.5 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J7307",null,"Etonogestrel implant system",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J7314",null,"Inj., yutiq, 0.01 mg",null,518.33199999999999,null,518.33199999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J7323",null,"Euflexxa inj per dose",null,131.20599999999999,null,131.20599999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J7402",null,"Mometasone sinus sinuva",null,10.56,null,10.56,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["J7502",null,"Cyclosporine oral 100 mg",null,2.2290000000000001,null,2.2290000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J7517",null,"Mycophenolate mofetil oral",null,0.25600000000000001,null,0.25600000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J7599",null,"Immunosuppressive drug noc",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["J7615",null,"Levalbuterol comp unit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J7629",null,"Bitolterol mesylate comp unt",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J7637",null,"Dexamethasone comp con",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J7644",null,"Ipratropium bromide non-comp",null,0.19600000000000001,null,0.19600000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J7676",null,"Pentamidine comp unit dose",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J7681",null,"Terbutaline sulf comp unit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J8515",null,"Cabergoline, oral 0.25mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J8560",null,"Etoposide oral 50 mg",null,75.516000000000005,null,75.516000000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9000",null,"Doxorubicin hcl injection",null,3.008,null,3.008,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9023",null,"Injection, avelumab, 10 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J9035",null,"Bevacizumab injection",null,69.491,null,69.491,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9044",null,"Inj, bortezomib, nos, 0.1 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J9130",null,"Dacarbazine 100 mg inj",null,5.5350000000000001,null,5.5350000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9150",null,"Daunorubicin injection",null,39.576999999999998,null,39.576999999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9181",null,"Etoposide injection",null,0.76700000000000002,null,0.76700000000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9200",null,"Floxuridine injection",null,97.424000000000007,null,97.424000000000007,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9212",null,"Interferon alfacon-1 inj",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM"]
["J9219",null,"Leuprolide acetate implant",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J9230",null,"Mechlorethamine hcl inj",null,321.72000000000003,null,321.72000000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9267",null,"Paclitaxel injection",null,0.128,null,0.128,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["J9299",null,"Injection, nivolumab",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J9303",null,"Panitumumab injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["J9319",null,"Inj romidepsin lyophil 0.1mg",null,34.690400000000004,null,34.690400000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["J9340",null,"Thiotepa injection",null,306.84300000000002,null,306.84300000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9360",null,"Vinblastine sulfate inj",null,4.0170000000000003,null,4.0170000000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9999",null,"Chemotherapy drug",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["K0004","NU","High strength ltwt whlchr",null,1093.0360000000001,null,1093.0360000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0009","NU","Other manual wheelchair/base",null,936.88800000000003,null,936.88800000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0014","RR","Other power whlchr base",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["K0018","RR","Detach adjust armrst upper",null,2.9870000000000001,null,2.9870000000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["K0020","NU","Fixed adjust armrest pair",null,50.274300000000004,null,50.274300000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["K0042","NU","Standard size ftplate rep ea",null,33.639799999999994,null,33.639799999999994,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["K0050","NU","Ratchet assembly replacement",null,34.803699999999999,null,34.803699999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["K0052","NU","Swingaway detach ftrest repl",null,91.443399999999997,null,91.443399999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["K0105","NU","Iv hanger",null,120.51,null,120.51,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["K0455","RR","Pump uninterrupted infusion",null,333.76120000000003,null,333.76120000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["K0608",null,"Repl garment for aed",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["K0733","RR","12-24hr sealed lead acid",null,3.3063000000000002,null,3.3063000000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["K0740",null,"Repair/svc oxygen equipment",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["K0813","NU","Pwc gp 1 std port seat/back",null,3506.2230000000004,null,3506.2230000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0816","RR","Pwc gp 1 std cap chair",null,437.39980000000003,null,437.39980000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0824","NU","Pwc gp 2 hd seat/back",null,6464.7950000000001,null,6464.7950000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0831","NU","Pwc gp2 std seat elevate cap",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["K0837","RR","Pwc gp 2 hd sing pow opt s/b",null,644.17229999999995,null,644.17229999999995,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0843","RR","Pwc gp2 hd mult pow opt s/b",null,683.6110000000001,null,683.6110000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0850","RR","Pwc gp 3 hd seat/back",null,998.62620000000004,null,998.62620000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0852","NU","Pwc gp 3 vhd seat/back",null,11538.575000000001,null,11538.575000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0858","NU","Pwc gp3 hd sing pow opt s/b",null,11465.445000000002,null,11465.445000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0861","RR","Pwc gp3 std mult pow opt s/b",null,925.57860000000005,null,925.57860000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0869","NU","Pwc gp 4 std cap chair",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["K0884","NU","Pwc gp4 std mult pow opt s/b",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["K0891","RR","Pwc gp5 ped mult pow opt s/b",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["K1004","NU","Lo freq us diathermy device",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["K1009","RR","Speech volume modulation sys",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL"]
["K1015",null,"Foot, adductus position, adj",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["K1027",null,"Oral dev without fix mech",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["L0112",null,"Cranial cervical orthosis",null,1772.7252000000001,null,1772.7252000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L0174",null,"Cerv sr 2pc thor ext pre ots",null,350.27939999999995,null,350.27939999999995,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L0464",null,"Tlso 4mod sacro-scap pre",null,1882.6625999999999,null,1882.6625999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L0480",null,"Tlso rigid plastic custom fa",null,2019.4754999999998,null,2019.4754999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L0625",null,"Lo flex l1-below l5 pre ots",null,59.753399999999999,null,59.753399999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L0631",null,"Lso sag r an/pos pnl pre cst",null,1300.2329999999999,null,1300.2329999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L0634",null,"Lso flexion control custom",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["L0650",null,"Lso sc r ant/pos pnl pre ots",null,1248.2532000000001,null,1248.2532000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L0859",null,"Mri compatible system",null,1478.1648,null,1478.1648,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L0984",null,"Protect body sock ea pre ots",null,82.963499999999996,null,82.963499999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L1085",null,"Outrigger bil w/ vert extens",null,199.4076,null,199.4076,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L1220",null,"Anterior thoracic extension",null,328.8528,null,328.8528,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L1610",null,"Ho frejka cov only pre cst",null,53.271300000000004,null,53.271300000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L1660",null,"Ho abduction static plastic",null,225.02849999999998,null,225.02849999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L1686",null,"Ho post-op hip abduction",null,1122.3626999999999,null,1122.3626999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L1832",null,"Ko adj jnt pos r sup pre cst",null,737.6925,null,737.6925,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L1845",null,"Ko double upright pre cst",null,1029.9650999999999,null,1029.9650999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L1902",null,"Afo ankle gauntlet pre ots",null,118.7688,null,118.7688,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L1945",null,"Afo molded plas rig ant tib",null,1267.4535000000001,null,1267.4535000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L2020",null,"Kafo dbl solid stirrup band/",null,1889.0585999999998,null,1889.0585999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L2050",null,"Hkafo torsion cable hip pelv",null,586.21800000000007,null,586.21800000000007,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L2126",null,"Kafo fem fx cast thermoplas",null,1452.9621,null,1452.9621,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L2134",null,"Kafo fem fx cast semi-rigid",null,1227.2325000000001,null,1227.2325000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L2230",null,"Split flat caliper stirr & p",null,114.31619999999999,null,114.31619999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L2270",null,"Varus/valgus strap padded/li",null,86.887199999999993,null,86.887199999999993,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L2375",null,"Torsion ank & half solid sti",null,137.0958,null,137.0958,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L2405",null,"Knee joint drop lock ea jnt",null,110.41709999999999,null,110.41709999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L2550",null,"Thigh/wght bear high roll cu",null,380.22989999999999,null,380.22989999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L2627",null,"Plastic mold recipro hip & c",null,2080.0775999999996,null,2080.0775999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L2760",null,"Extension per extension per",null,75.300600000000003,null,75.300600000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L2785",null,"Drop lock retainer each",null,42.447299999999998,null,42.447299999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3002",null,"Foot insert plastazote or eq",null,204.56129999999999,null,204.56129999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3040",null,"Ft arch suprt premold longit",null,59.593500000000006,null,59.593500000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3202",null,"Oxford w/ supinat/pronator c",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["L3211",null,"Surgical boot each junior",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["L3230",null,"Custom shoes depth inlay",null,438.94400000000002,null,438.94400000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3260",null,"Ambulatory surgical boot eac",null,30.808799999999998,null,30.808799999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3360",null,"Shoe sole wedge outside sole",null,45.104100000000003,null,45.104100000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3390",null,"Shoe outflare wedge",null,62.779199999999996,null,62.779199999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3530",null,"Ortho shoe add half sole",null,40.2333,null,40.2333,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3550",null,"O shoe add standard toe tap",null,11.2422,null,11.2422,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3650",null,"So 8 abd restraint pre ots",null,75.066900000000004,null,75.066900000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3678",null,"So hard plas stabili pre ots",null,149.68799999999999,null,149.68799999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3766",null,"Ewhfo w/joint(s) cf",null,1565.1258,null,1565.1258,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L3904",null,"Whfo electric custom fitted",null,3477.0746999999997,null,3477.0746999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L3919",null,"Ho w/o joints cf",null,312.1986,null,312.1986,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L3924",null,"Hfo without joints pre ots",null,113.5167,null,113.5167,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3976",null,"Sewhfo airplane w/o jnts cf",null,1936.6472999999999,null,1936.6472999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L3978",null,"Sewhfo airplane w/jnt(s) cf",null,2286.5331000000001,null,2286.5331000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L4040",null,"Replace molded thigh lacer",null,660.38699999999994,null,660.38699999999994,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L4090",null,"Repl met band kafo-afo calf/",null,145.97640000000001,null,145.97640000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L4392",null,"Replace afo soft interface",null,29.310899999999997,null,29.310899999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L5020",null,"Tibial tubercle hgt w/ toe f",null,3037.2608,null,3037.2608,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5230",null,"Fem focal defic constant fri",null,6616.8064000000004,null,6616.8064000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5280",null,"Hemipelvect canad sing axis",null,9132.7360000000008,null,9132.7360000000008,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5530",null,"Prep bk ptb thermopls molded",null,2699.6864,null,2699.6864,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5540",null,"Prep bk ptb laminated socket",null,2976.4223999999999,null,2976.4223999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5616",null,"Ak univ multiplex sys frict",null,1827.0592000000001,null,1827.0592000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5628",null,"Test socket hemipelvectomy",null,813.32479999999998,null,813.32479999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5643",null,"Hip flex inner socket ext fr",null,2403.6480000000001,null,2403.6480000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5651",null,"Ak flex inner socket ext fra",null,1615.5264000000002,null,1615.5264000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5668",null,"Bk molded distal cushion",null,150.9376,null,150.9376,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5672",null,"Bk removable medial brim sus",null,434.0992,null,434.0992,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5694",null,"Ak pelvic control belt pad/l",null,324.1216,null,324.1216,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5696",null,"Ak/knee disartic pelvic join",null,331.86559999999997,null,331.86559999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5710",null,"Kne-shin exo sng axi mnl loc",null,612.08320000000003,null,612.08320000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5724",null,"Knee-shin exo fluid swing ph",null,2160.64,null,2160.64,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5811",null,"Endo knee-shin mnl lck ultra",null,981.10720000000003,null,981.10720000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5828",null,"Endo knee-shin fluid swg/sta",null,3798.8864000000003,null,3798.8864000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5920",null,"Endo ak/hip alignable system",null,713.77919999999995,null,713.77919999999995,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5940",null,"Endo bk ultra-light material",null,838.97600000000011,null,838.97600000000011,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5978",null,"Ft prosth multiaxial ankl/ft",null,475.96800000000002,null,475.96800000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5980",null,"Flex foot system",null,5453.6448,null,5453.6448,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6100",null,"Elb mold sock flex hinge pad",null,3145.92,null,3145.92,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6130",null,"Elbow stump activated lock h",null,4643.2767999999996,null,4643.2767999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6380",null,"Postop dsg cast chg wrst/elb",null,1839.5776000000001,null,1839.5776000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6550",null,"Shldr disar prosth tiss shap",null,6396.8128000000006,null,6396.8128000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6615",null,"Disconnect locking wrist uni",null,287.50080000000003,null,287.50080000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6621",null,"Flex/ext wrist w/wo friction",null,3020.672,null,3020.672,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L6647",null,"Shoulder lock actuator",null,685.70880000000011,null,685.70880000000011,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L6650",null,"Shoulder universal joint",null,459.94239999999996,null,459.94239999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6690",null,"Frame typ sock interscap-tho",null,1233.3568,null,1233.3568,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6693",null,"Lockingelbow forearm cntrbal",null,3749.2736,null,3749.2736,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L6708",null,"Term dev mech hand vol open",null,1320.1152,null,1320.1152,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L6722",null,"Hook/hand, hvy dty, vol clos",null,2677.6576,null,2677.6576,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L6905",null,"Hand restoration multiple fi",null,2633.4720000000002,null,2633.4720000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6940",null,"Elbow disarticulation switch",null,13598.131200000002,null,13598.131200000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L7045",null,"Pediatric electric hook",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X","Y"]
["L7180",null,"Electronic elbow sequential",null,49286.720000000001,null,49286.720000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L7403",null,"Add ue prost b/e acrylic",null,486.32319999999999,null,486.32319999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L7499",null,"Upper extremity prosthes nos",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N","Y","Y-CM"]
["L8010",null,"Mastectomy sleeve",null,106.59439999999999,null,106.59439999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L8039",null,"Breast prosthesis nos",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["L8310",null,"Truss double w/ standard pad",null,197.47839999999999,null,197.47839999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L8420",null,"Prosthetic sock multi ply bk",null,26.982399999999998,null,26.982399999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L8505",null,"Artificial larynx, accessory",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["L8509",null,"Trach-esoph voice pros md in",null,144.2176,null,144.2176,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["L8612",null,"Aqueous shunt prosthesis",null,974.29759999999999,null,974.29759999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L8615",null,"Coch implant headset replace",null,595.62239999999997,null,595.62239999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["L8627",null,"Cid ext speech process repl",null,9151.756800000001,null,9151.756800000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["L8659",null,"Interphalangeal joint repl",null,2548.3904000000002,null,2548.3904000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L8689",null,"External recharg sys intern",null,2278.0032000000001,null,2278.0032000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["L8696",null,"Ext antenna phren nerve stim",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["M0240",null,"CASIRI AND IMDEV REPEAT",null,463.5,null,463.5,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["M0243",null,"CASIRIVI AND IMDEVI INFUSION",null,463.5,null,463.5,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["M1009",null,"Dc eoc doc med rec",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["M1012",null,"Dc eoc doc med rec",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["M1028",null,"Doc of pt prm hda dx and otr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["M1039",null,"Pt dx lum sp reg inf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["M1057",null,"Aspirin not used, no rsn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["M1106",null,"Start eoc doc med rec",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["M1115",null,"Oc ni pt selfdc 1-2 vis",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["M1118",null,"Oc ni pt 1-2 vis",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["M1134",null,"Oc ni pt self dc 1-2 vis",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["M1142",null,"Emerge cases",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["M1149",null,"No neck fs prom incap",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["P9016",null,"Rbc leukocytes reduced",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["P9034",null,"Platelets, pheresis",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["P9044",null,"Cryoprecipitatereducedplasma",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["P9054",null,"Blood, l/r, froz/degly/wash",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["P9057",null,"Rbc, frz/deg/wsh, l/r, irrad",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["Q0081",null,"Infusion ther other than che",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["Q0085",null,"Chemo by both infusion and o",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,null,"O"]
["Q0114",null,"Fern test",null,13.9282,null,13.9282,null,"000",0,0,0,9,9,9,9,9,9,null,"L"]
["Q0173",null,"Trimethobenzamide hcl 250mg",null,1.08,null,1.08,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["Q0247",null,"Sotrovimab",null,2465.8200000000002,null,2465.8200000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["Q0483",null,"Monitor elec vad, rep",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q0492",null,"Emr pwr cbl elec vad, rep",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q0499",null,"Belt/vest elec/combo vad rep",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q0512",null,"Px sup fee anti-can sub pres",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q0515",null,"Sermorelin acetate injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q2028",null,"Inj, sculptra, 0.5mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q2054",null,"Lisocabtagene mara car pos t",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["Q4006",null,"Cast sup long arm adult fbrg",null,32.898200000000003,null,32.898200000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["Q4015",null,"Cast sup gauntlet ped plster",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4024",null,"Cast sup sht arm splnt ped f",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4031",null,"Cast sup lng leg ped plaster",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4043",null,"Cast sup lng leg splnt ped p",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4046",null,"Cast sup sht leg splnt fbrgl",null,21.022300000000001,null,21.022300000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["Q4074",null,"Iloprost non-comp unit dose",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4110",null,"Primatrix",null,40.328000000000003,null,40.328000000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["Q4117",null,"Hyalomatrix",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4135",null,"Mediskin",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4145",null,"Epifix, inj, 1mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4152",null,"Dermapure 1 square cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4164",null,"Helicoll, per square cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4167",null,"Truskin, per sq centimeter",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4174",null,"Palingen or promatrx",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4205",null,"Membrane graft or wrap sq cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4213",null,"Ascent, 0.5 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4229",null,"Cogenex amnio memb per sq cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4239",null,"Amnio-maxx or lite per sq cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q4247",null,"Amniotext patch, per sq cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["Q5001",null,"Hospice or home hlth in home",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["Q5004",null,"Hospice in snf",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["Q5010",null,"Hospice home care in hospice",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["Q5119",null,"Inj ruxience, 10 mg",null,49.816000000000003,null,49.816000000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["Q9951",null,"Locm >= 400 mg/ml iodine,1ml",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["Q9959",null,"Hocm 150-199mg/ml iodine,1ml",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["Q9992",null,"Buprenorphine xr over 100 mg",null,1781.309,null,1781.309,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["R0075",null,"Transport port x-ray multipl",null,32.2778611584,null,32.2778611584,null,"000",0,0,0,3,0,0,0,0,0,null,"F"]
["R0320",null,"Retraining examination and license fees",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S0020",null,"Injection, bupivicaine hydro",null,0.05,null,0.05,null,"000",0,0,0,9,9,9,9,9,9,null,"D"]
["S0028",null,"Injection, famotidine, 20 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S0088",null,"Imatinib 100 mg",null,3.14,null,3.14,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["S0122",null,"Inj menotropins 75 iu",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S0139",null,"Minoxidil, 10 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S0170",null,"Anastrozole 1 mg",null,0.13,null,0.13,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["S0178",null,"Lomustine 10 mg",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["S0189",null,"Testosterone pellet 75 mg",null,108.18,null,108.18,null,"000",0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["S0250",null,"Comp geriatr assmt team",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S0260",null,"H&p for surgery",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S0316",null,"Follow-up/reassessment",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S0500",null,"Dispos cont lens",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S0515",null,"Scleral lens liquid bandage",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S0595",null,"New lenses in pts old frame",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S0810",null,"Photorefractive keratectomy",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S1016",null,"Non-pvc intravenous administ",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S2061",null,"Donor lobectomy (lung)",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S2067",null,"Breast \"stacked\" diep/gap",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S2117",null,"Arthroereisis, subtalar",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S2208",null,"Minimally invasive direct co",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S2266",null,"Induced abortion 29-31 wks",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S2348",null,"Decompress disc rf lumbar",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S3000",null,"Bilat dil retinal exam",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S3630",null,"Eosinophil blood count",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S3846",null,"Gene test beta-thalassemia",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S3852",null,"Dna analysis apoe alzheimer",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S4014",null,"Compl zift case rate",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S4027",null,"Store prev froz embryos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S4042",null,"Ovulation mgmt per cycle",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S5000",null,"Prescription drug, generic",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S5108",null,"Homecare train pt 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S5116",null,"Nonfamily hc train/session",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S5150",null,"Unskilled respite care /15m",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S5161",null,"Emer rspns sys serv permonth",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["S5520",null,"Hit picc insert kit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S5553",null,"Insulin long acting 5 u",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8030",null,"Tantalum ring application",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8080",null,"Scintimammography",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8185",null,"Flutter device",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8265",null,"Haberman feeder",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8270",null,"Enuresis alarm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8301",null,"Infect control supplies nos",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["S8415",null,"Supplies for home delivery",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8420",null,"Custom gradient sleev/glov",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8421",null,"Ready gradient sleev/glov",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8422",null,"Custom grad sleeve med",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8423",null,"Custom grad sleeve heavy",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8424",null,"Ready gradient sleeve",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8425",null,"Custom grad glove med",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8426",null,"Custom grad glove heavy",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8427",null,"Ready gradient glove",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8428",null,"Ready gradient gauntlet",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8429",null,"Gradient pressure wrap",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8430",null,"Padding for comprssn bdg",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8431",null,"Compression bandage",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S8450",null,"Splint digit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8451",null,"Splint wrist or ankle",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8452",null,"Splint elbow",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8460",null,"Camisole post-mast",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8490",null,"100 insulin syringes",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8930",null,"Auricular electrostimulation",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8940",null,"Hippotherapy per session",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8948",null,"Low-level laser trmt 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8950",null,"Complex lymphedema therapy,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8990",null,"Pt or manip for maint",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S8999",null,"Resuscitation bag",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9001",null,"Home uterine monitor with or",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9007",null,"Ultrafiltration monitor",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9024",null,"Paranasal sinus ultrasound",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9025",null,"Omnicardiogram/cardiointegra",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9034",null,"Eswl for gallstones",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9055",null,"Procuren or other growth fac",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9056",null,"Coma stimulation per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9061",null,"Medical supplies and equipme",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9083",null,"Urgent care center global",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9088",null,"Services provided in urgent",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9090",null,"Vertebral axial decompressio",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9097",null,"Home visit wound care",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9098",null,"Home phototherapy visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9110",null,"Telemonitoring/home per mnth",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9117",null,"Back school visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9122",null,"Home health aide or certifie",null,33.051876,null,33.051876,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["S9123",null,"Nursing care in home rn",null,66.459510374399997,null,66.459510374399997,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["S9124",null,"Nursing care, in the home; b",null,48.005746588800001,null,48.005746588800001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["S9125",null,"Respite care, in the home, p",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9126",null,"Hospice care, in the home, p",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9127",null,"Social work visit, in the ho",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9128",null,"Speech therapy, in the home,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9129",null,"Occupational therapy, in the",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9131",null,"Pt in the home per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9140",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9141",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9145",null,"Insulin pump initiation",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9150",null,"Evaluation by ocularist",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9152",null,"Speech therapy, re-eval",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9208",null,"Home mgmt preterm labor",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9209",null,"Home mgmt pprom",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9211",null,"Home mgmt gest hypertension",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9212",null,"Hm postpar hyper per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9213",null,"Hm preeclamp per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9214",null,"Hm gest dm per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9325",null,"Hit pain mgmt per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9326",null,"Hit cont pain per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9327",null,"Hit int pain per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9328",null,"Hit pain imp pump diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9329",null,"Hit chemo per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9330",null,"Hit cont chem diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9331",null,"Hit intermit chemo diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9335",null,"Ht hemodialysis diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9336",null,"Hit cont anticoag diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9338",null,"Hit immunotherapy diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9339",null,"Hit periton dialysis diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9340",null,"Hit enteral per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9341",null,"Hit enteral grav diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9342",null,"Hit enteral pump diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9343",null,"Hit enteral bolus nurs",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9345",null,"Hit anti-hemophil diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9346",null,"Hit alpha-1-proteinas diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9347",null,"Hit longterm infusion diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9348",null,"Hit sympathomim diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9349",null,"Hit tocolysis diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9351",null,"Hit cont antiemetic diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9353",null,"Hit cont insulin diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9355",null,"Hit chelation diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9357",null,"Hit enzyme replace diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9359",null,"Hit anti-tnf per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9361",null,"Hit diuretic infus diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9363",null,"Hit anti-spasmotic diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9364",null,"Hit tpn total diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9365",null,"Hit tpn 1 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9366",null,"Hit tpn 2 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9367",null,"Hit tpn 3 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9368",null,"Hit tpn over 3l diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9370",null,"Ht inj antiemetic diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9372",null,"Ht inj anticoag diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9373",null,"Hit hydra total diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9374",null,"Hit hydra 1 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9375",null,"Hit hydra 2 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9376",null,"Hit hydra 3 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9377",null,"Hit hydra over 3l diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9379",null,"Hit noc per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9381",null,"Hit high risk/escort",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9401",null,"Anticoag clinic per session",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9430",null,"Pharmacy comp/disp serv",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9432",null,"Med food non inborn err meta",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9433",null,"Medical food oral 100% nutr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9434",null,"Mod solid food suppl",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9435",null,"Medical foods for inborn err",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9436",null,"Lamaze class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9437",null,"Childbirth refresher class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9438",null,"Cesarean birth class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9439",null,"Vbac class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9441",null,"Asthma education",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9442",null,"Birthing class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9443",null,"Lactation class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9444",null,"Parenting class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9445",null,"Pt education noc individ",null,44.652483532799998,null,44.652483532799998,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["S9446",null,"Pt education noc group",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9447",null,"Infant safety class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9449",null,"Weight mgmt class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9451",null,"Exercise class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9452",null,"Nutrition class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9453",null,"Smoking cessation class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9454",null,"Stress mgmt class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9455",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9460",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9465",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9470",null,"Nutritional counseling, diet",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9472",null,"Cardiac rehabilitation progr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9473",null,"Pulmonary rehabilitation pro",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9474",null,"Enterostomal therapy by a re",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9475",null,"Ambulatory setting substance",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9476",null,"Vestibular rehab per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9480",null,"Intensive outpatient psychia",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["S9482",null,"Family stabilization 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9484",null,"Crisis intervention per hour",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9485",null,"Crisis intervention mental h",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9490",null,"Hit corticosteroid/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9494",null,"Hit antibiotic total diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9497",null,"Hit antibiotic q3h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9500",null,"Hit antibiotic q24h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9501",null,"Hit antibiotic q12h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9502",null,"Hit antibiotic q8h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9503",null,"Hit antibiotic q6h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9504",null,"Hit antibiotic q4h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9529",null,"Venipuncture home/snf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9537",null,"Ht hem horm inj diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9538",null,"Hit blood products diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9542",null,"Ht inj noc per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9558",null,"Ht inj growth horm diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9559",null,"Hit inj interferon diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9560",null,"Ht inj hormone diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9562",null,"Ht inj palivizumab diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9590",null,"Ht irrigation diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9810",null,"Ht pharm per hour",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9900",null,"Christian sci pract visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9901",null,"Christian sci nurse visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9960",null,"Air ambulanc nonemerg fixed",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9961",null,"Air ambulan nonemerg rotary",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9970",null,"Health club membership yr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9975",null,"Transplant related per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9976",null,"Lodging per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9977",null,"Meals per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9981",null,"Med record copy admin",null,28.913781124800003,null,28.913781124800003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["S9982",null,"Med record copy per page",null,0.57329981280000009,null,0.57329981280000009,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["S9986",null,"Not medically necessary svc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9988",null,"Serv part of phase i trial",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9989",null,"Services outside us",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9990",null,"Services provided as part of",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9991",null,"Services provided as part of",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9992",null,"Transportation costs to and",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9994",null,"Lodging costs (e.g. hotel ch",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9996",null,"Meals for clinical trial par",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["S9999",null,"Sales tax",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1000",null,"Private duty/independent nsg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1001",null,"Nursing assessment/evaluatn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1002",null,"Rn services up to 15 minutes",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1003",null,"Lpn/lvn services up to 15min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1004",null,"Nsg aide service up to 15min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1005",null,"Respite care service 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1006",null,"Family/couple counseling",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1007",null,"Treatment plan development",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1009",null,"Child sitting services",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1010",null,"Meals when receive services",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1012",null,"Alcohol/substance abuse skil",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1013",null,"Sign lang/oral interpreter",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1014",null,"Telehealth transmit, per min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1015",null,"Clinic service",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["T1016",null,"Case management",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1017",null,"Targeted case management",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1018",null,"School-based iep ser bundled",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1019",null,"Personal care ser per 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1020",null,"Personal care ser per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1021",null,"Hh aide or cn aide per visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1022",null,"Contracted services per day",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1023",null,"Program intake assessment",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1024",null,"Team evaluation & management",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1025",null,"Ped compr care pkg, per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1026",null,"Ped compr care pkg, per hour",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1027",null,"Family training & counseling",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1028",null,"Home environment assessment",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1029",null,"Dwelling lead investigation",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1030",null,"Rn home care per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1031",null,"Lpn home care per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1040",null,"Comm bh clinic svc per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1041",null,"Comm bh clinic svc per month",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1502",null,"Medication admin visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1503",null,"Med admin, not oral/inject",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1505",null,"Elec med comp dev, noc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T1999",null,"Noc retail items andsupplies",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2001",null,"N-et; patient attend/escort",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2002",null,"N-et; per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2003",null,"N-et; encounter/trip",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2004",null,"N-et; commerc carrier pass",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2005",null,"N-et; stretcher van",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2007",null,"Non-emer transport wait time",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2010",null,"Pasrr level i",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2011",null,"Pasrr level ii",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2012",null,"Habil ed waiver, per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2013",null,"Habil ed waiver per hour",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2014",null,"Habil prevoc waiver, per d",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2015",null,"Habil prevoc waiver per hr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2016",null,"Habil res waiver per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2017",null,"Habil res waiver 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2018",null,"Habil sup empl waiver/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2019",null,"Habil sup empl waiver 15min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2020",null,"Day habil waiver per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2021",null,"Day habil waiver per 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2022",null,"Case management, per month",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2023",null,"Targeted case mgmt per month",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2024",null,"Serv asmnt/care plan waiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2025",null,"Waiver service, nos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2026",null,"Special childcare waiver/d",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2027",null,"Spec childcare waiver 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2028",null,"Special supply, nos waiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2029",null,"Special med equip, noswaiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2030",null,"Assist living waiver/month",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2031",null,"Assist living waiver/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2032",null,"Res care, nos waiver/month",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2033",null,"Res, nos waiver per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2034",null,"Crisis interven waiver/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2035",null,"Utility services waiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2036",null,"Camp overnite waiver/session",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2037",null,"Camp day waiver/session",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2038",null,"Comm trans waiver/service",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2039",null,"Vehicle mod waiver/service",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2040",null,"Financial mgt waiver/15min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2041",null,"Support broker waiver/15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2042",null,"Hospice routine home care",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2043",null,"Hospice continuous home care",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2044",null,"Hospice respite care",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2045",null,"Hospice general care",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2046",null,"Hospice long term care, r&b",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2047",null,"Hab prevo waiver per 15",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2048",null,"Bh ltc res r&b, per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2049",null,"N-et; stretcher van, mileage",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2050",null,"Financial mgt waiver/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2051",null,"Support broker waiver/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T2101",null,"Breast milk proc/store/dist",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T4521",null,"Adult size brief/diaper sm",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4522",null,"Adult size brief/diaper med",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4523",null,"Adult size brief/diaper lg",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4524",null,"Adult size brief/diaper xl",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4525",null,"Adult size pull-on sm",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4526",null,"Adult size pull-on med",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4527",null,"Adult size pull-on lg",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4528",null,"Adult size pull-on xl",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4529",null,"Ped size brief/diaper sm/med",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T4530",null,"Ped size brief/diaper lg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T4531",null,"Ped size pull-on sm/med",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T4532",null,"Ped size pull-on lg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T4533",null,"Youth size brief/diaper",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4534",null,"Youth size pull-on",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4535",null,"Disposable liner/shield/pad",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4536",null,"Reusable pull-on any size",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4537",null,"Reusable underpad bed size",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4538",null,"Diaper serv reusable diaper",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T4539",null,"Reuse diaper/brief any size",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4540",null,"Reusable underpad chair size",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4541",null,"Large disposable underpad",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4542",null,"Small disposable underpad",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4543",null,"Adult disp brief/diap abv xl",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T4544",null,"Adlt disp und/pull on abv xl",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T4545",null,"Incon disposable penile wrap",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["T5001",null,"Position seat spec orth need",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["T5999",null,"Supply, nos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["U0001",null,"2019-ncov diagnostic p",null,51.365600000000001,null,51.365600000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
["U0002",null,"Covid-19 lab test non-cdc",null,73.3733,null,73.3733,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
["U0003",null,"SARS-COV-2 DNA/RNA HIGH THROUGHPUT",null,107.25,null,107.25,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
["U0004",null,"2019-NCOV ANY TECHNIQUE HIGH THROUGHPUT",null,107.25,null,107.25,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
["U0005",null,"Infec agen detec ampli probe",null,35.75,null,35.75,null,"000",0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
["V0028",null,"Travel, vocational services, claimant",null,"State Rate",null,"State Rate",null,"000",0,0,0,9,9,9,9,9,9,null,"S"]
["V2020",null,"Vision svcs frames purchases",null,76.755600000000001,null,76.755600000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2025",null,"Eyeglasses delux frames",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2100",null,"Lens spher single plano 4.00",null,48.482100000000003,null,48.482100000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2101",null,"Single visn sphere 4.12-7.00",null,49.862299999999998,null,49.862299999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2102",null,"Singl visn sphere 7.12-20.00",null,62.850600000000007,null,62.850600000000007,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2103",null,"Spherocylindr 4.00d/12-2.00d",null,46.051300000000005,null,46.051300000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2104",null,"Spherocylindr 4.00d/2.12-4d",null,47.400600000000004,null,47.400600000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2105",null,"Spherocylinder 4.00d/4.25-6d",null,53.467299999999994,null,53.467299999999994,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2106",null,"Spherocylinder 4.00d/>6.00d",null,57.360700000000001,null,57.360700000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2107",null,"Spherocylinder 4.25d/12-2d",null,49.718100000000007,null,49.718100000000007,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2108",null,"Spherocylinder 4.25d/2.12-4d",null,48.513000000000005,null,48.513000000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2109",null,"Spherocylinder 4.25d/4.25-6d",null,59.554600000000001,null,59.554600000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2110",null,"Spherocylinder 4.25d/over 6d",null,52.962600000000002,null,52.962600000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2111",null,"Spherocylindr 7.25d/.25-2.25",null,55.208000000000006,null,55.208000000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2112",null,"Spherocylindr 7.25d/2.25-4d",null,61.161400000000008,null,61.161400000000008,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2113",null,"Spherocylindr 7.25d/4.25-6d",null,72.244200000000006,null,72.244200000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2114",null,"Spherocylinder over 12.00d",null,78.712600000000009,null,78.712600000000009,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2115",null,"Lens lenticular bifocal",null,95.058700000000016,null,95.058700000000016,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2118",null,"Lens aniseikonic single",null,89.712999999999994,null,89.712999999999994,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2121",null,"Lenticular lens, single",null,100.4147,null,100.4147,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2199",null,"Lens single vision not oth c",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2200",null,"Lens spher bifoc plano 4.00d",null,68.989400000000003,null,68.989400000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2201",null,"Lens sphere bifocal 4.12-7.0",null,69.267499999999998,null,69.267499999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2202",null,"Lens sphere bifocal 7.12-20.",null,76.178799999999995,null,76.178799999999995,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2203",null,"Lens sphcyl bifocal 4.00d/.1",null,67.691599999999994,null,67.691599999999994,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2204",null,"Lens sphcy bifocal 4.00d/2.1",null,68.021200000000007,null,68.021200000000007,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2205",null,"Lens sphcy bifocal 4.00d/4.2",null,70.390200000000007,null,70.390200000000007,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2206",null,"Lens sphcy bifocal 4.00d/ove",null,70.946399999999997,null,70.946399999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2207",null,"Lens sphcy bifocal 4.25-7d/.",null,66.167199999999994,null,66.167199999999994,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2208",null,"Lens sphcy bifocal 4.25-7/2.",null,64.920900000000003,null,64.920900000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2209",null,"Lens sphcy bifocal 4.25-7/4.",null,74.932500000000005,null,74.932500000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2210",null,"Lens sphcy bifocal 4.25-7/ov",null,84.975000000000009,null,84.975000000000009,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2211",null,"Lens sphcy bifo 7.25-12/.25-",null,92.782399999999996,null,92.782399999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2212",null,"Lens sphcyl bifo 7.25-12/2.2",null,93.482800000000012,null,93.482800000000012,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2213",null,"Lens sphcyl bifo 7.25-12/4.2",null,90.032299999999992,null,90.032299999999992,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2214",null,"Lens sphcyl bifocal over 12.",null,94.523099999999999,null,94.523099999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2215",null,"Lens lenticular bifocal",null,113.5472,null,113.5472,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2218",null,"Lens aniseikonic bifocal",null,118.86200000000001,null,118.86200000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2219",null,"Lens bifocal seg width over",null,48.1937,null,48.1937,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2220",null,"Lens bifocal add over 3.25d",null,39.088500000000003,null,39.088500000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2221",null,"Lenticular lens, bifocal",null,104.854,null,104.854,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2299",null,"Lens bifocal speciality",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2300",null,"Lens sphere trifocal 4.00d",null,81.720200000000006,null,81.720200000000006,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2301",null,"Lens sphere trifocal 4.12-7.",null,85.871100000000013,null,85.871100000000013,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2302",null,"Lens sphere trifocal 7.12-20",null,88.775700000000001,null,88.775700000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2303",null,"Lens sphcy trifocal 4.0/.12-",null,81.205200000000005,null,81.205200000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2304",null,"Lens sphcy trifocal 4.0/2.25",null,75.0458,null,75.0458,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2305",null,"Lens sphcy trifocal 4.0/4.25",null,84.573300000000003,null,84.573300000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2306",null,"Lens sphcyl trifocal 4.00/>6",null,86.787800000000004,null,86.787800000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2307",null,"Lens sphcy trifocal 4.25-7/.",null,88.250400000000013,null,88.250400000000013,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2308",null,"Lens sphc trifocal 4.25-7/2.",null,97.860300000000009,null,97.860300000000009,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2309",null,"Lens sphc trifocal 4.25-7/4.",null,101.1769,null,101.1769,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2310",null,"Lens sphc trifocal 4.25-7/>6",null,96.614000000000004,null,96.614000000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2311",null,"Lens sphc trifo 7.25-12/.25-",null,96.449200000000005,null,96.449200000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2312",null,"Lens sphc trifo 7.25-12/2.25",null,99.322900000000004,null,99.322900000000004,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2313",null,"Lens sphc trifo 7.25-12/4.25",null,111.40479999999999,null,111.40479999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2314",null,"Lens sphcyl trifocal over 12",null,116.3488,null,116.3488,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2315",null,"Lens lenticular trifocal",null,131.69579999999999,null,131.69579999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2318",null,"Lens aniseikonic trifocal",null,158.78479999999999,null,158.78479999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2319",null,"Lens trifocal seg width > 28",null,53.755699999999997,null,53.755699999999997,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2320",null,"Lens trifocal add over 3.25d",null,64.179299999999998,null,64.179299999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2321",null,"Lenticular lens, trifocal",null,127.31830000000001,null,127.31830000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2399",null,"Lens trifocal speciality",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2410",null,"Lens variab asphericity sing",null,114.845,null,114.845,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2430",null,"Lens variable asphericity bi",null,119.92290000000001,null,119.92290000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2499",null,"Variable asphericity lens",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2500",null,"Contact lens pmma spherical",null,117.30670000000001,null,117.30670000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2501",null,"Cntct lens pmma-toric/prism",null,134.02360000000002,null,134.02360000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2502",null,"Contact lens pmma bifocal",null,165.10900000000001,null,165.10900000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2503",null,"Cntct lens pmma color vision",null,162.20439999999999,null,162.20439999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2510",null,"Cntct gas permeable sphericl",null,150.36970000000002,null,150.36970000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2511",null,"Cntct toric prism ballast",null,172.57650000000001,null,172.57650000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2512",null,"Cntct lens gas permbl bifocl",null,203.9194,null,203.9194,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2513",null,"Contact lens extended wear",null,186.93470000000002,null,186.93470000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2520",null,"Contact lens hydrophilic",null,126.60760000000001,null,126.60760000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2521",null,"Cntct lens hydrophilic toric",null,196.55490000000003,null,196.55490000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2522",null,"Cntct lens hydrophil bifocl",null,191.28130000000002,null,191.28130000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2523",null,"Cntct lens hydrophil extend",null,166.45830000000001,null,166.45830000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2524",null,"Cntct lens hydrophil photoch",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2525",null,"Cl, hydrophilic, dual focus",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V2530",null,"Contact lens gas impermeable",null,241.43200000000002,null,241.43200000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2531",null,"Contact lens gas permeable",null,575.40949999999998,null,575.40949999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V2599",null,"Contact lens/es other type",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2600",null,"Hand held low vision aids",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2610",null,"Single lens spectacle mount",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2615",null,"Telescop/othr compound lens",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2623",null,"Plastic eye prosth custom",null,1164.6313,null,1164.6313,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2624",null,"Polishing artifical eye",null,87.86930000000001,null,87.86930000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2625",null,"Enlargemnt of eye prosthesis",null,534.20949999999993,null,534.20949999999993,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2626",null,"Reduction of eye prosthesis",null,287.9674,null,287.9674,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2627",null,"Scleral cover shell",null,1859.7885999999999,null,1859.7885999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2628",null,"Fabrication & fitting",null,439.1302,null,439.1302,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2629",null,"Prosthetic eye other type",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2630",null,"Anter chamber intraocul lens",null,128.85300000000001,null,128.85300000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2631",null,"Iris support intraoclr lens",null,128.85300000000001,null,128.85300000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2632",null,"Post chmbr intraocular lens",null,128.85300000000001,null,128.85300000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2700",null,"Balance lens",null,47.421199999999999,null,47.421199999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2702",null,"Deluxe lens feature",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2710",null,"Glass/plastic slab off prism",null,69.411699999999996,null,69.411699999999996,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2715",null,"Prism lens/es",null,15.470599999999999,null,15.470599999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2718",null,"Fresnell prism press-on lens",null,30.910300000000003,null,30.910300000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2730",null,"Special base curve",null,22.8248,null,22.8248,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2744",null,"Tint photochromatic lens/es",null,19.662700000000001,null,19.662700000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2745",null,"Tint, any color/solid/grad",null,13.2973,null,13.2973,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2750",null,"Anti-reflective coating",null,20.661799999999999,null,20.661799999999999,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2755",null,"Uv lens/es",null,19.250700000000002,null,19.250700000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2756",null,"Eye glass case",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2760",null,"Scratch resistant coating",null,17.334899999999998,null,17.334899999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2761",null,"Mirror coating",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2762",null,"Polarization, any lens",null,63.334700000000005,null,63.334700000000005,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2770",null,"Occluder lens/es",null,21.321000000000002,null,21.321000000000002,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2780",null,"Oversize lens/es",null,13.565100000000001,null,13.565100000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2781",null,"Progressive lens per lens",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2782",null,"Lens, 1.54-1.65 p/1.60-1.79g",null,68.412599999999998,null,68.412599999999998,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2783",null,"Lens, >= 1.66 p/>=1.80 g",null,77.116100000000003,null,77.116100000000003,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2784",null,"Lens polycarb or equal",null,50.150700000000001,null,50.150700000000001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V2785",null,"Corneal tissue processing",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2786",null,"Occupational multifocal lens",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2787",null,"Astigmatism-correct function",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2788",null,"Presbyopia-correct function",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V2790",null,"Amniotic membrane",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2797",null,"Vis item/svc in other code",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V2799",null,"Misc vision item or service",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5008",null,"Hearing screening",null,89.919316226694221,null,89.919316226694221,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5010",null,"Assessment for hearing aid",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["V5011",null,"Hearing aid fitting/checking",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["V5014",null,"Hearing aid repair/modifying",null,59.949888950746086,null,59.949888950746086,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["V5020",null,"Conformity evaluation",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,null,"Bundled"]
["V5030",null,"Body-worn hearing aid air",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5040",null,"Body-worn hearing aid bone",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5050",null,"Hearing aid monaural in ear",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5060",null,"Behind ear hearing aid",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5070",null,"Glasses air conduction",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5080",null,"Glasses bone conduction",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5090",null,"Hearing aid dispensing fee",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5095",null,"Implant mid ear hearing pros",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5100",null,"Body-worn bilat hearing aid",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5110",null,"Hearing aid dispensing fee",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5120",null,"Body-worn binaur hearing aid",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5130",null,"In ear binaural hearing aid",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5140",null,"Behind ear binaur hearing ai",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5150",null,"Glasses binaural hearing aid",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5160",null,"Dispensing fee binaural",null,1702.5415361248697,null,1702.5415361248697,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5171",null,"Hearing aid monaural ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5172",null,"Hearing aid monaural itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5181",null,"Hearing aid monaural bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5190",null,"Hearing aid monaural glasses",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5200",null,"Disp fee contralateral monau",null,1020.4612056258048,null,1020.4612056258048,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5211",null,"Hearing aid binaural ite/ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5212",null,"Hearing aid binaural ite/itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5213",null,"Hearing aid binaural ite/bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5214",null,"Hearing aid binaural itc/itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5215",null,"Hearing aid binaural itc/bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5221",null,"Hearing aid binaural bte/bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5230",null,"Hearing aid binaural glasses",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5240",null,"Disp fee contralateral binau",null,1020.4612056258048,null,1020.4612056258048,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5241",null,"Dispensing fee, monaural",null,851.27076806243485,null,851.27076806243485,null,"000",0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5242",null,"Hearing aid, monaural, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5243",null,"Hearing aid, monaural, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5244",null,"Hearing aid, prog, mon, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5245",null,"Hearing aid, prog, mon, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5246",null,"Hearing aid, prog, mon, ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5247",null,"Hearing aid, prog, mon, bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5248",null,"Hearing aid, binaural, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5249",null,"Hearing aid, binaural, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5250",null,"Hearing aid, prog, bin, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5251",null,"Hearing aid, prog, bin, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5252",null,"Hearing aid, prog, bin, ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5253",null,"Hearing aid, prog, bin, bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5254",null,"Hearing id, digit, mon, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5255",null,"Hearing aid, digit, mon, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5256",null,"Hearing aid, digit, mon, ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5257",null,"Hearing aid, digit, mon, bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5258",null,"Hearing aid, digit, bin, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5259",null,"Hearing aid, digit, bin, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5260",null,"Hearing aid, digit, bin, ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5261",null,"Hearing aid, digit, bin, bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5262",null,"Hearing aid, disp, monaural",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5263",null,"Hearing aid, disp, binaural",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5264",null,"Ear mold/insert",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL"]
["V5265",null,"Ear mold/insert, disp",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5266",null,"Battery for hearing device",null,1.0482678907272001,null,1.0482678907272001,null,"000",0,0,0,9,9,9,9,9,9,null,"F"]
["V5267",null,"Hearing aid sup/access/dev",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL"]
["V5268",null,"Ald telephone amplifier",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5269",null,"Alerting device, any type",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5270",null,"Ald, tv amplifier, any type",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5271",null,"Ald, tv caption decoder",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5272",null,"Tdd",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5273",null,"Ald for cochlear implant",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5274",null,"Ald unspecified",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5275",null,"Ear impression",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5281",null,"Ald fm/dm system, monaural",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5282",null,"Ald fm/dm system binaural",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5283",null,"Ald neck, loop ind receiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5284",null,"Ald fm/dm ear level receiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5285",null,"Ald fm/dm aud input receiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5286",null,"Ald blu tooth fm/dm receiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5287",null,"Ald fm/dm receiver, nos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5288",null,"Ald fm/dm transmitter ald",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5289",null,"Ald fm/dm adapt/boot couplin",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5290",null,"Ald transmitter microphone",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5298",null,"Hearing aid noc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,null,"X"]
["V5299",null,"Hearing service",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,null,"X"]
["V5336",null,"Repair communication device",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V5362",null,"Speech screening",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V5363",null,"Language screening",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["V5364",null,"Dysphagia screening",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]

{"sheet":"Field 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[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["Professional Services Fee Schedule"]
[]
["CPT® Through Local Codes"]
[]
[]
[]
["Effective for Dates of Service on or After"]
[]
["2022-07-01"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["ANESTHESIA SERVICES FEE SCHEDULE                   "]
["FIELD KEY:  "]
["Column Title",null,"Column Description",null,null,"Column Values",null,"Value Definitions"]
["CPTÒ CODE",null,"2021 CPT® anesthesia code.",null,null,null,null,"2021 CPT® anesthesia code."]
["ANES VALUE",null,"Indicates the anesthesia base units, maximum dollar value, or coverage for the anesthesia service.",null,null,"Number",null,"Anesthesia base units for services paid with the base and time payment method."]
[null,null,null,null,null,"Dollar Value",null,"Fee schedule dollar value for services paid with the maximum fee method."]
[null,null,null,null,null,"By Report",null,"Service paid on a “by report” basis."]
[null,null,null,null,null,"Not Covered",null,"Procedure code is not covered."]
["PAYMENT METHOD",null,"Indicates the payment method for the anesthesia service.",null,null,"Base/Time",null,"Service paid with base and time units."]
[null,null,null,null,null,"By Report",null,"Service paid on a “by report” basis."]
[null,null,null,null,null,"Maximum Fee",null,"Service paid based on a maximum dollar value."]
[null,null,null,null,null,"Not Covered",null,"Procedure code is not covered,"]
["BASE SOURCE",null,"Indicates the source of the anesthesia base units.",null,null,"CMS",null,"Base unit source is the Centers for Medicare and Medicaid Services (CMS)."]
[null,null,null,null,null,"ASA",null,"Base unit source is the American Society of Anesthesiologists’ Relative Value Guide."]
[null,null,null,null,null,"N/A",null,"Service not paid by base and time unit method"]
["FSI",null,"Fee Schedule Indicator \nThis column indicates the payment status for the procedure code.",null,null,"A",null,"Paid using base units"]
[null,null,null,null,null,"F",null,"Flat Fee developed by the department"]
[null,null,null,null,null,"N",null,"No fee or RVUs available, paid By Report"]
[null,null,null,null,null,"R",null,"Fee set by RBRVS RVUs"]
[null,null,null,null,null,"X",null,"Non-covered code"]
["PRIOR AUTH",null,"Prior authorization indicator              This column indicates whether prior authorization and utilization review is required. Link provided in cell."]
[]
[null,null,null,null,null,"Y-CM",null,"Prior authorization required, contact claims manager"]
[null,null,null,null,null,"Y-UR",null,"Prior authorization and UR required"]
[null,null,null,null,null,"Y-ONC",null,"Prior authorization required, contact occupational nurse consultant"]
[null,null,null,null,null,"Y-PHL",null,"Prior authorization required, contact Provider Hotline"]
[]
[]
["EVALUATION AND MANAGEMENT THROUGH HCPCS FEES"]
["FIELD KEY:  "]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["CPTÒ CODE/\nHCPCS CODE",null,"2021 CPT® or HCPCS code",null,null,null,null,null,null,null,"2021 CPT® or HCPCS code"]
[]
["ABBREVIATED DESCRIPTION",null,"Abbreviated HCPCS code description. No descriptions are provided for CPTÒ codes.",null,null,null,null,null,null,null,"Abbreviated description for reference purposes only. Refer to a 2021 CPT® or HCPCS code book for complete code descriptions."]
[]
[]
[]
["DOLLAR VALUE\nNON-FACILITY SETTING",null,"This column indicates the:\n• Maximum dollar amount for covered services provided in a non-facility setting, or\n• Pricing method for the procedure code, or\n• Coverage status for the procedure code.\n",null,null,null,null,null,"Dollar Value",null,"Maximum dollar amount payable for covered services."]
[null,null,null,null,null,null,null,null,"Bundled",null,"Bundled code, not separately payable."]
[null,null,null,null,null,null,null,null,"By Report",null,"Service paid on a “by report” basis."]
[null,null,null,null,null,null,null,null,"Contracted",null,"Contracted service. Payable only to department’s contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured workers."]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,"Facility Only",null,"Procedure code for facility outpatient use only."]
[null,null,null,null,null,null,null,null,"Not Covered",null,"Procedure code is not covered."]
["DOLLAR VALUE\nFACILITY SETTING",null,"This column indicates the:\n• Maximum dollar amount for covered services provided in a facility setting, or\n• Pricing method for the procedure code, or\n• Coverage status for the procedure code.\n",null,null,null,null,null,"Dollar Value",null,"Maximum dollar amount payable for covered services."]
[null,null,null,null,null,null,null,null,"Bundled",null,"Bundled code, not separately payable."]
[null,null,null,null,null,null,null,null,"By Report",null,"Service paid on a “by report” basis."]
[null,null,null,null,null,null,null,null,"Contracted",null,"Contracted service. Payable only to department’s contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured workers."]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,"Hosp. Only",null,"Procedure code for hospital outpatient use only."]
[null,null,null,null,null,null,null,null,"Not Covered",null,"Procedure code is not covered."]
[]
[]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["FOL UP",null,"Follow-up Days for Global Surgery",null,null,null,null,null,"Number",null,"The number of days following surgery during which charges for normal postoperative care are bundled in the global surgery fee."]
[]
[]
[]
["PRE OP \n(-56)",null,"Preoperative Percentage\n(Modifier –56)",null,null,null,null,null,"Percent",null,"The percent of the total global surgery dollar value that is allowed when modifier –56 is billed."]
[]
[]
["INTRA OP  (-54)",null,"Intraoperative Percentage\n(Modifier –54)",null,null,null,null,null,"Percent",null,"The percent of the total global surgery dollar value that is allowed when modifier -54 is billed."]
[]
[]
["POST OP \n(-55)",null,"Postoperative Percentage\n(Modifier –55)",null,null,null,null,null,"Percent ",null,"The percent of the total global surgery dollar value that is allowed when modifier -55 is billed."]
[]
[]
[]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["PCTC\n(26/TC)",null,"Professional and Technical Component (Modifiers –26 and –TC)\nThis field identifies whether professional and technical component modifiers (-26/-TC) are valid with the procedure code.",null,null,null,null,null,0,null,"Modifiers -26 and -TC are not valid. The procedure is for physician services only; the concept of PC/TC does not apply"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"Modifiers -26 and -TC are valid. Diagnostic test or radiology service which has both a professional and technical component. "]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,2,null,"Modifiers -26 and -TC are not valid. Stand alone code for the professional component of a diagnostic test. An associated code describes the technical component of the diagnostic test or the global procedure (professional and technical components)."]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,3,null,"Modifiers -26 and -TC are not valid. Stand alone code for the technical component of a diagnostic test. An associated code describes the professional component of the diagnostic test or the global procedure (professional and technical components). "]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,4,null,"Modifiers -26 and -TC are not valid. Stand alone code for the global procedure for a diagnostic test. Associated codes describe the professional and technical components of the diagnostic test. "]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,5,null,"Modifiers -26 and -TC are not valid. Covered service incident to a physician’s service when provided by auxiliary personnel employed by and working under the direct supervision of the physician. This service not payable when provided to hospital inpatients or outpatients."]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,6,null,"Modifier -TC is not valid; modifier -26 may be valid. Clinical laboratory or other service for which separate payment for interpretations by laboratory physicians or other physicians may be made."]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,7,null,"This indicator is not currently in use."]
[null,null,null,null,null,null,null,null,8,null,"Professional component of a clinical laboratory code; payable only if the physician interprets an abnormal smear for a hospital inpatient. No -TC modifier billing is recognized; payment for the underlying clinical laboratory test is made to the hospital. Not payable when furnished to hospital outpatients or non-hospital patients."]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,9,null,"Modifiers -26 and -TC are not valid. Concept of a professional/technical component split does not apply."]
[]
[]
[]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["MSI",null,"Multiple Surgery Indicator\n(Modifier –51)\nThis field indicates whether multiple surgery payment rules apply to the service.\n",null,null,null,null,null,0,null,"Modifier -51 is not valid. Payment adjustment rules for multiple surgeries do not apply."]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"This indicator is not currently in use."]
[null,null,null,null,null,null,null,null,2,null,"Modifier -51 is valid. Standard multiple surgery payment policy applies (100%, 50%, 50%, 50%, 50%). "]
[]
[]
[]
[null,null,null,null,null,null,null,null,3,null,"Modifier -51 may be valid. Multiple endoscopic procedures payment policy applies if this service is billed with another endoscopy in the same family. "]
[]
[]
[]
[null,null,null,null,null,null,null,null,4,null,"This indicator is not currently in use."]
[null,null,null,null,null,null,null,null,5,null,"This indicator is not currently in use."]
[null,null,null,null,null,null,null,null,9,null,"Modifier -51 is not valid. Concept of multiple surgery does not apply."]
[]
[]
["BSI",null,"Bilateral Surgery Indicator\n(Modifier –50)\nThis field indicates whether the procedure is subject to a payment adjustment for bilateral surgery.\n",null,null,null,null,null,0,null,"Modifier -50 is not valid. Payment adjustment rule for bilateral surgery does not apply. "]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"Modifier -50 is valid. Payment adjustment for bilateral procedures (150%) applies to this procedure."]
[]
[]
[]
[null,null,null,null,null,null,null,null,2,null,"Modifier -50 is not valid. Payment adjustment for bilateral procedures does not apply. Procedures in this category include services for which the code descriptor specifically states that the procedure is bilateral; procedures that are usually performed as bilateral procedures; or procedures for which the code descriptor indicates the procedures may be performed either unilaterally or bilaterally. "]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,3,null,"Modifier -50 is not valid. Payment adjustment for bilateral procedure does not apply. This is a radiology procedure which is not subject to payment rules for bilateral surgeries. "]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,9,null,"Modifier -50 is not valid. Concept of bilateral surgery does not apply. "]
[]
[]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["ASI",null,"Assistant Surgeon Indicator\n(Modifiers –80, -81, -82)\nThis field indicates whether or not an assistant surgeon may be paid for the procedure.\n",null,null,null,null,null,0,null,"Modifiers -80, -81 and -82 are not valid under normal situations. Assistant at surgery is not usually paid for this procedure. Supporting documentation is necessary to establish medical necessity. "]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"Modifiers -80, -81 and -82 are not valid. Assistant at surgery may not be paid for this procedure. "]
[]
[]
[]
[null,null,null,null,null,null,null,null,2,null,"Modifiers -80, -81 and -82 are valid. Assistant at surgery may be paid."]
[]
[]
[null,null,null,null,null,null,null,null,9,null,"Modifiers -80, -81 and -82 are not valid. Concept does not apply."]
[]
[]
["CSI",null,"Co-surgeons Indicator\n(Modifier –62)\nThis field indicates whether or not co-surgeons may be paid for the procedure.\n",null,null,null,null,null,0,null,"Modifier -62 is not valid. Co-surgeons not permitted."]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"Modifier -62 is not valid under normal situations. Supporting documentation is required to establish medical necessity of two surgeons."]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,2,null,"Modifier -62 is valid. Co-surgeons may be paid for this procedure. Supporting documentation is not required if two specialty requirement is met."]
[]
[]
[]
[null,null,null,null,null,null,null,null,9,null,"Modifier -62 is not valid with this procedure. Concept of co-surgeons does not apply."]
[]
[]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["TSI",null,"Team Surgeons Indicator\n(Modifier -66)\nThis field indicates whether or not team surgeons may be paid for the procedure.\n",null,null,null,null,null,0,null,"Modifier -66 is not valid. Team surgeons not permitted."]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"Modifier -66 is not valid under normal situations. Team surgeons may be payable. Supporting documentation is required to establish medical necessity of a team."]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,2,null,"Modifier -66 is valid. Team surgeons permitted."]
[]
[null,null,null,null,null,null,null,null,9,null,"Modifier -66 is not valid. Concept of team surgery does not apply."]
[]
[]
["ENDO BASE",null,"Endoscopy Base Code",null,null,null,null,null,"Code number",null,"This column contains the endoscopic base code for procedure codes that are part of an endoscopy family. The Multiple Surgery Indicator for procedures in an endoscopy family is 3."]
[]
[]
[]
[]
["FSI",null,"Fee Schedule Indicator\nThis column indicates the payment status for the procedure code.",null,null,null,null,null,"B",null,"Bundled code, not separately payable."]
[null,null,null,null,null,null,null,null,"C",null,"Contracted service. Payable only to department’s contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured workers. "]
[]
[]
[]
[null,null,null,null,null,null,null,null,"D",null,"Drug fee based on Average Wholesale Price (AWP) or Average Average Wholesale Price (AAWP)."]
[]
[]
[]
[null,null,null,null,null,null,null,null,"F",null,"Flat fee developed by the department"]
[null,null,null,null,null,null,null,null,"L",null,"Clinical lab fee"]
[null,null,null,null,null,null,null,null,"N",null,"No fee or RVUs available, code paid by report."]
[null,null,null,null,null,null,null,null,"O",null,"For hospital outpatient use only."]
[null,null,null,null,null,null,null,null,"R",null,"RBRVS fee"]
[null,null,null,null,null,null,null,null,"S",null,"State Rate"]
[null,null,null,null,null,null,null,null,"T",null,"Tracking code"]
[null,null,null,null,null,null,null,null,"X",null,"Non-covered code"]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["LIC\nREQ",null,"Licensure Required",null,null,null,null,null,"Y",null,"Appropriate professional licensure is required to bill the department for these codes."]
[]
[null,null,null,null,null,null,null,null,"blank",null,"No special professional licensure is required to bill the department."]
[]
["PRIOR           AUTH",null,"Prior authorization indicator \nThis column indicates whether prior authorization and utilization review is required.",null,null,null,null,null,"Y",null,"Prior authorization required"]
[]
[null,null,null,null,null,null,null,null,"Y-UR",null,"Prior authorization and UR required"]
[]
[]
["LOCAL CODES FEE SCHEDULE"]
["FIELD KEY:  "]
["Column Title",null,"Column Description",null,null,null,null,"Column Values",null,"Value Definitions"]
["LOCAL\nCODE",null,"2021 Local Code.",null,null,null,null,null,null,"A code assigned by the department to represent a specific service that is unique to injured workers."]
["Description",null,"Local Code Description",null,null,null,null,null,null,"Description of the unique service."]
["Dollar Value Nonfacility Setting",null,"This column indicates the:\nMaximum dollar amount for covered services provided in a non-facility setting, or\nPricing method for the procedure code",null,null,null,null,"Dollar Value",null,"Maximum dollar amount payable for covered services."]
[null,null,null,null,null,null,null,"By Report",null,"No fee or RVUs available, code paid By Report"]
[null,null,null,null,null,null,null,"Contracted",null,"Contracted service. \nPayable only to department’s contracted vendor for State Fund claims. \nPayable to providers treating Self-Insured injured workers."]
[null,null,null,null,null,null,null,"State Rate",null,"Service paid at state rate for travel or lodging."]
["Dollar Value Facility Setting",null,"This column indicates the:\nMaximum dollar amount for covered services provided in a facility setting, or\nPricing method for the procedure code",null,null,null,null,"Dollar Value",null,"Maximum dollar amount payable for covered services."]
[null,null,null,null,null,null,null,"By Report",null,"No fee or RVUs available, code paid By Report"]
[null,null,null,null,null,null,null,"Contracted",null,"Contracted service. \n\nPayable only to department’s contracted vendor for State Fund claims. \n\nPayable to providers treating Self-Insured injured workers."]
[null,null,null,null,null,null,null,"State Rate",null,"Service paid at state rate for travel or lodging."]
[]
["Field Key: Local Codes (continued)"]
["Column Title",null,"Column Description",null,null,null,null,"Column Values",null,"Value Definitions"]
["Payment Policy Reference",null,"The reason for the code or a reference to a page in another document where the reason for the code can be found",null,null,null,null,"To reimburse claimant’s costs",null,"Reference to payment policies related to the local code."]
[null,null,null,null,null,null,null,"Professional Services",null,"The local code is used to pay professional services."]
[null,null,null,null,null,null,null,"Facility Services",null,"The local code is used to pay facility services."]
[null,null,null,null,null,null,null,"Medical Examiner’s Handbook",null,"A publication for Independent Medical Examiners"]
[null,null,null,null,null,null,null,"For approved DPE providers only",null,"Disability Prevention Evaluation providers"]
[]
["LOCAL CODES by SPECIALTY FEE SCHEDULE"]
["FIELD KEY:  "]
["Column Title",null,"Column Description",null,null,null,null,"Column Values",null,"Value Definitions"]
["Specialty Code",null,"Code assigned to the specialty",null,null,null,null,"AU",null,"Audiology"]
[null,null,null,null,null,null,null,"CM",null,"Case Management"]
[null,null,null,null,null,null,null,"CH",null,"Chiropractic Care"]
[null,null,null,null,null,null,null,"CL",null,"Claimant Only"]
[null,null,null,null,null,null,null,"DM",null,"Durable Medical Equipment & Supplies"]
[null,null,null,null,null,null,null,"EM",null,"Employer Reimbursement"]
[null,null,null,null,null,null,null,"HM",null,"Home Modification"]
[null,null,null,null,null,null,null,"HC",null,"Home & Attendant Care"]
[null,null,null,null,null,null,null,"HO",null,"Hospice Care"]
[null,null,null,null,null,null,null,"IM",null,"Independent Medical Exam"]
[null,null,null,null,null,null,null,"IR",null,"Impairment Rating"]
[null,null,null,null,null,null,null,"IN",null,"Interpretive Services"]
[null,null,null,null,null,null,null,"JM",null,"Job Modification"]
[null,null,null,null,null,null,null,"MS",null,"Miscellaneous & Special Services"]
[null,null,null,null,null,null,null,"PA",null,"Pain Treatment"]
[null,null,null,null,null,null,null,"RS",null,"Residential Services"]
[null,null,null,null,null,null,null,"RT",null,"Retraining"]
[null,null,null,null,null,null,null,"SR",null,"Special Reports"]
[null,null,null,null,null,null,null,"TL",null,"Travel, Lodging & Meals"]
[null,null,null,null,null,null,null,"UR",null,"Utilization Review Services"]
[null,null,null,null,null,null,null,"VM",null,"Vehicle Modification"]
[null,null,null,null,null,null,null,"VR",null,"Vocational & Related Services"]
[null,null,null,null,null,null,null,"WL",null,"Weight Loss Services"]
[null,null,null,null,null,null,null,"WH ",null,"Work Hardening"]
["Specialty Title",null,null,null,null,null,null,null,null,"Title of the area or specialty to which the local code pertains"]
[]
["Field Key: Local Codes by Specialty (continued)"]
["Column Title",null,"Column Description",null,null,null,null,"Column Values",null,"Value Definitions"]
["LOCAL\nCODE",null,"2022 Local Code.",null,null,null,null,null,null,"A code assigned by the department to represent a specific service that is unique to injured workers."]
["Description",null,"Local Code Description",null,null,null,null,null,null,"Description of the unique service."]
["Dollar Value Nonfacility Setting",null,"This column indicates the:\nMaximum dollar amount for covered services provided in a non-facility setting, or\nPricing method for the procedure code",null,null,null,null,"Dollar Value",null,"Maximum dollar amount payable for covered services."]
[null,null,null,null,null,null,null,"By Report",null,"No fee or RVUs available, code paid By Report"]
[null,null,null,null,null,null,null,"Contracted",null,"Contracted service. \n\nPayable only to department’s contracted vendor for State Fund claims. \n\nPayable to providers treating Self-Insured injured workers."]
[null,null,null,null,null,null,null,"State Rate",null,"Service paid at state rate for travel or lodging."]
["Dollar Value Facility Setting",null,"This column indicates the:\nMaximum dollar amount for covered services provided in a facility setting, or\nPricing method for the procedure code",null,null,null,null,"Dollar Value",null,"Maximum dollar amount payable for covered services."]
[null,null,null,null,null,null,null,"By Report",null,"No fee or RVUs available, code paid By Report"]
[null,null,null,null,null,null,null,"Contracted",null,"Contracted service. \n\nPayable only to department’s contracted vendor for State Fund claims. \n\nPayable to providers treating Self-Insured injured workers."]
[null,null,null,null,null,null,null,"State Rate",null,"Service paid at state rate for travel or lodging."]
[]
["Field Key: Local Codes by Specialty (continued)"]
["Column Title",null,"Column Description",null,null,null,null,"Column Values",null,"Value Definitions"]
["Payment Policy Reference",null,"The reason for the code or a reference to a page in another document where the reason for the code can be found",null,null,null,null,"To reimburse claimant’s costs",null,"Reference to payment policies related to the local code."]
[null,null,null,null,null,null,null,"Professional Services, Page nn",null,"The location within the Professional Services of the Medical Aid Rules and Fee Schedule where the code is discussed."]
[null,null,null,null,null,null,null,"Facility Services, Page nn",null,"The location within the Facility Services of the Medical Aid Rules and Fee Schedule where the code is discussed."]
[null,null,null,null,null,null,null,"Medical Examiner’s Handbook",null,"A publication for Independent Medical Examiners"]
[null,null,null,null,null,null,null,"For approved DPE providers only",null,"Disability Prevention Evaluation providers"]

{"sheet":"2022 Professional Fee Schedule","index":3,"n_rows":19986,"n_cols":22,"rows_kept":4500,"cut":true,"hidden":false,"merged":[[0,0,0,11],[1,0,1,11],[4,4,4,7],[4,9,4,17],[5,4,5,5],[5,6,5,7]],"bounds":{"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0}}
["Professional Services Fee Schedule"]
[]
[]
[]
[null,null,null,null,"DOLLAR VALUE",null,null,null,null,"MODIFIERS"]
["CODE","Modifiers","Short Description (HCPCS and Local Only)",null,"NON-FACILITY SETTING",null,"FACILITY SETTING",null,"FOL UP","PRE OP\n(-56)","INTRA OP\n(-54)","POST OP\n(-55)","PCTC\n(26/TC)","MSI\n(-51)","BSI\n(-50)","ASI\n(-80)","CSI\n(-62)","TSI\n(-66)","ENDO\nBASE","FSI","LIC REQ","Prior Auth"]
[10004,null,"See CPT",null,90.973799999999997,null,75.514200000000002,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[10005,null,"See CPT",null,252.11040000000003,null,130.2174,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[10006,null,"See CPT",null,107.62260000000001,null,88.595399999999998,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[10007,null,"See CPT",null,559.51859999999999,null,159.94739999999999,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[10008,null,"See CPT",null,304.43520000000001,null,100.48739999999999,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[10009,null,"See CPT",null,844.33199999999999,null,195.02879999999999,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[10010,null,"See CPT",null,494.11260000000004,null,139.73099999999999,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[10011,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,0,0,0,0,"","N",null,"Y-CM"]
[10012,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,"","N",null,"Y-CM"]
[10021,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,"","X"]
[10030,null,"See CPT",null,1240.9302,null,236.6508,null,"000",0,0,0,9,2,9,0,0,0,"","R",null,"Y-CM"]
[10035,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,"","X"]
[10036,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[10040,null,"See CPT",null,213.4614,null,91.568399999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[10060,null,"See CPT",null,227.13720000000001,null,188.48820000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[10061,null,"See CPT",null,385.8954,null,328.2192,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[10080,null,"See CPT",null,478.65300000000008,null,187.89360000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[10081,null,"See CPT",null,645.73559999999998,null,305.02980000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[10120,null,"See CPT",null,275.2998,null,186.10980000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[10121,null,"See CPT",null,483.40980000000008,null,327.03000000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[10140,null,"See CPT",null,311.57040000000001,null,211.083,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[10160,null,"See CPT",null,236.05620000000002,null,170.0556,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[10180,null,"See CPT",null,482.22059999999999,null,317.51639999999998,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11000,null,"See CPT",null,106.43340000000001,null,48.757199999999997,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11001,null,"See CPT",null,48.162600000000005,null,24.973199999999999,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[11004,null,"See CPT",null,997.14419999999996,null,997.14419999999996,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11005,null,"See CPT",null,1356.8772000000001,null,1356.8772000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[11006,null,"See CPT",null,1227.2544,null,1227.2544,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11008,null,"See CPT",null,478.05839999999995,null,478.05839999999995,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[11010,null,"See CPT",null,831.84540000000004,null,488.76120000000003,null,"010",0.1,0.8,0.1,0,2,2,1,0,0,"","R"]
[11011,null,"See CPT",null,912.1164,null,522.05880000000002,null,"000",0,0,0,0,2,2,1,0,0,"","R"]
[11012,null,"See CPT",null,1181.4702,null,731.95260000000007,null,"000",0,0,0,0,2,2,1,0,0,"","R"]
[11042,null,"See CPT",null,239.02919999999997,null,106.43340000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11043,null,"See CPT",null,422.166,null,270.54300000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11044,null,"See CPT",null,557.73480000000006,null,394.81439999999998,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11045,null,"See CPT",null,73.730400000000003,null,45.784199999999998,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[11046,null,"See CPT",null,131.4066,null,96.919799999999995,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[11047,null,"See CPT",null,214.6506,null,169.46100000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[11055,null,"See CPT",null,134.37959999999998,null,27.946199999999997,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11056,null,"See CPT",null,153.4068,null,38.649000000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11057,null,"See CPT",null,167.6772,null,50.540999999999997,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11102,null,"See CPT",null,189.08280000000002,null,66.595200000000006,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11103,null,"See CPT",null,93.94680000000001,null,38.649000000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[11104,null,"See CPT",null,234.86700000000002,null,82.6494,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11105,null,"See CPT",null,109.4064,null,45.189599999999999,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[11106,null,"See CPT",null,290.75939999999997,null,99.892799999999994,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11107,null,"See CPT",null,132.00120000000001,null,54.703200000000002,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[11200,null,"See CPT",null,164.1096,null,136.1634,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11201,null,"See CPT",null,32.703000000000003,null,28.540800000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM"]
[11300,null,"See CPT",null,189.67740000000001,null,60.054600000000001,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11301,null,"See CPT",null,226.54259999999999,null,89.784599999999998,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11302,null,"See CPT",null,255.678,null,105.83880000000001,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11303,null,"See CPT",null,281.84040000000005,null,124.2714,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11305,null,"See CPT",null,198.59639999999999,null,67.189799999999991,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11306,null,"See CPT",null,227.73180000000002,null,86.811599999999999,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11307,null,"See CPT",null,259.84019999999998,null,110.5956,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11308,null,"See CPT",null,274.70519999999999,null,124.2714,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11310,null,"See CPT",null,215.8398,null,80.271000000000001,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11311,null,"See CPT",null,253.89419999999998,null,110.001,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11312,null,"See CPT",null,287.1918,null,129.62280000000001,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11313,null,"See CPT",null,334.16520000000003,null,169.46100000000001,null,"000",0,0,0,0,2,9,0,0,0,"","R"]
[11400,null,"See CPT",null,236.05620000000002,null,149.83920000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11401,null,"See CPT",null,287.78640000000001,null,189.08280000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11402,null,"See CPT",null,316.3272,null,206.92080000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11403,null,"See CPT",null,361.51679999999999,null,265.19159999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11404,null,"See CPT",null,410.86860000000001,null,292.54320000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11406,null,"See CPT",null,579.1404,null,440.59860000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11420,null,"See CPT",null,235.4616,null,147.46080000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11421,null,"See CPT",null,293.73240000000004,null,195.02879999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11422,null,"See CPT",null,328.81380000000001,null,242.00220000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11423,null,"See CPT",null,374.0034,null,277.08359999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11424,null,"See CPT",null,427.51740000000001,null,315.73259999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11426,null,"See CPT",null,603.51900000000001,null,482.81519999999995,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11440,null,"See CPT",null,264.59700000000004,null,189.67740000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11441,null,"See CPT",null,319.89479999999998,null,237.84,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11442,null,"See CPT",null,353.78700000000003,null,261.62400000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11443,null,"See CPT",null,416.22,null,318.7056,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11444,null,"See CPT",null,516.11279999999999,null,401.94959999999998,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11446,null,"See CPT",null,699.24959999999999,null,567.84300000000007,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11450,null,"See CPT",null,805.68300000000011,null,469.73400000000004,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R"]
[11451,null,"See CPT",null,974.54939999999999,null,590.43780000000004,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R"]
[11462,null,"See CPT",null,783.08820000000003,null,447.13919999999996,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R"]
[11463,null,"See CPT",null,991.79279999999994,null,596.38379999999995,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R"]
[11470,null,"See CPT",null,843.14279999999997,null,511.95059999999995,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[11471,null,"See CPT",null,1006.6578,null,628.49220000000003,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[11600,null,"See CPT",null,364.4898,null,217.62360000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11601,null,"See CPT",null,419.19299999999998,null,263.40780000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11602,null,"See CPT",null,446.5446,null,286.59720000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11603,null,"See CPT",null,507.19379999999995,null,341.30040000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11604,null,"See CPT",null,564.87,null,375.78720000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11606,null,"See CPT",null,809.25059999999996,null,560.11320000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11620,null,"See CPT",null,365.67900000000003,null,218.81280000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11621,null,"See CPT",null,420.38220000000001,null,264.59700000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11622,null,"See CPT",null,461.40960000000001,null,299.67840000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11623,null,"See CPT",null,538.70760000000007,null,369.84120000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11624,null,"See CPT",null,612.4380000000001,null,420.38220000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11626,null,"See CPT",null,737.30400000000009,null,516.70740000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11640,null,"See CPT",null,374.0034,null,225.35339999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11641,null,"See CPT",null,433.46340000000004,null,275.2998,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11642,null,"See CPT",null,488.76120000000003,null,322.27319999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11643,null,"See CPT",null,572.59980000000007,null,401.94959999999998,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11644,null,"See CPT",null,704.601,null,498.86940000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11646,null,"See CPT",null,912.71100000000001,null,689.73599999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11719,null,"See CPT",null,24.973199999999999,null,13.081200000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11720,null,"See CPT",null,58.865400000000001,null,25.567799999999998,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[11721,null,"See CPT",null,79.676400000000001,null,42.2166,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[11730,null,"See CPT",null,211.67760000000001,null,94.54140000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11732,null,"See CPT",null,61.2438,null,30.3246,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[11740,null,"See CPT",null,105.24420000000001,null,56.486999999999995,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11750,null,"See CPT",null,293.13779999999997,null,180.75839999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11755,null,"See CPT",null,225.94799999999998,null,106.43340000000001,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[11760,null,"See CPT",null,346.65180000000004,null,198.0018,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11762,null,"See CPT",null,531.57240000000002,null,335.94900000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11765,null,"See CPT",null,306.21900000000005,null,164.1096,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[11770,null,"See CPT",null,671.30340000000001,null,331.78680000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11771,null,"See CPT",null,1160.0646000000002,null,806.27760000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11772,null,"See CPT",null,1428.2292,null,1047.0906,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,"Y-CM"]
[11900,null,"See CPT",null,103.46040000000001,null,51.730200000000004,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11901,null,"See CPT",null,127.839,null,80.865600000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[11920,null,"See CPT",null,356.76,null,194.4342,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[11921,null,"See CPT",null,404.92259999999999,null,229.51560000000001,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[11922,null,"See CPT",null,109.4064,null,51.730200000000004,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[11950,null,"See CPT",null,144.48780000000002,null,91.568399999999997,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[11951,null,"See CPT",null,193.83959999999999,null,129.0282,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[11952,null,"See CPT",null,258.0564,null,181.35299999999998,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[11954,null,"See CPT",null,284.21880000000004,null,198.0018,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[11960,null,"See CPT",null,1827.8003999999999,null,1827.8003999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[11970,null,"See CPT",null,1004.2794,null,1004.2794,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R"]
[11971,null,"See CPT",null,984.0630000000001,null,984.0630000000001,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R"]
[11976,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,"","X"]
[11980,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,1,0,0,"","X"]
[11981,null,"See CPT",null,183.13679999999999,null,111.1902,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[11982,null,"See CPT",null,204.54239999999999,null,130.2174,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[11983,null,"See CPT",null,256.27259999999995,null,181.94759999999999,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[12001,null,"See CPT",null,171.2448,null,79.081800000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[12002,null,"See CPT",null,205.73160000000001,null,103.46040000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[12004,null,"See CPT",null,238.43459999999999,null,127.24440000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[12005,null,"See CPT",null,321.084,null,165.89340000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[12006,null,"See CPT",null,374.59800000000001,null,203.9478,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[12007,null,"See CPT",null,420.38220000000001,null,254.48880000000003,null,"000",0,0,0,0,2,0,1,1,0,"","R"]
[12011,null,"See CPT",null,204.54239999999999,null,96.325200000000009,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[12013,null,"See CPT",null,212.86680000000001,null,101.67659999999999,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[12014,null,"See CPT",null,260.4348,null,130.2174,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[12015,null,"See CPT",null,311.57040000000001,null,164.70420000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[12016,null,"See CPT",null,397.78740000000005,null,224.75879999999998,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[12017,null,"See CPT",null,265.78620000000001,null,265.78620000000001,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[12018,null,"See CPT",null,301.4622,null,301.4622,null,"000",0,0,0,0,2,0,2,0,0,"","R"]
[12020,null,"See CPT",null,551.78879999999992,null,334.16520000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12021,null,"See CPT",null,322.27319999999997,null,251.51580000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12031,null,"See CPT",null,487.57199999999995,null,268.75919999999996,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12032,null,"See CPT",null,557.14019999999994,null,336.54360000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12034,null,"See CPT",null,614.81640000000004,null,363.30060000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12035,null,"See CPT",null,714.1146,null,427.51740000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12036,null,"See CPT",null,793.19640000000004,null,501.8424,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12037,null,"See CPT",null,883.57560000000001,null,580.32960000000003,null,"010",0.1,0.8,0.1,0,2,0,0,1,0,"","R"]
[12041,null,"See CPT",null,489.35580000000004,null,255.08340000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12042,null,"See CPT",null,570.81600000000003,null,346.65180000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12044,null,"See CPT",null,701.62800000000004,null,377.57099999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12045,null,"See CPT",null,748.0068,null,482.22059999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12046,null,"See CPT",null,923.41379999999992,null,567.84300000000007,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[12047,null,"See CPT",null,1007.847,null,629.68140000000005,null,"010",0.1,0.8,0.1,0,2,0,2,1,0,"","R"]
[12051,null,"See CPT",null,523.84260000000006,null,300.27299999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12052,null,"See CPT",null,580.32960000000003,null,352.59780000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12053,null,"See CPT",null,671.30340000000001,null,379.35480000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12054,null,"See CPT",null,709.3578,null,385.30080000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12055,null,"See CPT",null,926.98140000000001,null,528.00480000000005,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[12056,null,"See CPT",null,1064.3339999999998,null,683.79,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[12057,null,"See CPT",null,1121.4156,null,744.43920000000003,null,"010",0.1,0.8,0.1,0,2,0,2,1,0,"","R"]
[13100,null,"See CPT",null,628.49220000000003,null,354.38159999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[13101,null,"See CPT",null,733.14179999999999,null,440.59860000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[13102,null,"See CPT",null,213.4614,null,127.24440000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[13120,null,"See CPT",null,654.65459999999996,null,414.43619999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[13121,null,"See CPT",null,782.49360000000001,null,454.27440000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[13122,null,"See CPT",null,230.70480000000001,null,144.48780000000002,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[13131,null,"See CPT",null,712.33080000000007,null,427.51740000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[13132,null,"See CPT",null,863.9538,null,534.54539999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[13133,null,"See CPT",null,303.84060000000005,null,220.00200000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[13151,null,"See CPT",null,774.76379999999995,null,491.73419999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[13152,null,"See CPT",null,908.54880000000003,null,592.22160000000008,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[13153,null,"See CPT",null,333.57060000000001,null,240.2184,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[13160,null,"See CPT",null,1418.7156,null,1418.7156,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[14000,null,"See CPT",null,1150.5510000000002,null,895.46760000000006,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[14001,null,"See CPT",null,1461.5267999999999,null,1160.0646000000002,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[14020,null,"See CPT",null,1268.8764000000001,null,1005.4686,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[14021,null,"See CPT",null,1559.6358,null,1256.9844000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[14040,null,"See CPT",null,1365.7962,null,1104.7667999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[14041,null,"See CPT",null,1654.7718,null,1348.5527999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[14060,null,"See CPT",null,1378.8774000000001,null,1178.4972,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[14061,null,"See CPT",null,1783.8,null,1448.4456,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[14301,null,"See CPT",null,1956.2339999999999,null,1539.4194,null,"090",0.1,0.71,0.19,0,2,0,2,0,0,"","R"]
[14302,null,"See CPT",null,379.35480000000001,null,379.35480000000001,null,"000",0,0,0,0,0,0,2,0,0,"","R"]
[14350,null,"See CPT",null,1211.2002,null,1211.2002,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15002,null,"See CPT",null,635.03279999999995,null,386.49,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[15003,null,"See CPT",null,126.6498,null,79.676400000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[15004,null,"See CPT",null,720.65519999999992,null,460.22040000000004,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[15005,null,"See CPT",null,211.083,null,159.3528,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[15040,null,"See CPT",null,487.57199999999995,null,217.62360000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15050,null,"See CPT",null,1086.9288000000001,null,829.46699999999998,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15100,null,"See CPT",null,1575.0953999999999,null,1276.0116,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15101,null,"See CPT",null,345.46260000000001,null,198.59639999999999,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15110,null,"See CPT",null,1495.4189999999999,null,1259.3628000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15111,null,"See CPT",null,199.78559999999999,null,178.38,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15115,null,"See CPT",null,1445.4726000000001,null,1221.903,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15116,null,"See CPT",null,290.75939999999997,null,262.21860000000004,null,"000",0,0,0,0,0,0,1,1,0,"","R"]
[15120,null,"See CPT",null,1526.3382000000001,null,1225.4705999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15121,null,"See CPT",null,387.67919999999998,null,239.62380000000002,null,"000",0,0,0,0,0,0,1,1,0,"","R"]
[15130,null,"See CPT",null,1314.6605999999999,null,1067.307,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15131,null,"See CPT",null,172.434,null,158.1636,null,"000",0,0,0,0,0,0,1,1,0,"","R"]
[15135,null,"See CPT",null,1584.0144,null,1347.9582,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15136,null,"See CPT",null,170.65020000000001,null,158.1636,null,"000",0,0,0,0,0,0,1,1,0,"","R"]
[15150,null,"See CPT",null,1277.2008000000001,null,1142.2266,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15151,null,"See CPT",null,209.8938,null,192.65040000000002,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15152,null,"See CPT",null,259.84019999999998,null,244.38060000000002,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15155,null,"See CPT",null,1432.9860000000001,null,1298.6064000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15156,null,"See CPT",null,281.84040000000005,null,264.59700000000004,null,"000",0,0,0,0,0,0,1,1,0,"","R"]
[15157,null,"See CPT",null,313.35419999999999,null,287.78640000000001,null,"000",0,0,0,0,0,0,1,1,0,"","R"]
[15200,null,"See CPT",null,1516.23,null,1195.7406000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15201,null,"See CPT",null,257.46179999999998,null,133.785,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15220,null,"See CPT",null,1390.1748,null,1083.3612000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15221,null,"See CPT",null,240.2184,null,121.2984,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15240,null,"See CPT",null,1674.3936000000001,null,1413.3642,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15241,null,"See CPT",null,316.3272,null,184.92060000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15260,null,"See CPT",null,1793.9082000000001,null,1498.9866000000002,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15261,null,"See CPT",null,375.19259999999997,null,240.2184,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15271,null,"See CPT",null,283.02960000000002,null,147.46080000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[15272,null,"See CPT",null,45.189599999999999,null,30.9192,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15273,null,"See CPT",null,576.76199999999994,null,347.24639999999999,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[15274,null,"See CPT",null,153.4068,null,79.676400000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15275,null,"See CPT",null,290.75939999999997,null,164.1096,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[15276,null,"See CPT",null,58.270800000000001,null,44.594999999999999,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15277,null,"See CPT",null,632.05980000000011,null,395.40900000000005,null,"000",0,0,0,0,2,0,1,1,0,"","R"]
[15278,null,"See CPT",null,176.59620000000001,null,99.298199999999994,null,"000",0,0,0,0,0,0,1,1,0,"","R"]
[15570,null,"See CPT",null,1647.6366,null,1304.5524,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15572,null,"See CPT",null,1578.663,null,1303.9577999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15574,null,"See CPT",null,1588.7711999999999,null,1315.2552000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15576,null,"See CPT",null,1417.5264,null,1158.8753999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15600,null,"See CPT",null,623.14080000000001,null,380.54400000000004,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15610,null,"See CPT",null,673.68180000000007,null,436.43639999999999,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15620,null,"See CPT",null,816.98040000000003,null,585.08640000000003,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15630,null,"See CPT",null,841.35900000000004,null,613.62720000000002,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15650,null,"See CPT",null,930.54899999999998,null,681.41160000000002,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15730,null,"See CPT",null,2619.8076000000001,null,1626.231,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R"]
[15731,null,"See CPT",null,2019.8561999999999,null,1776.6648,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15733,null,"See CPT",null,1833.7464,null,1833.7464,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R"]
[15734,null,"See CPT",null,2667.3755999999998,null,2667.3755999999998,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R"]
[15736,null,"See CPT",null,2167.9115999999999,null,2167.9115999999999,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R"]
[15738,null,"See CPT",null,2267.2098000000001,null,2267.2098000000001,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R"]
[15740,null,"See CPT",null,1814.1246000000001,null,1490.6622,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15750,null,"See CPT",null,1660.1232000000002,null,1660.1232000000002,null,"090",0.1,0.71,0.19,0,2,0,2,0,0,"","R"]
[15756,null,"See CPT",null,4061.7126000000003,null,4061.7126000000003,null,"090",0.1,0.71,0.19,0,2,0,2,2,0,"","R"]
[15757,null,"See CPT",null,4039.1178000000004,null,4039.1178000000004,null,"090",0.1,0.71,0.19,0,2,0,2,2,0,"","R"]
[15758,null,"See CPT",null,4036.1447999999996,null,4036.1447999999996,null,"090",0.1,0.71,0.19,0,2,0,2,2,0,"","R"]
[15760,null,"See CPT",null,1522.7706000000001,null,1244.4978000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15769,null,"See CPT",null,853.84559999999999,null,853.84559999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM"]
[15770,null,"See CPT",null,1200.4974000000002,null,1200.4974000000002,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R"]
[15771,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","X"]
[15772,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,1,0,0,"","X"]
[15773,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","X"]
[15774,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,1,0,0,"","X"]
[15775,null,"See CPT",null,686.76300000000003,null,451.3014,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[15776,null,"See CPT",null,926.38679999999999,null,616.60019999999997,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[15777,null,"See CPT",null,378.7602,null,378.7602,null,"000",0,0,0,0,0,1,1,0,0,"","R"]
[15780,null,"See CPT",null,1531.6896000000002,null,1174.9296000000002,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15781,null,"See CPT",null,985.25220000000002,null,768.81780000000003,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15782,null,"See CPT",null,881.79179999999997,null,656.4384,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15783,null,"See CPT",null,812.81820000000005,null,628.49220000000003,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15786,null,"See CPT",null,424.5444,null,236.6508,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[15787,null,"See CPT",null,56.486999999999995,null,30.3246,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[15788,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","X"]
[15789,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","X"]
[15792,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","X"]
[15793,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","X"]
[15819,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","X"]
[15820,null,"See CPT",null,1044.1176,null,922.22460000000001,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM"]
[15821,null,"See CPT",null,1120.8210000000001,null,987.03600000000006,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM"]
[15822,null,"See CPT",null,838.98059999999998,null,718.87139999999999,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM"]
[15823,null,"See CPT",null,1121.4156,null,986.44140000000004,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM"]
[15824,null,"See CPT",null,1576.4879493792002,null,1576.4879493792002,null,"000",0,0,0,0,2,1,0,0,0,"","F",null,"Y-CM"]
[15825,null,"See CPT",null,1355.5079139888001,null,1355.5079139888001,null,"000",0,0,0,0,2,1,0,0,0,"","F",null,"Y-CM"]
[15826,null,"See CPT",null,1281.8334795552003,null,1281.8334795552003,null,"000",0,0,0,0,2,1,0,0,0,"","F",null,"Y-CM"]
[15828,null,"See CPT",null,4390.6220248176014,null,4390.6220248176014,null,"000",0,0,0,0,2,1,0,0,0,"","F",null,"Y-CM"]
[15829,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,1,0,0,0,"","N",null,"Y-CM"]
[15830,null,"See CPT",null,2085.2622000000001,null,2085.2622000000001,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,"Y-CM"]
[15832,null,"See CPT",null,1635.7446000000002,null,1635.7446000000002,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM"]
[15833,null,"See CPT",null,1565.5817999999999,null,1565.5817999999999,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM"]
[15834,null,"See CPT",null,1594.1225999999999,null,1594.1225999999999,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM"]
[15835,null,"See CPT",null,1658.934,null,1658.934,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,"Y-CM"]
[15836,null,"See CPT",null,1424.067,null,1424.067,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM"]
[15837,null,"See CPT",null,1564.9872,null,1278.9846,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,"Y-CM"]
[15838,null,"See CPT",null,1161.8483999999999,null,1161.8483999999999,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,"Y-CM"]
[15839,null,"See CPT",null,1609.5822000000001,null,1318.8227999999999,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,"Y-CM"]
[15840,null,"See CPT",null,1813.53,null,1813.53,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15841,null,"See CPT",null,3167.4342000000001,null,3167.4342000000001,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R"]
[15842,null,"See CPT",null,4792.4759999999997,null,4792.4759999999997,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R"]
[15845,null,"See CPT",null,1894.3956000000001,null,1894.3956000000001,null,"090",0.1,0.71,0.19,0,2,0,2,0,0,"","R"]
[15847,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,2,1,0,"","N",null,"Y-CM"]
[15850,null,"See CPT",null,0,null,0,null,"000",0,0,0,9,9,9,9,9,9,"","Bundledundled"]
[15851,null,"See CPT",null,197.40719999999999,null,79.081800000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[15852,null,"See CPT",null,82.0548,null,82.0548,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[15860,null,"See CPT",null,187.29900000000001,null,187.29900000000001,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[15876,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,"","X"]
[15877,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,"","X"]
[15878,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,"","X"]
[15879,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,"","X"]
[15920,null,"See CPT",null,1149.9564,null,1149.9564,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15922,null,"See CPT",null,1429.4184,null,1429.4184,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R"]
[15931,null,"See CPT",null,1251.0383999999999,null,1251.0383999999999,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15933,null,"See CPT",null,1562.6088000000002,null,1562.6088000000002,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15934,null,"See CPT",null,1694.6100000000001,null,1694.6100000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15935,null,"See CPT",null,2067.4242000000004,null,2067.4242000000004,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R"]
[15936,null,"See CPT",null,1615.5282000000002,null,1615.5282000000002,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R"]
[15937,null,"See CPT",null,1869.4224000000002,null,1869.4224000000002,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R"]
[15940,null,"See CPT",null,1254.0114000000001,null,1254.0114000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15941,null,"See CPT",null,1670.826,null,1670.826,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15944,null,"See CPT",null,1673.2044000000001,null,1673.2044000000001,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15945,null,"See CPT",null,1824.8274000000001,null,1824.8274000000001,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R"]
[15946,null,"See CPT",null,2887.3776000000003,null,2887.3776000000003,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R"]
[15950,null,"See CPT",null,1143.4158,null,1143.4158,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R"]
[15951,null,"See CPT",null,1614.9336000000001,null,1614.9336000000001,null,"090",0.1,0.71,0.19,0,2,0,0,1,0,"","R"]
[15952,null,"See CPT",null,1639.3122000000001,null,1639.3122000000001,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R"]
[15953,null,"See CPT",null,1807.5839999999998,null,1807.5839999999998,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R"]
[15956,null,"See CPT",null,2094.7757999999999,null,2094.7757999999999,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R"]
[15958,null,"See CPT",null,2132.2356,null,2132.2356,null,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R"]
[15999,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,0,0,1,1,"","N"]
[16000,null,"See CPT",null,137.3526,null,79.081800000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[16020,null,"See CPT",null,154.596,null,96.919799999999995,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[16025,null,"See CPT",null,286.00259999999997,null,196.8126,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[16030,null,"See CPT",null,357.94919999999996,null,231.89400000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[16035,null,"See CPT",null,337.13819999999998,null,337.13819999999998,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[16036,null,"See CPT",null,137.3526,null,137.3526,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[17000,null,"See CPT",null,122.4876,null,98.703599999999994,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17003,null,"See CPT",null,12.486599999999999,null,3.5676000000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM"]
[17004,null,"See CPT",null,309.19200000000001,null,173.02860000000001,null,"010",0.1,0.8,0.1,0,0,0,1,0,0,"","R",null,"Y-CM"]
[17106,null,"See CPT",null,618.38400000000001,null,488.76120000000003,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17107,null,"See CPT",null,805.68300000000011,null,637.41120000000001,null,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17108,null,"See CPT",null,1133.3075999999999,null,928.76519999999994,null,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,"Y-CM"]
[17110,null,"See CPT",null,208.7046,null,119.51459999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17111,null,"See CPT",null,243.78599999999997,null,145.67700000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17250,null,"See CPT",null,165.89340000000001,null,66.595200000000006,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[17260,null,"See CPT",null,181.94759999999999,null,125.4606,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17261,null,"See CPT",null,270.54300000000001,null,152.81219999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17262,null,"See CPT",null,326.43540000000002,null,194.4342,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17263,null,"See CPT",null,352.59780000000001,null,215.24520000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17264,null,"See CPT",null,376.97640000000001,null,230.11020000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17266,null,"See CPT",null,428.11200000000002,null,269.94839999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17270,null,"See CPT",null,271.13759999999996,null,166.488,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17271,null,"See CPT",null,302.65140000000002,null,184.32600000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17272,null,"See CPT",null,344.27339999999998,null,213.4614,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17273,null,"See CPT",null,380.54400000000004,null,241.40759999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17274,null,"See CPT",null,443.57159999999999,null,294.92160000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17276,null,"See CPT",null,514.92359999999996,null,354.97620000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17280,null,"See CPT",null,255.678,null,152.2176,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17281,null,"See CPT",null,327.62459999999999,null,208.11,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17282,null,"See CPT",null,374.0034,null,240.2184,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17283,null,"See CPT",null,440.00400000000002,null,299.0838,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17284,null,"See CPT",null,500.05860000000001,null,350.21940000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17286,null,"See CPT",null,638.60040000000004,null,472.70699999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17311,null,"See CPT",null,1223.6867999999999,null,624.33000000000004,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17312,null,"See CPT",null,748.0068,null,331.78680000000003,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM"]
[17313,null,"See CPT",null,1151.1456000000001,null,560.70780000000002,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[17314,null,"See CPT",null,716.49300000000005,null,307.40820000000002,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM"]
[17315,null,"See CPT",null,139.13639999999998,null,88.000799999999998,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM"]
[17340,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","X"]
[17360,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","X"]
[17380,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,"","X"]
[17999,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,0,0,1,1,"","N"]
[19000,null,"See CPT",null,189.67740000000001,null,74.919600000000003,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[19001,null,"See CPT",null,47.568000000000005,null,36.865200000000002,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM"]
[19020,null,"See CPT",null,868.11599999999999,null,562.49160000000006,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R"]
[19030,null,"See CPT",null,304.43520000000001,null,132.5958,null,"000",0,0,0,0,2,1,1,0,0,"","R",null,"Y-CM"]
[19081,null,"See CPT",null,950.7654,null,288.38099999999997,null,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM"]
[19082,null,"See CPT",null,749.19600000000003,null,145.08240000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[19083,null,"See CPT",null,963.84660000000008,null,272.32679999999999,null,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM"]
[19084,null,"See CPT",null,741.46620000000007,null,134.9742,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[19085,null,"See CPT",null,1487.0946000000001,null,316.3272,null,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM"]
[19086,null,"See CPT",null,1164.2267999999999,null,157.56899999999999,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[19100,null,"See CPT",null,284.8134,null,121.89299999999999,null,"000",0,0,0,0,2,1,1,0,0,"","R",null,"Y-CM"]
[19101,null,"See CPT",null,609.46500000000003,null,400.7604,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,"Y-CM"]
[19105,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,1,0,0,"","X"]
[19110,null,"See CPT",null,898.44060000000002,null,632.65440000000001,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM"]
[19112,null,"See CPT",null,855.03480000000002,null,582.11339999999996,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM"]
[19120,null,"See CPT",null,941.2518,null,745.62839999999994,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM"]
[19125,null,"See CPT",null,1036.3878,null,825.89940000000001,null,"090",0.1,0.71,0.19,0,2,1,1,1,0,"","R",null,"Y-CM"]
[19126,null,"See CPT",null,281.84040000000005,null,281.84040000000005,null,"000",0,0,0,0,0,0,1,1,0,"","R",null,"Y-CM"]
[19281,null,"See CPT",null,442.97700000000003,null,174.21780000000001,null,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM"]
[19282,null,"See CPT",null,317.51639999999998,null,86.811599999999999,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[19283,null,"See CPT",null,483.40980000000008,null,175.40700000000001,null,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM"]
[19284,null,"See CPT",null,363.89519999999999,null,88.000799999999998,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[19285,null,"See CPT",null,714.1146,null,148.65,null,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM"]
[19286,null,"See CPT",null,592.22160000000008,null,74.919600000000003,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[19287,null,"See CPT",null,1238.5518,null,221.19120000000001,null,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM"]
[19288,null,"See CPT",null,965.6303999999999,null,111.1902,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[19294,null,"See CPT",null,288.97560000000004,null,288.97560000000004,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[19296,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,"","X"]
[19297,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[19298,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,"","X"]
[19300,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","X"]
[19301,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","X"]
[19302,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","X"]
[19303,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","X"]
[19305,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","X"]
[19306,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","X"]
[19307,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","X"]
[19316,null,"See CPT",null,1412.175,null,1412.175,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM"]
[19318,null,"See CPT",null,1946.7204000000002,null,1946.7204000000002,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM"]
[19325,null,"See CPT",null,1100.01,null,1100.01,null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM"]
[19328,null,"See CPT",null,991.19820000000016,null,991.19820000000016,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM"]
[19330,null,"See CPT",null,1154.7132000000001,null,1154.7132000000001,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM"]
[19340,null,"See CPT",null,1353.9041999999999,null,1353.9041999999999,null,"090",0.1,0.71,0.19,0,2,1,1,1,0,"","R",null,"Y-CM"]
[19342,null,"See CPT",null,1359.8502000000001,null,1359.8502000000001,null,"090",0.1,0.71,0.19,0,2,1,0,1,0,"","R",null,"Y-CM"]
[19350,null,"See CPT",null,1501.365,null,1202.8758,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM"]
[19355,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","X"]
[19357,null,"See CPT",null,2078.1270000000004,null,2078.1270000000004,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM"]
[19361,null,"See CPT",null,2771.4306000000001,null,2771.4306000000001,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM"]
[19364,null,"See CPT",null,4832.3141999999998,null,4832.3141999999998,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM"]
[19367,null,"See CPT",null,3148.4070000000002,null,3148.4070000000002,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM"]
[19368,null,"See CPT",null,3857.1702000000005,null,3857.1702000000005,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM"]
[19369,null,"See CPT",null,3584.8434000000002,null,3584.8434000000002,null,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM"]
[19370,null,"See CPT",null,1199.3082000000002,null,1199.3082000000002,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM"]
[19371,null,"See CPT",null,1271.2547999999999,null,1271.2547999999999,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM"]
[19380,null,"See CPT",null,1441.3103999999998,null,1441.3103999999998,null,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM"]
[19396,null,"See CPT",null,509.57220000000001,null,252.70500000000001,null,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM"]
[19499,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,1,0,1,1,"","N"]
[20100,null,"See CPT",null,1066.7124000000001,null,1066.7124000000001,null,"010",0.1,0.8,0.1,0,2,1,2,0,0,"","R"]
[20101,null,"See CPT",null,1115.4696000000001,null,375.19259999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[20102,null,"See CPT",null,1160.0646000000002,null,454.27440000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[20103,null,"See CPT",null,1037.577,null,613.0326,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[20150,null,"See CPT",null,1787.3676,null,1787.3676,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[20200,null,"See CPT",null,408.49020000000002,null,166.488,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[20205,null,"See CPT",null,563.68080000000009,null,271.13759999999996,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[20206,null,"See CPT",null,429.89580000000001,null,101.08199999999999,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[20220,null,"See CPT",null,444.76080000000002,null,152.81219999999999,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[20225,null,"See CPT",null,735.52019999999993,null,228.32640000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[20240,null,"See CPT",null,249.13740000000001,null,249.13740000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[20245,null,"See CPT",null,611.24879999999996,null,611.24879999999996,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[20250,null,"See CPT",null,688.54679999999996,null,688.54679999999996,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[20251,null,"See CPT",null,751.57440000000008,null,751.57440000000008,null,"010",0.1,0.8,0.1,0,2,0,2,0,0,"","R"]
[20500,null,"See CPT",null,220.5966,null,155.7852,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[20501,null,"See CPT",null,274.70519999999999,null,65.406000000000006,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[20520,null,"See CPT",null,399.57119999999998,null,264.59700000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[20525,null,"See CPT",null,862.17,null,440.59860000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[20526,null,"See CPT",null,148.05540000000002,null,101.08199999999999,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[20527,null,"See CPT",null,156.9744,null,115.947,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[20550,null,"See CPT",null,103.46040000000001,null,68.97359999999999,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[20551,null,"See CPT",null,104.64960000000001,null,68.97359999999999,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[20552,null,"See CPT",null,96.919799999999995,null,66.595200000000006,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[20553,null,"See CPT",null,111.78479999999999,null,75.514200000000002,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[20555,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,0,0,0,"","X"]
[20560,null,"See CPT",null,48.162600000000005,null,26.757000000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM"]
[20561,null,"See CPT",null,68.378999999999991,null,39.243600000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM"]
[20600,null,"See CPT",null,95.73060000000001,null,63.027600000000007,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[20604,null,"See CPT",null,148.65,null,80.865600000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[20605,null,"See CPT",null,98.703599999999994,null,65.406000000000006,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[20606,null,"See CPT",null,161.7312,null,90.973799999999997,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[20610,null,"See CPT",null,117.1362,null,79.676400000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[20611,null,"See CPT",null,180.75839999999999,null,104.64960000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[20612,null,"See CPT",null,115.947,null,72.541200000000003,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[20615,null,"See CPT",null,461.40960000000001,null,286.00259999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[20650,null,"See CPT",null,406.11180000000002,null,288.38099999999997,null,"010",0.1,0.8,0.1,0,2,0,1,1,0,"","R"]
[20660,null,"See CPT",null,419.7876,null,419.7876,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[20661,null,"See CPT",null,916.8732,null,916.8732,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[20662,null,"See CPT",null,937.08960000000002,null,937.08960000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[20663,null,"See CPT",null,863.9538,null,863.9538,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[20664,null,"See CPT",null,1573.3116,null,1573.3116,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[20665,null,"See CPT",null,209.8938,null,171.83940000000001,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[20670,null,"See CPT",null,671.30340000000001,null,258.65100000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[20680,null,"See CPT",null,1100.01,null,748.0068,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[20690,null,"See CPT",null,1063.7394000000002,null,1063.7394000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[20692,null,"See CPT",null,1998.4505999999999,null,1998.4505999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20693,null,"See CPT",null,794.98019999999997,null,794.98019999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[20694,null,"See CPT",null,781.899,null,610.65419999999995,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[20696,null,"See CPT",null,2107.2624000000001,null,2107.2624000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20697,null,"See CPT",null,3553.9242000000004,null,3553.9242000000004,null,"000",0,0,0,3,0,0,2,1,0,"","R"]
[20700,null,"See CPT",null,149.83920000000001,null,149.83920000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[20701,null,"See CPT",null,113.5686,null,113.5686,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[20702,null,"See CPT",null,252.11040000000003,null,252.11040000000003,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[20703,null,"See CPT",null,183.73140000000001,null,183.73140000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[20704,null,"See CPT",null,266.38080000000002,null,266.38080000000002,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[20705,null,"See CPT",null,218.2182,null,218.2182,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[20802,null,"See CPT",null,4858.4766,null,4858.4766,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[20805,null,"See CPT",null,5768.8091999999997,null,5768.8091999999997,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[20808,null,"See CPT",null,6957.4146000000001,null,6957.4146000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[20816,null,"See CPT",null,3637.7628,null,3637.7628,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20822,null,"See CPT",null,3146.6232,null,3146.6232,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20824,null,"See CPT",null,3644.3033999999998,null,3644.3033999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[20827,null,"See CPT",null,3229.2726000000002,null,3229.2726000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[20838,null,"See CPT",null,4938.7476000000006,null,4938.7476000000006,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[20900,null,"See CPT",null,726.00660000000005,null,321.084,null,"000",0,0,0,0,2,0,2,1,0,"","R"]
[20902,null,"See CPT",null,488.76120000000003,null,488.76120000000003,null,"000",0,0,0,0,2,0,2,1,0,"","R"]
[20910,null,"See CPT",null,855.03480000000002,null,855.03480000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[20912,null,"See CPT",null,864.54840000000002,null,864.54840000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[20920,null,"See CPT",null,714.70920000000001,null,714.70920000000001,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R"]
[20922,null,"See CPT",null,1087.5234,null,869.89980000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20924,null,"See CPT",null,906.76499999999999,null,906.76499999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20930,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
[20931,null,"See CPT",null,192.0558,null,192.0558,null,"000",0,0,0,0,0,0,1,1,0,"","R"]
[20932,null,"See CPT",null,1328.3363999999999,null,1328.3363999999999,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR"]
[20933,null,"See CPT",null,1219.5246000000002,null,1219.5246000000002,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR"]
[20934,null,"See CPT",null,1327.1472000000001,null,1327.1472000000001,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR"]
[20936,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
[20937,null,"See CPT",null,291.35400000000004,null,291.35400000000004,null,"000",0,0,0,0,0,0,2,1,0,"","R"]
[20938,null,"See CPT",null,320.48939999999999,null,320.48939999999999,null,"000",0,0,0,0,0,0,2,1,0,"","R"]
[20939,null,"See CPT",null,121.2984,null,121.2984,null,"000",0,0,0,0,0,1,0,0,0,"","R",null,"Y-UR"]
[20950,null,"See CPT",null,498.27480000000003,null,155.7852,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[20955,null,"See CPT",null,4376.2559999999994,null,4376.2559999999994,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20956,null,"See CPT",null,4674.7452000000003,null,4674.7452000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20957,null,"See CPT",null,4868.5847999999996,null,4868.5847999999996,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20962,null,"See CPT",null,4727.07,null,4727.07,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20969,null,"See CPT",null,4813.2870000000003,null,4813.2870000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20970,null,"See CPT",null,5038.6403999999993,null,5038.6403999999993,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[20972,null,"See CPT",null,5023.1808000000001,null,5023.1808000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[20973,null,"See CPT",null,5306.8050000000003,null,5306.8050000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[20974,null,"See CPT",null,147.46080000000001,null,88.000799999999998,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM"]
[20975,null,"See CPT",null,305.02980000000002,null,305.02980000000002,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM"]
[20979,null,"See CPT",null,99.892799999999994,null,55.297800000000002,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM"]
[20982,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,1,0,0,"","X"]
[20983,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,1,0,0,"","X"]
[20985,null,"See CPT",null,255.08340000000001,null,255.08340000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[20999,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,0,0,1,1,"","N"]
[21010,null,"See CPT",null,1329.5255999999999,null,1329.5255999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM"]
[21011,null,"See CPT",null,687.35760000000005,null,466.16640000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21012,null,"See CPT",null,608.2758,null,608.2758,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21013,null,"See CPT",null,979.30619999999999,null,719.46600000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21014,null,"See CPT",null,934.11660000000006,null,934.11660000000006,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21015,null,"See CPT",null,1250.4438,null,1250.4438,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM"]
[21016,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","X"]
[21025,null,"See CPT",null,1425.8507999999999,null,1179.0917999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21026,null,"See CPT",null,972.17100000000005,null,767.62860000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21029,null,"See CPT",null,1387.7963999999999,null,1106.5506,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,"Y-CM"]
[21030,null,"See CPT",null,843.14279999999997,null,650.49239999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM"]
[21031,null,"See CPT",null,706.38480000000004,null,489.9504,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM"]
[21032,null,"See CPT",null,682.00620000000004,null,467.9502,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM"]
[21034,null,"See CPT",null,2342.7240000000002,null,2014.5048000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21040,null,"See CPT",null,855.62940000000003,null,655.84379999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM"]
[21044,null,"See CPT",null,1548.3383999999999,null,1548.3383999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21045,null,"See CPT",null,2141.7492000000002,null,2141.7492000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21046,null,"See CPT",null,1802.8271999999999,null,1802.8271999999999,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R",null,"Y-CM"]
[21047,null,"See CPT",null,2233.3176000000003,null,2233.3176000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21048,null,"See CPT",null,1815.9084,null,1815.9084,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R",null,"Y-CM"]
[21049,null,"See CPT",null,2176.2360000000003,null,2176.2360000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21050,null,"See CPT",null,1557.8520000000001,null,1557.8520000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM"]
[21060,null,"See CPT",null,1412.175,null,1412.175,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[21070,null,"See CPT",null,1093.4694,null,1093.4694,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM"]
[21073,null,"See CPT",null,687.95220000000006,null,441.19319999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM"]
[21076,null,"See CPT",null,1532.8788000000002,null,1247.4708000000001,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[21077,null,"See CPT",null,3764.4126000000001,null,3071.1089999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[21079,null,"See CPT",null,2584.1316000000002,null,2067.4242000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21080,null,"See CPT",null,2993.2164000000002,null,2358.7782000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21081,null,"See CPT",null,2747.6466,null,2153.0466000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21082,null,"See CPT",null,2522.8878,null,1959.8016,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21083,null,"See CPT",null,2411.1030000000001,null,1820.0706,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21084,null,"See CPT",null,2750.6196,null,2106.0732000000003,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21085,null,"See CPT",null,1210.0110000000002,null,853.84559999999999,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[21086,null,"See CPT",null,2804.1335999999997,null,2264.8314,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[21087,null,"See CPT",null,2804.1335999999997,null,2264.8314,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21088,null,"See CPT",null,"By Report",null,"By Report",null,"090",0.1,0.69,0.21,0,0,0,0,0,0,"","N"]
[21089,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,0,0,1,1,1,"","N"]
[21100,null,"See CPT",null,1149.9564,null,635.03279999999995,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21110,null,"See CPT",null,1617.9066,null,1337.85,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21116,null,"See CPT",null,415.03080000000006,null,80.271000000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[21120,null,"See CPT",null,1222.4975999999999,null,925.79219999999998,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-CM"]
[21121,null,"See CPT",null,1149.3617999999999,null,951.95460000000014,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21122,null,"See CPT",null,1356.2826,null,1356.2826,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21123,null,"See CPT",null,1537.6356000000001,null,1537.6356000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21125,null,"See CPT",null,5030.3159999999998,null,1189.7946000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21127,null,"See CPT",null,7727.4216000000006,null,1364.0124000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21137,null,"See CPT",null,1342.6068,null,1342.6068,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21138,null,"See CPT",null,1632.7716,null,1632.7716,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21139,null,"See CPT",null,1956.2339999999999,null,1956.2339999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21141,null,"See CPT",null,2391.4812000000002,null,2391.4812000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21142,null,"See CPT",null,2454.5088000000001,null,2454.5088000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21143,null,"See CPT",null,2528.2392000000004,null,2528.2392000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21145,null,"See CPT",null,2777.9712,null,2777.9712,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21146,null,"See CPT",null,2899.8642000000004,null,2899.8642000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21147,null,"See CPT",null,3051.4872,null,3051.4872,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21150,null,"See CPT",null,2934.9456,null,2934.9456,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21151,null,"See CPT",null,3226.8942000000002,null,3226.8942000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21154,null,"See CPT",null,3471.8694,null,3471.8694,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21155,null,"See CPT",null,3847.6565999999998,null,3847.6565999999998,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21159,null,"See CPT",null,4605.7716,null,4605.7716,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21160,null,"See CPT",null,4992.8562000000002,null,4992.8562000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21172,null,"See CPT",null,3742.4123999999997,null,3742.4123999999997,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21175,null,"See CPT",null,3939.2249999999999,null,3939.2249999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21179,null,"See CPT",null,2711.3760000000002,null,2711.3760000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21180,null,"See CPT",null,3026.5140000000001,null,3026.5140000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21181,null,"See CPT",null,1324.7688000000001,null,1324.7688000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,"Y-CM"]
[21182,null,"See CPT",null,3760.8450000000003,null,3760.8450000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21183,null,"See CPT",null,4089.6588000000002,null,4089.6588000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21184,null,"See CPT",null,4397.6615999999995,null,4397.6615999999995,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21188,null,"See CPT",null,2844.5664000000002,null,2844.5664000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21193,null,"See CPT",null,2204.1822000000002,null,2204.1822000000002,null,"090",0.1,0.69,0.21,0,2,2,2,1,0,"","R",null,"Y-CM"]
[21194,null,"See CPT",null,2553.2123999999999,null,2553.2123999999999,null,"090",0.1,0.69,0.21,0,2,2,2,0,0,"","R",null,"Y-CM"]
[21195,null,"See CPT",null,2417.6435999999999,null,2417.6435999999999,null,"090",0.1,0.69,0.21,0,2,2,2,0,0,"","R",null,"Y-CM"]
[21196,null,"See CPT",null,2581.7532000000001,null,2581.7532000000001,null,"090",0.1,0.69,0.21,0,2,2,2,1,0,"","R",null,"Y-CM"]
[21198,null,"See CPT",null,1855.152,null,1855.152,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21199,null,"See CPT",null,1814.7192,null,1814.7192,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21206,null,"See CPT",null,1735.0427999999999,null,1735.0427999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21208,null,"See CPT",null,3093.1092000000003,null,1315.2552000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21209,null,"See CPT",null,1498.9866000000002,null,1116.6588000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[21210,null,"See CPT",null,3316.0842000000002,null,1350.3366000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21215,null,"See CPT",null,7882.0176000000001,null,1401.4721999999999,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R"]
[21230,null,"See CPT",null,1340.8230000000001,null,1340.8230000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21235,null,"See CPT",null,1331.904,null,1018.5498,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21240,null,"See CPT",null,1871.2061999999999,null,1871.2061999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[21242,null,"See CPT",null,1814.1246000000001,null,1814.1246000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[21243,null,"See CPT",null,2869.5396000000001,null,2869.5396000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[21244,null,"See CPT",null,1811.1516000000001,null,1811.1516000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21245,null,"See CPT",null,2139.3707999999997,null,1647.0419999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21246,null,"See CPT",null,1522.1760000000002,null,1522.1760000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21247,null,"See CPT",null,2827.9176000000002,null,2827.9176000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21248,null,"See CPT",null,1774.8810000000001,null,1409.202,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21249,null,"See CPT",null,2409.3192000000004,null,1977.6396,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21255,null,"See CPT",null,2412.2921999999999,null,2412.2921999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21256,null,"See CPT",null,2209.5335999999998,null,2209.5335999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21260,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","X"]
[21261,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","X"]
[21263,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","X"]
[21267,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[21268,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[21270,null,"See CPT",null,1830.1788000000001,null,1333.6877999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21275,null,"See CPT",null,1512.6624000000002,null,1512.6624000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21280,null,"See CPT",null,1048.8744000000002,null,1048.8744000000002,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[21282,null,"See CPT",null,715.30380000000002,null,715.30380000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[21295,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","X"]
[21296,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","X"]
[21299,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,"","N"]
[21315,null,"See CPT",null,278.86740000000003,null,104.64960000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[21320,null,"See CPT",null,404.32799999999997,null,168.8664,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[21325,null,"See CPT",null,816.38580000000002,null,816.38580000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21330,null,"See CPT",null,975.73860000000002,null,975.73860000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21335,null,"See CPT",null,1295.6333999999999,null,1295.6333999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21336,null,"See CPT",null,1176.1188000000002,null,1176.1188000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21337,null,"See CPT",null,771.79079999999999,null,541.68060000000003,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21338,null,"See CPT",null,1230.8219999999999,null,1230.8219999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21339,null,"See CPT",null,1386.6072000000001,null,1386.6072000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21340,null,"See CPT",null,1344.9852000000001,null,1344.9852000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21343,null,"See CPT",null,1966.3422,null,1966.3422,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21344,null,"See CPT",null,2502.6714000000002,null,2502.6714000000002,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R"]
[21345,null,"See CPT",null,1453.2024000000001,null,1144.605,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21346,null,"See CPT",null,1877.7467999999999,null,1877.7467999999999,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R"]
[21347,null,"See CPT",null,1887.2603999999999,null,1887.2603999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21348,null,"See CPT",null,1951.4772,null,1951.4772,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R"]
[21355,null,"See CPT",null,814.00739999999996,null,588.654,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R"]
[21356,null,"See CPT",null,994.76580000000001,null,727.79039999999998,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R"]
[21360,null,"See CPT",null,938.87339999999995,null,938.87339999999995,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[21365,null,"See CPT",null,1932.45,null,1932.45,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21366,null,"See CPT",null,2276.7233999999999,null,2276.7233999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[21385,null,"See CPT",null,1318.8227999999999,null,1318.8227999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21386,null,"See CPT",null,1236.768,null,1236.768,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[21387,null,"See CPT",null,1375.3098,null,1375.3098,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[21390,null,"See CPT",null,1438.3374000000001,null,1438.3374000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21395,null,"See CPT",null,1802.8271999999999,null,1802.8271999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21400,null,"See CPT",null,386.49,null,299.0838,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[21401,null,"See CPT",null,937.68420000000003,null,589.84320000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[21406,null,"See CPT",null,1049.4689999999998,null,1049.4689999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21407,null,"See CPT",null,1150.5510000000002,null,1150.5510000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21408,null,"See CPT",null,1614.3389999999999,null,1614.3389999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[21421,null,"See CPT",null,1186.2269999999999,null,994.76580000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21422,null,"See CPT",null,1123.7939999999999,null,1123.7939999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21423,null,"See CPT",null,1434.1752000000001,null,1434.1752000000001,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R"]
[21431,null,"See CPT",null,1273.6332000000002,null,1273.6332000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[21432,null,"See CPT",null,1299.7955999999999,null,1299.7955999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[21433,null,"See CPT",null,3086.5686000000001,null,3086.5686000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21435,null,"See CPT",null,2509.212,null,2509.212,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[21436,null,"See CPT",null,3623.4924000000001,null,3623.4924000000001,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R"]
[21440,null,"See CPT",null,1291.4712,null,1032.8202000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21445,null,"See CPT",null,1493.0406,null,1196.3352,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[21450,null,"See CPT",null,1110.1182000000001,null,896.65679999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21451,null,"See CPT",null,1436.5536,null,1193.3622,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21452,null,"See CPT",null,1423.4724000000001,null,874.06200000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21453,null,"See CPT",null,2048.3970000000004,null,1737.4212,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21454,null,"See CPT",null,869.89980000000003,null,869.89980000000003,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R"]
[21461,null,"See CPT",null,3448.68,null,1950.2879999999998,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R"]
[21462,null,"See CPT",null,3769.1694000000002,null,2170.8845999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21465,null,"See CPT",null,1417.5264,null,1417.5264,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21470,null,"See CPT",null,2075.154,null,2075.154,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21480,null,"See CPT",null,262.21860000000004,null,54.108600000000003,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[21485,null,"See CPT",null,1834.3410000000001,null,1492.4460000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[21490,null,"See CPT",null,1396.1208000000001,null,1396.1208000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[21497,null,"See CPT",null,1327.1472000000001,null,1098.8208,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21499,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,"","N"]
[21501,null,"See CPT",null,894.87300000000005,null,600.54599999999994,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21502,null,"See CPT",null,907.95420000000001,null,907.95420000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[21510,null,"See CPT",null,812.22360000000003,null,812.22360000000003,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[21550,null,"See CPT",null,494.7072,null,279.46199999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[21552,null,"See CPT",null,799.73699999999997,null,799.73699999999997,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21554,null,"See CPT",null,1303.9577999999999,null,1303.9577999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21555,null,"See CPT",null,800.92619999999999,null,551.78879999999992,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM"]
[21556,null,"See CPT",null,951.95460000000014,null,951.95460000000014,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM"]
[21557,null,"See CPT",null,1698.7722000000001,null,1698.7722000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21558,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","X"]
[21600,null,"See CPT",null,1004.8739999999999,null,1004.8739999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[21601,null,"See CPT",null,2042.451,null,2042.451,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R"]
[21602,null,"See CPT",null,2762.5116000000003,null,2762.5116000000003,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R"]
[21603,null,"See CPT",null,2995.5948000000003,null,2995.5948000000003,null,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R"]
[21610,null,"See CPT",null,2126.2896000000001,null,2126.2896000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21615,null,"See CPT",null,1082.172,null,1082.172,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[21616,null,"See CPT",null,1249.8491999999999,null,1249.8491999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[21620,null,"See CPT",null,903.19740000000002,null,903.19740000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21627,null,"See CPT",null,972.17100000000005,null,972.17100000000005,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[21630,null,"See CPT",null,2342.1294000000003,null,2342.1294000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21632,null,"See CPT",null,2139.9654,null,2139.9654,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21685,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","X"]
[21700,null,"See CPT",null,624.33000000000004,null,624.33000000000004,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[21705,null,"See CPT",null,931.73820000000001,null,931.73820000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[21720,null,"See CPT",null,947.19780000000003,null,947.19780000000003,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21725,null,"See CPT",null,975.14399999999989,null,975.14399999999989,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21740,null,"See CPT",null,1801.6380000000001,null,1801.6380000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[21742,null,"See CPT",null," By Report ",null," By Report ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","N",null,"Y-CM"]
[21743,null,"See CPT",null," By Report ",null," By Report ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","N",null,"Y-CM"]
[21750,null,"See CPT",null,1192.7675999999999,null,1192.7675999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21811,null,"See CPT",null,1039.3607999999999,null,1039.3607999999999,null,"000",0,0,0,0,2,1,2,0,0,"","R"]
[21812,null,"See CPT",null,1261.1466,null,1261.1466,null,"000",0,0,0,0,2,1,2,0,0,"","R"]
[21813,null,"See CPT",null,1724.34,null,1724.34,null,"000",0,0,0,0,2,1,2,0,0,"","R"]
[21820,null,"See CPT",null,272.32679999999999,null,266.97540000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21825,null,"See CPT",null,982.27919999999995,null,982.27919999999995,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[21899,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,"","N",null,"Y-UR"]
[21920,null,"See CPT",null,478.05839999999995,null,278.86740000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[21925,null,"See CPT",null,906.17039999999997,null,678.43860000000006,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21930,null,"See CPT",null,922.81920000000002,null,652.27620000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[21931,null,"See CPT",null,840.16980000000001,null,840.16980000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[21932,null,"See CPT",null,1185.0378000000001,null,1185.0378000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[21933,null,"See CPT",null,1318.2282,null,1318.2282,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[21935,null,"See CPT",null,1824.2328,null,1824.2328,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-CM"]
[21936,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","X"]
[22010,null,"See CPT",null,1723.1508000000001,null,1723.1508000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[22015,null,"See CPT",null,1694.0154,null,1694.0154,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[22100,null,"See CPT",null,1542.9870000000001,null,1542.9870000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22101,null,"See CPT",null,1534.068,null,1534.068,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22102,null,"See CPT",null,1392.5532000000001,null,1392.5532000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22103,null,"See CPT",null,236.6508,null,236.6508,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM"]
[22110,null,"See CPT",null,1873.5846000000001,null,1873.5846000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22112,null,"See CPT",null,2009.7479999999998,null,2009.7479999999998,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22114,null,"See CPT",null,2009.7479999999998,null,2009.7479999999998,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22116,null,"See CPT",null,246.16439999999997,null,246.16439999999997,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM"]
[22206,null,"See CPT",null,4309.0662000000002,null,4309.0662000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22207,null,"See CPT",null,4224.0384000000004,null,4224.0384000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22208,null,"See CPT",null,1025.6849999999999,null,1025.6849999999999,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR"]
[22210,null,"See CPT",null,3162.0828000000001,null,3162.0828000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22212,null,"See CPT",null,2678.6729999999998,null,2678.6729999999998,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22214,null,"See CPT",null,2679.8622,null,2679.8622,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22216,null,"See CPT",null,632.65440000000001,null,632.65440000000001,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM"]
[22220,null,"See CPT",null,2868.9450000000002,null,2868.9450000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22222,null,"See CPT",null,3100.8389999999999,null,3100.8389999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22224,null,"See CPT",null,2820.7824000000001,null,2820.7824000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22226,null,"See CPT",null,629.08680000000004,null,629.08680000000004,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM"]
[22310,null,"See CPT",null,562.49160000000006,null,535.7346,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM"]
[22315,null,"See CPT",null,1587.5819999999999,null,1378.8774000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM"]
[22318,null,"See CPT",null,2896.2966000000001,null,2896.2966000000001,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-CM"]
[22319,null,"See CPT",null,3220.9482000000003,null,3220.9482000000003,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-CM"]
[22325,null,"See CPT",null,2603.1588000000002,null,2603.1588000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22326,null,"See CPT",null,2664.9972000000002,null,2664.9972000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22327,null,"See CPT",null,2709.5922,null,2709.5922,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22328,null,"See CPT",null,488.16660000000007,null,488.16660000000007,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM"]
[22505,null,"See CPT",null,230.11020000000002,null,230.11020000000002,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[22510,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","X"]
[22511,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","X"]
[22512,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,1,0,0,"","X"]
[22513,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","X"]
[22514,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","X"]
[22515,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,1,0,0,"","X"]
[22526,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,9,9,9,9,9,9,"","X"]
[22527,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[22532,null,"See CPT",null,3181.11,null,3181.11,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22533,null,"See CPT",null,2931.9726000000001,null,2931.9726000000001,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22534,null,"See CPT",null,626.70839999999998,null,626.70839999999998,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22548,null,"See CPT",null,3451.6529999999998,null,3451.6529999999998,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22551,null,"See CPT",null,2998.5677999999998,null,2998.5677999999998,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22552,null,"See CPT",null,689.73599999999999,null,689.73599999999999,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22554,null,"See CPT",null,2226.777,null,2226.777,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22556,null,"See CPT",null,2940.297,null,2940.297,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22558,null,"See CPT",null,2700.0785999999998,null,2700.0785999999998,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22585,null,"See CPT",null,567.24839999999995,null,567.24839999999995,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22586,null,"See CPT",null,3570.5729999999999,null,3570.5729999999999,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22590,null,"See CPT",null,2799.3768,null,2799.3768,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22595,null,"See CPT",null,2677.4838,null,2677.4838,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22600,null,"See CPT",null,2301.1020000000003,null,2301.1020000000003,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22610,null,"See CPT",null,2263.6422000000002,null,2263.6422000000002,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22612,null,"See CPT",null,2804.7282,null,2804.7282,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22614,null,"See CPT",null,680.81700000000001,null,680.81700000000001,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22630,null,"See CPT",null,2791.0524,null,2791.0524,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22632,null,"See CPT",null,557.14019999999994,null,557.14019999999994,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22633,null,"See CPT",null,3261.3810000000003,null,3261.3810000000003,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22634,null,"See CPT",null,863.9538,null,863.9538,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22800,null,"See CPT",null,2408.7246,null,2408.7246,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22802,null,"See CPT",null,3735.2772,null,3735.2772,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22804,null,"See CPT",null,4284.6876000000002,null,4284.6876000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22808,null,"See CPT",null,3226.2995999999998,null,3226.2995999999998,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22810,null,"See CPT",null,3560.4648000000002,null,3560.4648000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22812,null,"See CPT",null,3901.7652000000003,null,3901.7652000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22818,null,"See CPT",null,3807.2238000000002,null,3807.2238000000002,null,"090",0.11,0.76,0.13,0,2,0,2,2,2,"","R",null,"Y-UR"]
[22819,null,"See CPT",null,4382.7965999999997,null,4382.7965999999997,null,"090",0.11,0.76,0.13,0,2,0,2,2,2,"","R",null,"Y-UR"]
[22830,null,"See CPT",null,1460.9322,null,1460.9322,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22840,null,"See CPT",null,1321.7958000000001,null,1321.7958000000001,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR"]
[22841,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled",null,"Y-UR"]
[22842,null,"See CPT",null,1328.3363999999999,null,1328.3363999999999,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22843,null,"See CPT",null,1420.4994000000002,null,1420.4994000000002,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22844,null,"See CPT",null,1717.7994000000001,null,1717.7994000000001,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22845,null,"See CPT",null,1265.9033999999999,null,1265.9033999999999,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22846,null,"See CPT",null,1315.8498,null,1315.8498,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22847,null,"See CPT",null,1406.8235999999999,null,1406.8235999999999,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22848,null,"See CPT",null,627.303,null,627.303,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22849,null,"See CPT",null,2310.6156000000001,null,2310.6156000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22850,null,"See CPT",null,1311.6876,null,1311.6876,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22852,null,"See CPT",null,1260.5519999999999,null,1260.5519999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22853,null,"See CPT",null,448.923,null,448.923,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22854,null,"See CPT",null,582.70800000000008,null,582.70800000000008,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22855,null,"See CPT",null,1961.5854000000002,null,1961.5854000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[22856,null,"See CPT",null,2874.8910000000001,null,2874.8910000000001,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22857,null,"See CPT",null,3134.1366000000003,null,3134.1366000000003,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22858,null,"See CPT",null,882.38639999999998,null,882.38639999999998,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22859,null,"See CPT",null,579.73500000000001,null,579.73500000000001,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22861,null,"See CPT",null,4058.145,null,4058.145,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22862,null,"See CPT",null,4061.7126000000003,null,4061.7126000000003,null,"090",0.1,0.71,0.19,0,2,0,2,2,2,"","R",null,"Y-UR"]
[22864,null,"See CPT",null,3626.4654,null,3626.4654,null,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR"]
[22865,null,"See CPT",null,3965.9820000000004,null,3965.9820000000004,null,"090",0.1,0.71,0.19,0,2,0,2,2,2,"","R",null,"Y-UR"]
[22867,null,"See CPT",null,1902.1253999999999,null,1902.1253999999999,null,"090",0.1,0.8,0.1,0,2,0,2,0,0,"","R",null,"Y-UR"]
[22868,null,"See CPT",null,423.35520000000002,null,423.35520000000002,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22869,null,"See CPT",null,776.54759999999999,null,776.54759999999999,null,"090",0.1,0.8,0.1,0,2,0,2,0,0,"","R",null,"Y-UR"]
[22870,null,"See CPT",null,209.8938,null,209.8938,null,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR"]
[22899,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,2,1,1,"","N",null,"Y-UR"]
[22900,null,"See CPT",null,1010.82,null,1010.82,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22901,null,"See CPT",null,1192.7675999999999,null,1192.7675999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22902,null,"See CPT",null,871.08900000000006,null,599.35680000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22903,null,"See CPT",null,788.43960000000004,null,788.43960000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[22904,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,1,1,"","X"]
[22905,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,1,1,"","X"]
[22999,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,"","N",null,"Y-CM"]
[23000,null,"See CPT",null,1063.7394000000002,null,667.14120000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23020,null,"See CPT",null,1240.3355999999999,null,1240.3355999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM"]
[23030,null,"See CPT",null,818.16959999999995,null,457.84200000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[23031,null,"See CPT",null,789.62879999999996,null,393.62520000000001,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,"Y-CM"]
[23035,null,"See CPT",null,1228.4436000000001,null,1228.4436000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM"]
[23040,null,"See CPT",null,1293.2550000000001,null,1293.2550000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23044,null,"See CPT",null,1020.3336,null,1020.3336,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-CM"]
[23065,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","X"]
[23066,null,"See CPT",null,1041.1446000000001,null,658.22220000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[23071,null,"See CPT",null,753.35820000000001,null,753.35820000000001,null,"090",0.1,0.8,0.1,0,2,1,2,0,0,"","R"]
[23073,null,"See CPT",null,1245.6869999999999,null,1245.6869999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[23075,null,"See CPT",null,962.65740000000005,null,592.81620000000009,null,"090",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[23076,null,"See CPT",null,975.73860000000002,null,975.73860000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23077,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[23078,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[23100,null,"See CPT",null,915.68400000000008,null,915.68400000000008,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23101,null,"See CPT",null,827.08860000000004,null,827.08860000000004,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[23105,null,"See CPT",null,1152.9294,null,1152.9294,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23106,null,"See CPT",null,909.14339999999993,null,909.14339999999993,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[23107,null,"See CPT",null,1189.2,null,1189.2,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23120,null,"See CPT",null,1060.1717999999998,null,1060.1717999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23125,null,"See CPT",null,1276.6061999999999,null,1276.6061999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23130,null,"See CPT",null,1118.4425999999999,null,1118.4425999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[23140,null,"See CPT",null,1002.4956,null,1002.4956,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM"]
[23145,null,"See CPT",null,1252.8222000000001,null,1252.8222000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23146,null,"See CPT",null,1124.3886,null,1124.3886,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM"]
[23150,null,"See CPT",null,1191.5783999999999,null,1191.5783999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23155,null,"See CPT",null,1432.9860000000001,null,1432.9860000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23156,null,"See CPT",null,1221.903,null,1221.903,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM"]
[23170,null,"See CPT",null,1019.1444,null,1019.1444,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM"]
[23172,null,"See CPT",null,1029.2526,null,1029.2526,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM"]
[23174,null,"See CPT",null,1374.7152000000001,null,1374.7152000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23180,null,"See CPT",null,1196.3352,null,1196.3352,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-CM"]
[23182,null,"See CPT",null,1211.7947999999999,null,1211.7947999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM"]
[23184,null,"See CPT",null,1328.931,null,1328.931,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23190,null,"See CPT",null,1037.577,null,1037.577,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23195,null,"See CPT",null,1333.0932,null,1333.0932,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23200,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[23210,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[23220,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[23330,null,"See CPT",null,559.51859999999999,null,300.86759999999998,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R"]
[23333,null,"See CPT",null,852.06180000000006,null,852.06180000000006,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM"]
[23334,null,"See CPT",null,1893.8010000000002,null,1893.8010000000002,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[23335,null,"See CPT",null,2255.3177999999998,null,2255.3177999999998,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[23350,null,"See CPT",null,314.54340000000002,null,88.000799999999998,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[23395,null,"See CPT",null,2281.4802,null,2281.4802,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[23397,null,"See CPT",null,2028.1805999999999,null,2028.1805999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM"]
[23400,null,"See CPT",null,1739.7996000000001,null,1739.7996000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23405,null,"See CPT",null,1114.2803999999999,null,1114.2803999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[23406,null,"See CPT",null,1335.4716000000001,null,1335.4716000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[23410,null,"See CPT",null,1469.8512000000001,null,1469.8512000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23412,null,"See CPT",null,1526.3382000000001,null,1526.3382000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23415,null,"See CPT",null,1257.579,null,1257.579,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[23420,null,"See CPT",null,1744.5563999999999,null,1744.5563999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23430,null,"See CPT",null,1337.2554,null,1337.2554,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23440,null,"See CPT",null,1356.2826,null,1356.2826,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23450,null,"See CPT",null,1691.6369999999999,null,1691.6369999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23455,null,"See CPT",null,1773.0971999999999,null,1773.0971999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23460,null,"See CPT",null,1947.3150000000001,null,1947.3150000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23462,null,"See CPT",null,1904.5038000000002,null,1904.5038000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23465,null,"See CPT",null,1997.2614000000003,null,1997.2614000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23466,null,"See CPT",null,2002.6128000000001,null,2002.6128000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23470,null,"See CPT",null,2136.3978000000002,null,2136.3978000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23472,null,"See CPT",null,2571.0504000000001,null,2571.0504000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23473,null,"See CPT",null,2862.4043999999999,null,2862.4043999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23474,null,"See CPT",null,3087.1632,null,3087.1632,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23480,null,"See CPT",null,1469.8512000000001,null,1469.8512000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[23485,null,"See CPT",null,1698.7722000000001,null,1698.7722000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23490,null,"See CPT",null,1541.2032000000002,null,1541.2032000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM"]
[23491,null,"See CPT",null,1816.5030000000002,null,1816.5030000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[23500,null,"See CPT",null,408.49020000000002,null,417.4092,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23505,null,"See CPT",null,660.00599999999997,null,611.24879999999996,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23515,null,"See CPT",null,1293.8496,null,1293.8496,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[23520,null,"See CPT",null,443.57159999999999,null,437.03100000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[23525,null,"See CPT",null,727.79039999999998,null,664.16819999999996,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[23530,null,"See CPT",null,1039.3607999999999,null,1039.3607999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[23532,null,"See CPT",null,1129.1453999999999,null,1129.1453999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[23540,null,"See CPT",null,439.40940000000001,null,432.27420000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23545,null,"See CPT",null,645.73559999999998,null,577.95120000000009,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[23550,null,"See CPT",null,1032.2256,null,1032.2256,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23552,null,"See CPT",null,1177.9025999999999,null,1177.9025999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[23570,null,"See CPT",null,431.67959999999999,null,444.76080000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23575,null,"See CPT",null,753.35820000000001,null,693.89819999999997,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[23585,null,"See CPT",null,1748.7185999999999,null,1748.7185999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[23600,null,"See CPT",null,614.81640000000004,null,581.51879999999994,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23605,null,"See CPT",null,859.79160000000002,null,778.33140000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23615,null,"See CPT",null,1582.8252,null,1582.8252,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[23616,null,"See CPT",null,2199.4254000000001,null,2199.4254000000001,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[23620,null,"See CPT",null,498.86940000000004,null,478.65300000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23625,null,"See CPT",null,704.601,null,642.76260000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23630,null,"See CPT",null,1397.9046000000001,null,1397.9046000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[23650,null,"See CPT",null,598.76220000000001,null,539.30219999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23655,null,"See CPT",null,745.03379999999993,null,745.03379999999993,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23660,null,"See CPT",null,1053.6312,null,1053.6312,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[23665,null,"See CPT",null,793.79099999999994,null,728.9796,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23670,null,"See CPT",null,1556.6628000000001,null,1556.6628000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[23675,null,"See CPT",null,1006.0632000000002,null,908.54880000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[23680,null,"See CPT",null,1658.934,null,1658.934,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[23700,null,"See CPT",null,352.59780000000001,null,352.59780000000001,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[23800,null,"See CPT",null,1834.9356,null,1834.9356,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23802,null,"See CPT",null,2286.8316,null,2286.8316,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23900,null,"See CPT",null,2463.4277999999999,null,2463.4277999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM"]
[23920,null,"See CPT",null,2002.6128000000001,null,2002.6128000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[23921,null,"See CPT",null,851.46720000000005,null,851.46720000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM"]
[23929,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,0,2,0,2,1,1,"","Bundled",null,"Y-UR"]
[23930,null,"See CPT",null,669.51959999999997,null,385.30080000000004,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[23931,null,"See CPT",null,566.05920000000003,null,289.5702,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[23935,null,"See CPT",null,921.63,null,921.63,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[24000,null,"See CPT",null,855.03480000000002,null,855.03480000000002,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,"Y-UR"]
[24006,null,"See CPT",null,1280.7683999999999,null,1280.7683999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,"Y-UR"]
[24065,null,"See CPT",null,482.81519999999995,null,294.327,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[24066,null,"See CPT",null,1141.6320000000001,null,754.54739999999993,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24071,null,"See CPT",null,727.79039999999998,null,727.79039999999998,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[24073,null,"See CPT",null,1238.5518,null,1238.5518,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[24075,null,"See CPT",null,"994.1+E7712",null,594.00540000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24076,null,"See CPT",null,979.9008,null,979.9008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24077,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","X"]
[24079,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[24100,null,"See CPT",null,760.49339999999995,null,760.49339999999995,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24101,null,"See CPT",null,912.1164,null,912.1164,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[24102,null,"See CPT",null,1115.4696000000001,null,1115.4696000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24105,null,"See CPT",null,655.24919999999997,null,655.24919999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24110,null,"See CPT",null,1065.5232000000001,null,1065.5232000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[24115,null,"See CPT",null,1324.7688000000001,null,1324.7688000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24116,null,"See CPT",null,1540.6086,null,1540.6086,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[24120,null,"See CPT",null,963.25199999999995,null,963.25199999999995,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[24125,null,"See CPT",null,1123.7939999999999,null,1123.7939999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24126,null,"See CPT",null,1172.5511999999999,null,1172.5511999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[24130,null,"See CPT",null,922.22460000000001,null,922.22460000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[24134,null,"See CPT",null,1342.6068,null,1342.6068,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[24136,null,"See CPT",null,1139.8482000000001,null,1139.8482000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24138,null,"See CPT",null,1242.1194,null,1242.1194,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[24140,null,"See CPT",null,1265.3088,null,1265.3088,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[24145,null,"See CPT",null,1072.6584,null,1072.6584,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[24147,null,"See CPT",null,1136.8752000000002,null,1136.8752000000002,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[24149,null,"See CPT",null,2108.4515999999999,null,2108.4515999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24150,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[24152,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[24155,null,"See CPT",null,1526.3382000000001,null,1526.3382000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24160,null,"See CPT",null,2229.75,null,2229.75,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[24164,null,"See CPT",null,1300.3902,null,1300.3902,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[24200,null,"See CPT",null,404.92259999999999,null,254.48880000000003,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R"]
[24201,null,"See CPT",null,1009.6308,null,659.41139999999996,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24220,null,"See CPT",null,361.51679999999999,null,116.5416,null,"000",0,0,0,0,2,1,0,0,0,"","R"]
[24300,null,"See CPT",null,796.76400000000001,null,796.76400000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24301,null,"See CPT",null,1346.769,null,1346.769,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[24305,null,"See CPT",null,1045.3067999999998,null,1045.3067999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,"Y-UR"]
[24310,null,"See CPT",null,860.98080000000004,null,860.98080000000004,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,"Y-UR"]
[24320,null,"See CPT",null,1399.6884,null,1399.6884,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[24330,null,"See CPT",null,1290.8766000000001,null,1290.8766000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[24331,null,"See CPT",null,1409.202,null,1409.202,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[24332,null,"See CPT",null,1110.7128,null,1110.7128,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[24340,null,"See CPT",null,1114.875,null,1114.875,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24341,null,"See CPT",null,1340.8230000000001,null,1340.8230000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24342,null,"See CPT",null,1390.7694000000001,null,1390.7694000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24343,null,"See CPT",null,1287.309,null,1287.309,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24344,null,"See CPT",null,1959.8016,null,1959.8016,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24345,null,"See CPT",null,1280.7683999999999,null,1280.7683999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24346,null,"See CPT",null,1976.4504000000002,null,1976.4504000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24357,null,"See CPT",null,760.49339999999995,null,760.49339999999995,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR"]
[24358,null,"See CPT",null,956.71140000000003,null,956.71140000000003,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR"]
[24359,null,"See CPT",null,1192.173,null,1192.173,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR"]
[24360,null,"See CPT",null,1618.5011999999999,null,1618.5011999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24361,null,"See CPT",null,1802.8271999999999,null,1802.8271999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24362,null,"See CPT",null,1895.5847999999999,null,1895.5847999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[24363,null,"See CPT",null,2572.2395999999999,null,2572.2395999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[24365,null,"See CPT",null,1155.3078,null,1155.3078,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24366,null,"See CPT",null,1225.4705999999999,null,1225.4705999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24370,null,"See CPT",null,2732.1870000000004,null,2732.1870000000004,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[24371,null,"See CPT",null,3136.5149999999999,null,3136.5149999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[24400,null,"See CPT",null,1481.1486,null,1481.1486,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24410,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[24420,null,"See CPT",null,1924.7202,null,1924.7202,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24430,null,"See CPT",null,1883.6928,null,1883.6928,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24435,null,"See CPT",null,1932.45,null,1932.45,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24470,null,"See CPT",null,1211.2002,null,1211.2002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM"]
[24495,null,"See CPT",null,1475.2025999999998,null,1475.2025999999998,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[24498,null,"See CPT",null,1551.9060000000002,null,1551.9060000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24500,null,"See CPT",null,665.952,null,613.0326,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24505,null,"See CPT",null,922.22460000000001,null,824.71019999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24515,null,"See CPT",null,1580.4467999999999,null,1580.4467999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24516,null,"See CPT",null,1538.2302,null,1538.2302,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[24530,null,"See CPT",null,702.81720000000007,null,643.95180000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24535,null,"See CPT",null,1126.1724000000002,null,1031.6310000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24538,null,"See CPT",null,1431.7967999999998,null,1431.7967999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24545,null,"See CPT",null,1660.7177999999999,null,1660.7177999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24546,null,"See CPT",null,1852.1789999999999,null,1852.1789999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[24560,null,"See CPT",null,614.22180000000003,null,541.68060000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24565,null,"See CPT",null,989.4144,null,900.22440000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24566,null,"See CPT",null,1299.7955999999999,null,1299.7955999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24575,null,"See CPT",null,1317.039,null,1317.039,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24576,null,"See CPT",null,648.70860000000005,null,576.16739999999993,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24577,null,"See CPT",null,1016.7660000000001,null,924.60300000000007,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24579,null,"See CPT",null,1495.4189999999999,null,1495.4189999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24582,null,"See CPT",null,1472.2296000000001,null,1472.2296000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24586,null,"See CPT",null,1940.7744,null,1940.7744,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24587,null,"See CPT",null,1943.7474,null,1943.7474,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24600,null,"See CPT",null,684.38459999999998,null,616.60019999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24605,null,"See CPT",null,869.89980000000003,null,869.89980000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24615,null,"See CPT",null,1281.9576,null,1281.9576,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24620,null,"See CPT",null,1020.3336,null,1020.3336,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[24635,null,"See CPT",null,1215.3624000000002,null,1215.3624000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24640,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","X"]
[24650,null,"See CPT",null,486.38279999999997,null,451.3014,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24655,null,"See CPT",null,819.95339999999999,null,737.30400000000009,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24665,null,"See CPT",null,1187.4161999999999,null,1187.4161999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24666,null,"See CPT",null,1315.8498,null,1315.8498,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24670,null,"See CPT",null,539.89679999999998,null,492.32879999999994,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24675,null,"See CPT",null,850.87260000000003,null,768.22320000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[24685,null,"See CPT",null,1178.4972,null,1178.4972,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24800,null,"See CPT",null,1496.0136,null,1496.0136,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[24802,null,"See CPT",null,1793.9082000000001,null,1793.9082000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[24900,null,"See CPT",null,1324.7688000000001,null,1324.7688000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24920,null,"See CPT",null,1315.8498,null,1315.8498,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[24925,null,"See CPT",null,1027.4688000000001,null,1027.4688000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[24930,null,"See CPT",null,1387.7963999999999,null,1387.7963999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[24931,null,"See CPT",null,1664.2854,null,1664.2854,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[24935,null,"See CPT",null,2201.8038000000001,null,2201.8038000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR"]
[24940,null,"See CPT",null,2003.7910155120003,null,2003.7910155120003,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","F",null,"Y-UR"]
[24999,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,0,1,1,"","N",null,"Y-UR"]
[25000,null,"See CPT",null,628.49220000000003,null,628.49220000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[25001,null,"See CPT",null,630.27599999999995,null,630.27599999999995,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[25020,null,"See CPT",null,1384.8234,null,1384.8234,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[25023,null,"See CPT",null,2417.049,null,2417.049,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR"]
[25024,null,"See CPT",null,1403.8506,null,1403.8506,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[25025,null,"See CPT",null,2101.3164000000002,null,2101.3164000000002,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR"]
[25028,null,"See CPT",null,1300.3902,null,1300.3902,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25031,null,"See CPT",null,669.51959999999997,null,669.51959999999997,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25035,null,"See CPT",null,1057.1988000000001,null,1057.1988000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25040,null,"See CPT",null,1007.847,null,1007.847,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25065,null,"See CPT",null,475.68,null,284.8134,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[25066,null,"See CPT",null,662.97900000000004,null,662.97900000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25071,null,"See CPT",null,761.08800000000008,null,761.08800000000008,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25073,null,"See CPT",null,962.06280000000004,null,962.06280000000004,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25075,null,"See CPT",null,969.19800000000009,null,569.03219999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25076,null,"See CPT",null,931.73820000000001,null,931.73820000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25077,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","X"]
[25078,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","X"]
[25085,null,"See CPT",null,811.03440000000001,null,811.03440000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25100,null,"See CPT",null,636.81660000000011,null,636.81660000000011,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25101,null,"See CPT",null,734.92560000000003,null,734.92560000000003,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25105,null,"See CPT",null,880.60260000000005,null,880.60260000000005,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R"]
[25107,null,"See CPT",null,1113.6858,null,1113.6858,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[25109,null,"See CPT",null,966.81960000000015,null,966.81960000000015,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[25110,null,"See CPT",null,630.27599999999995,null,630.27599999999995,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[25111,null,"See CPT",null,589.84320000000002,null,589.84320000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25112,null,"See CPT",null,707.57400000000007,null,707.57400000000007,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25115,null,"See CPT",null,1357.4718,null,1357.4718,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25116,null,"See CPT",null,1088.1180000000002,null,1088.1180000000002,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R"]
[25118,null,"See CPT",null,694.49279999999999,null,694.49279999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25119,null,"See CPT",null,909.73800000000006,null,909.73800000000006,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25120,null,"See CPT",null,907.3596,null,907.3596,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R"]
[25125,null,"See CPT",null,1075.0367999999999,null,1075.0367999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25126,null,"See CPT",null,1082.7666000000002,null,1082.7666000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25130,null,"See CPT",null,818.16959999999995,null,818.16959999999995,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25135,null,"See CPT",null,1013.793,null,1013.793,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25136,null,"See CPT",null,902.6028,null,902.6028,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25145,null,"See CPT",null,943.03559999999993,null,943.03559999999993,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25150,null,"See CPT",null,1025.0903999999998,null,1025.0903999999998,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[25151,null,"See CPT",null,1054.2257999999999,null,1054.2257999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25170,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[25210,null,"See CPT",null,890.71080000000006,null,890.71080000000006,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R"]
[25215,null,"See CPT",null,1115.4696000000001,null,1115.4696000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25230,null,"See CPT",null,783.68280000000004,null,783.68280000000004,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[25240,null,"See CPT",null,777.73680000000002,null,777.73680000000002,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R"]
[25246,null,"See CPT",null,372.21960000000001,null,128.43360000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[25248,null,"See CPT",null,759.30420000000004,null,759.30420000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25250,null,"See CPT",null,966.22500000000002,null,966.22500000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25251,null,"See CPT",null,1293.2550000000001,null,1293.2550000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25259,null,"See CPT",null,787.84500000000003,null,787.84500000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25260,null,"See CPT",null,1145.7942,null,1145.7942,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[25263,null,"See CPT",null,1145.7942,null,1145.7942,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[25265,null,"See CPT",null,1350.3366000000001,null,1350.3366000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[25270,null,"See CPT",null,893.68380000000002,null,893.68380000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[25272,null,"See CPT",null,1011.4146000000001,null,1011.4146000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[25274,null,"See CPT",null,1196.9297999999999,null,1196.9297999999999,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R"]
[25275,null,"See CPT",null,1210.0110000000002,null,1210.0110000000002,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R"]
[25280,null,"See CPT",null,1022.712,null,1022.712,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R"]
[25290,null,"See CPT",null,789.62879999999996,null,789.62879999999996,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[25295,null,"See CPT",null,952.54920000000004,null,952.54920000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[25300,null,"See CPT",null,1244.4978000000001,null,1244.4978000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25301,null,"See CPT",null,1157.6861999999999,null,1157.6861999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25310,null,"See CPT",null,1118.4425999999999,null,1118.4425999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[25312,null,"See CPT",null,1286.1197999999999,null,1286.1197999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[25315,null,"See CPT",null,1381.8504,null,1381.8504,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25316,null,"See CPT",null,1642.2852,null,1642.2852,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25320,null,"See CPT",null,1768.3404,null,1768.3404,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[25332,null,"See CPT",null,1515.0408,null,1515.0408,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25335,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","X"]
[25337,null,"See CPT",null,1590.5550000000001,null,1590.5550000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25350,null,"See CPT",null,1214.1732000000002,null,1214.1732000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25355,null,"See CPT",null,1374.7152000000001,null,1374.7152000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25360,null,"See CPT",null,1180.2810000000002,null,1180.2810000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25365,null,"See CPT",null,1644.069,null,1644.069,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25370,null,"See CPT",null,1814.1246000000001,null,1814.1246000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25375,null,"See CPT",null,1708.8804,null,1708.8804,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25390,null,"See CPT",null,1380.0666000000001,null,1380.0666000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25391,null,"See CPT",null,1782.6108000000002,null,1782.6108000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25392,null,"See CPT",null,1813.53,null,1813.53,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25393,null,"See CPT",null,2015.694,null,2015.694,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25394,null,"See CPT",null,1408.0128,null,1408.0128,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25400,null,"See CPT",null,1438.932,null,1438.932,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25405,null,"See CPT",null,1855.7466000000002,null,1855.7466000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25415,null,"See CPT",null,1733.8536000000001,null,1733.8536000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25420,null,"See CPT",null,2081.6945999999998,null,2081.6945999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25425,null,"See CPT",null,1726.7184,null,1726.7184,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25426,null,"See CPT",null,2004.3966,null,2004.3966,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25430,null,"See CPT",null,1315.8498,null,1315.8498,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25431,null,"See CPT",null,1413.3642,null,1413.3642,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25440,null,"See CPT",null,1378.2828,null,1378.2828,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25441,null,"See CPT",null,1680.3396,null,1680.3396,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25442,null,"See CPT",null,1454.3916000000002,null,1454.3916000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25443,null,"See CPT",null,1410.9858000000002,null,1410.9858000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25444,null,"See CPT",null,1487.6892,null,1487.6892,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25445,null,"See CPT",null,1292.0658000000001,null,1292.0658000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[25446,null,"See CPT",null,2087.6406000000002,null,2087.6406000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25447,null,"See CPT",null,1492.4460000000001,null,1492.4460000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25449,null,"See CPT",null,1848.0167999999999,null,1848.0167999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25450,null,"See CPT",null,1114.875,null,1114.875,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM"]
[25455,null,"See CPT",null,1315.8498,null,1315.8498,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM"]
[25490,null,"See CPT",null,1292.6604,null,1292.6604,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25491,null,"See CPT",null,1328.3363999999999,null,1328.3363999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25492,null,"See CPT",null,1625.6364000000001,null,1625.6364000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25500,null,"See CPT",null,525.03179999999998,null,472.70699999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25505,null,"See CPT",null,924.60300000000007,null,836.00760000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25515,null,"See CPT",null,1206.4433999999999,null,1206.4433999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25520,null,"See CPT",null,1053.6312,null,990.60360000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25525,null,"See CPT",null,1416.9317999999998,null,1416.9317999999998,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[25526,null,"See CPT",null,1714.2318,null,1714.2318,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[25530,null,"See CPT",null,486.97739999999999,null,445.95,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25535,null,"See CPT",null,907.95420000000001,null,834.22379999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25545,null,"See CPT",null,1127.3616000000002,null,1127.3616000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25560,null,"See CPT",null,535.14,null,475.68,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25565,null,"See CPT",null,949.57620000000009,null,846.71040000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25574,null,"See CPT",null,1215.3624000000002,null,1215.3624000000002,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[25575,null,"See CPT",null,1622.0688,null,1622.0688,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25600,null,"See CPT",null,625.51919999999996,null,597.57300000000009,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25605,null,"See CPT",null,985.84679999999992,null,929.95440000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25606,null,"See CPT",null,1205.8488,null,1205.8488,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25607,null,"See CPT",null,1330.1202000000001,null,1330.1202000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25608,null,"See CPT",null,1485.9053999999999,null,1485.9053999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25609,null,"See CPT",null,1884.8820000000001,null,1884.8820000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25622,null,"See CPT",null,567.24839999999995,null,522.65339999999992,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25624,null,"See CPT",null,902.00819999999999,null,814.60199999999998,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25628,null,"See CPT",null,1295.6333999999999,null,1295.6333999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25630,null,"See CPT",null,562.49160000000006,null,521.46420000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25635,null,"See CPT",null,855.62940000000003,null,774.16919999999993,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25645,null,"See CPT",null,1032.2256,null,1032.2256,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25650,null,"See CPT",null,608.2758,null,561.30240000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25651,null,"See CPT",null,886.54859999999996,null,886.54859999999996,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25652,null,"See CPT",null,1123.7939999999999,null,1123.7939999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[25660,null,"See CPT",null,818.76419999999996,null,818.76419999999996,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25670,null,"See CPT",null,1097.6316000000002,null,1097.6316000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25671,null,"See CPT",null,959.6844000000001,null,959.6844000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25675,null,"See CPT",null,822.92640000000006,null,740.27699999999993,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25676,null,"See CPT",null,1137.4697999999999,null,1137.4697999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25680,null,"See CPT",null,963.84660000000008,null,963.84660000000008,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25685,null,"See CPT",null,1321.2012,null,1321.2012,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25690,null,"See CPT",null,894.87300000000005,null,894.87300000000005,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25695,null,"See CPT",null,1144.0103999999999,null,1144.0103999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[25800,null,"See CPT",null,1314.6605999999999,null,1314.6605999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[25805,null,"See CPT",null,1521.5814,null,1521.5814,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[25810,null,"See CPT",null,1550.1222,null,1550.1222,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[25820,null,"See CPT",null,1180.8756000000001,null,1180.8756000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[25825,null,"See CPT",null,1438.3374000000001,null,1438.3374000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[25830,null,"See CPT",null,1894.3956000000001,null,1894.3956000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[25900,null,"See CPT",null,1287.9036000000001,null,1287.9036000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25905,null,"See CPT",null,1262.9304,null,1262.9304,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25907,null,"See CPT",null,1108.3344,null,1108.3344,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25909,null,"See CPT",null,1233.7950000000001,null,1233.7950000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25915,null,"See CPT",null,2078.1270000000004,null,2078.1270000000004,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25920,null,"See CPT",null,1325.9580000000001,null,1325.9580000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25922,null,"See CPT",null,1177.9025999999999,null,1177.9025999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25924,null,"See CPT",null,1296.2280000000001,null,1296.2280000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25927,null,"See CPT",null,1590.5550000000001,null,1590.5550000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[25929,null,"See CPT",null,1081.5774000000001,null,1081.5774000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[25931,null,"See CPT",null,1476.9864,null,1476.9864,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[25999,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,0,1,1,"","N"]
[26010,null,"See CPT",null,655.24919999999997,null,254.48880000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[26011,null,"See CPT",null,914.49480000000005,null,334.75979999999998,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[26020,null,"See CPT",null,1006.0632000000002,null,1006.0632000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26025,null,"See CPT",null,762.27719999999999,null,762.27719999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[26030,null,"See CPT",null,886.54859999999996,null,886.54859999999996,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[26034,null,"See CPT",null,999.5225999999999,null,999.5225999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26035,null,"See CPT",null,1546.5546000000002,null,1546.5546000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26037,null,"See CPT",null,1009.0361999999999,null,1009.0361999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[26040,null,"See CPT",null,574.97820000000002,null,574.97820000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[26045,null,"See CPT",null,855.62940000000003,null,855.62940000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[26055,null,"See CPT",null,1111.902,null,529.78859999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26060,null,"See CPT",null,467.35560000000004,null,467.35560000000004,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26070,null,"See CPT",null,582.70800000000008,null,582.70800000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[26075,null,"See CPT",null,613.62720000000002,null,613.62720000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[26080,null,"See CPT",null,724.81740000000002,null,724.81740000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26100,null,"See CPT",null,617.7894,null,617.7894,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[26105,null,"See CPT",null,621.9516000000001,null,621.9516000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[26110,null,"See CPT",null,592.22160000000008,null,592.22160000000008,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26111,null,"See CPT",null,747.41219999999998,null,747.41219999999998,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26113,null,"See CPT",null,982.87380000000007,null,982.87380000000007,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26115,null,"See CPT",null,1020.9282000000001,null,598.16759999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26116,null,"See CPT",null,945.41399999999999,null,945.41399999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26117,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","X"]
[26118,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","X"]
[26121,null,"See CPT",null,1080.9828,null,1080.9828,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[26123,null,"See CPT",null,1504.9325999999999,null,1504.9325999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[26125,null,"See CPT",null,473.89619999999996,null,473.89619999999996,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[26130,null,"See CPT",null,851.46720000000005,null,851.46720000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[26135,null,"See CPT",null,1001.9010000000001,null,1001.9010000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26140,null,"See CPT",null,919.25160000000005,null,919.25160000000005,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26145,null,"See CPT",null,932.33280000000002,null,932.33280000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26160,null,"See CPT",null,1155.3078,null,572.59980000000007,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26170,null,"See CPT",null,740.27699999999993,null,740.27699999999993,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26180,null,"See CPT",null,814.60199999999998,null,814.60199999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26185,null,"See CPT",null,1007.847,null,1007.847,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[26200,null,"See CPT",null,812.81820000000005,null,812.81820000000005,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26205,null,"See CPT",null,1093.4694,null,1093.4694,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26210,null,"See CPT",null,811.03440000000001,null,811.03440000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26215,null,"See CPT",null,1025.0903999999998,null,1025.0903999999998,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26230,null,"See CPT",null,903.19740000000002,null,903.19740000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26235,null,"See CPT",null,888.92700000000002,null,888.92700000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26236,null,"See CPT",null,799.73699999999997,null,799.73699999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26250,null,"See CPT",null,1900.3416,null,1900.3416,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26260,null,"See CPT",null,1427.04,null,1427.04,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26262,null,"See CPT",null,1133.3075999999999,null,1133.3075999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26320,null,"See CPT",null,635.62739999999997,null,635.62739999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26340,null,"See CPT",null,647.51940000000002,null,647.51940000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[26341,null,"See CPT",null,215.24520000000001,null,141.51480000000001,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[26350,null,"See CPT",null,1392.5532000000001,null,1392.5532000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26352,null,"See CPT",null,1545.96,null,1545.96,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26356,null,"See CPT",null,1438.3374000000001,null,1438.3374000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26357,null,"See CPT",null,1610.1768,null,1610.1768,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26358,null,"See CPT",null,1775.4756,null,1775.4756,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26370,null,"See CPT",null,1460.3375999999998,null,1460.3375999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26372,null,"See CPT",null,1696.9884,null,1696.9884,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26373,null,"See CPT",null,1635.7446000000002,null,1635.7446000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26390,null,"See CPT",null,1618.5011999999999,null,1618.5011999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26392,null,"See CPT",null,1850.3952000000002,null,1850.3952000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26410,null,"See CPT",null,1124.9832000000001,null,1124.9832000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26412,null,"See CPT",null,1334.2824000000001,null,1334.2824000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26415,null,"See CPT",null,1577.4738,null,1577.4738,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26416,null,"See CPT",null,1701.7452000000001,null,1701.7452000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26418,null,"See CPT",null,1168.9836,null,1168.9836,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26420,null,"See CPT",null,1384.2288000000001,null,1384.2288000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26426,null,"See CPT",null,910.33260000000007,null,910.33260000000007,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26428,null,"See CPT",null,1480.5539999999999,null,1480.5539999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26432,null,"See CPT",null,1019.1444,null,1019.1444,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26433,null,"See CPT",null,1069.6853999999998,null,1069.6853999999998,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26434,null,"See CPT",null,1295.6333999999999,null,1295.6333999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26437,null,"See CPT",null,1240.3355999999999,null,1240.3355999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26440,null,"See CPT",null,1218.93,null,1218.93,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26442,null,"See CPT",null,1824.8274000000001,null,1824.8274000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26445,null,"See CPT",null,1141.6320000000001,null,1141.6320000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26449,null,"See CPT",null,1257.579,null,1257.579,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26450,null,"See CPT",null,865.73760000000004,null,865.73760000000004,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26455,null,"See CPT",null,856.22400000000005,null,856.22400000000005,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26460,null,"See CPT",null,843.14279999999997,null,843.14279999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26471,null,"See CPT",null,1228.4436000000001,null,1228.4436000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26474,null,"See CPT",null,1215.9569999999999,null,1215.9569999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26476,null,"See CPT",null,1202.2811999999999,null,1202.2811999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26477,null,"See CPT",null,1166.0106000000001,null,1166.0106000000001,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R"]
[26478,null,"See CPT",null,1234.3896000000002,null,1234.3896000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26479,null,"See CPT",null,1259.3628000000001,null,1259.3628000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26480,null,"See CPT",null,1461.5267999999999,null,1461.5267999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26483,null,"See CPT",null,1612.5552,null,1612.5552,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26485,null,"See CPT",null,1548.3383999999999,null,1548.3383999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26489,null,"See CPT",null,1784.9892,null,1784.9892,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26490,null,"See CPT",null,1550.7167999999999,null,1550.7167999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26492,null,"See CPT",null,1709.4750000000001,null,1709.4750000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26494,null,"See CPT",null,1556.0682000000002,null,1556.0682000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26496,null,"See CPT",null,1670.826,null,1670.826,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26497,null,"See CPT",null,1669.0422000000001,null,1669.0422000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26498,null,"See CPT",null,2156.6142000000004,null,2156.6142000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26499,null,"See CPT",null,1607.7983999999999,null,1607.7983999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26500,null,"See CPT",null,1243.3086000000001,null,1243.3086000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26502,null,"See CPT",null,1402.0667999999998,null,1402.0667999999998,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26508,null,"See CPT",null,1257.579,null,1257.579,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[26510,null,"See CPT",null,1195.7406000000001,null,1195.7406000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26516,null,"See CPT",null,1378.2828,null,1378.2828,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[26517,null,"See CPT",null,1599.4739999999999,null,1599.4739999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[26518,null,"See CPT",null,1619.6904,null,1619.6904,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[26520,null,"See CPT",null,1277.2008000000001,null,1277.2008000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26525,null,"See CPT",null,1281.3630000000001,null,1281.3630000000001,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R"]
[26530,null,"See CPT",null,978.11699999999996,null,978.11699999999996,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26531,null,"See CPT",null,1138.6589999999999,null,1138.6589999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26535,null,"See CPT",null,790.8180000000001,null,790.8180000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26536,null,"See CPT",null,1394.337,null,1394.337,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26540,null,"See CPT",null,1299.201,null,1299.201,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R"]
[26541,null,"See CPT",null,1538.2302,null,1538.2302,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26542,null,"See CPT",null,1340.2284,null,1340.2284,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26545,null,"See CPT",null,1356.2826,null,1356.2826,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26546,null,"See CPT",null,1902.1253999999999,null,1902.1253999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[26548,null,"See CPT",null,1475.2025999999998,null,1475.2025999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26550,null,"See CPT",null,3002.73,null,3002.73,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[26551,null,"See CPT",null,5901.9996000000001,null,5901.9996000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[26553,null,"See CPT",null,5862.1614,null,5862.1614,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[26554,null,"See CPT",null,6814.116,null,6814.116,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[26555,null,"See CPT",null,2533.5906,null,2533.5906,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26556,null,"See CPT",null,6097.0284000000001,null,6097.0284000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26560,null,"See CPT",null,1186.2269999999999,null,1186.2269999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26561,null,"See CPT",null,1805.8002000000001,null,1805.8002000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26562,null,"See CPT",null,2505.6444000000001,null,2505.6444000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26565,null,"See CPT",null,1331.3094000000001,null,1331.3094000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26567,null,"See CPT",null,1334.877,null,1334.877,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26568,null,"See CPT",null,1725.5291999999999,null,1725.5291999999999,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26580,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","X"]
[26587,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","X"]
[26590,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","X"]
[26591,null,"See CPT",null,913.30560000000003,null,913.30560000000003,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26593,null,"See CPT",null,1201.6866,null,1201.6866,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26596,null,"See CPT",null,1500.1758,null,1500.1758,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26600,null,"See CPT",null,555.95100000000002,null,528.00480000000005,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26605,null,"See CPT",null,610.65419999999995,null,548.22120000000007,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26607,null,"See CPT",null,934.71120000000008,null,934.71120000000008,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26608,null,"See CPT",null,877.03499999999997,null,877.03499999999997,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26615,null,"See CPT",null,1040.55,null,1040.55,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26641,null,"See CPT",null,771.19620000000009,null,700.43880000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[26645,null,"See CPT",null,795.5748000000001,null,721.84440000000006,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[26650,null,"See CPT",null,877.62959999999998,null,877.62959999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[26665,null,"See CPT",null,1128.5508,null,1128.5508,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[26670,null,"See CPT",null,640.97879999999998,null,570.22140000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26675,null,"See CPT",null,847.30500000000006,null,770.60160000000008,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26676,null,"See CPT",null,926.98140000000001,null,926.98140000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26685,null,"See CPT",null,1042.3338000000001,null,1042.3338000000001,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R"]
[26686,null,"See CPT",null,1124.9832000000001,null,1124.9832000000001,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[26700,null,"See CPT",null,619.57320000000004,null,567.84300000000007,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26705,null,"See CPT",null,778.92600000000004,null,704.00639999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26706,null,"See CPT",null,812.22360000000003,null,812.22360000000003,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26715,null,"See CPT",null,1036.9824000000001,null,1036.9824000000001,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26720,null,"See CPT",null,369.2466,null,346.65180000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26725,null,"See CPT",null,629.08680000000004,null,557.14019999999994,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26727,null,"See CPT",null,863.35919999999999,null,863.35919999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26735,null,"See CPT",null,1074.4422,null,1074.4422,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26740,null,"See CPT",null,429.30119999999999,null,405.5172,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26742,null,"See CPT",null,687.35760000000005,null,614.22180000000003,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26746,null,"See CPT",null,1336.6608000000001,null,1336.6608000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26750,null,"See CPT",null,344.27339999999998,null,346.65180000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26755,null,"See CPT",null,588.654,null,502.43699999999995,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26756,null,"See CPT",null,775.95300000000009,null,775.95300000000009,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26765,null,"See CPT",null,910.92720000000008,null,910.92720000000008,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26770,null,"See CPT",null,523.84260000000006,null,474.49080000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26775,null,"See CPT",null,722.43900000000008,null,645.73559999999998,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26776,null,"See CPT",null,821.14260000000002,null,821.14260000000002,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26785,null,"See CPT",null,988.81979999999999,null,988.81979999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26820,null,"See CPT",null,1534.6625999999999,null,1534.6625999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[26841,null,"See CPT",null,1432.3914,null,1432.3914,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R"]
[26842,null,"See CPT",null,1538.8247999999999,null,1538.8247999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[26843,null,"See CPT",null,1450.8239999999998,null,1450.8239999999998,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26844,null,"See CPT",null,1589.3658,null,1589.3658,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26850,null,"See CPT",null,1361.634,null,1361.634,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26852,null,"See CPT",null,1535.8517999999999,null,1535.8517999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26860,null,"See CPT",null,1142.8211999999999,null,1142.8211999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26861,null,"See CPT",null,179.5692,null,179.5692,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[26862,null,"See CPT",null,1418.1210000000001,null,1418.1210000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[26863,null,"See CPT",null,400.16580000000005,null,400.16580000000005,null,"000",0,0,0,0,0,0,2,0,0,"","R"]
[26910,null,"See CPT",null,1408.0128,null,1408.0128,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26951,null,"See CPT",null,1298.6064000000001,null,1298.6064000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26952,null,"See CPT",null,1268.2818,null,1268.2818,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26989,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,1,1,1,"","N"]
[26990,null,"See CPT",null,1240.3355999999999,null,1240.3355999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[26991,null,"See CPT",null,1294.4441999999999,null,941.84640000000002,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[26992,null,"See CPT",null,1814.7192,null,1814.7192,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[27000,null,"See CPT",null,727.19580000000008,null,727.19580000000008,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27001,null,"See CPT",null,973.36020000000008,null,973.36020000000008,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27003,null,"See CPT",null,1080.3882000000001,null,1080.3882000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27005,null,"See CPT",null,1297.4172000000001,null,1297.4172000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27006,null,"See CPT",null,1288.4982000000002,null,1288.4982000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27025,null,"See CPT",null,1651.7988,null,1651.7988,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R"]
[27027,null,"See CPT",null,1581.0414000000001,null,1581.0414000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27030,null,"See CPT",null,1673.2044000000001,null,1673.2044000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27033,null,"See CPT",null,1735.6374000000001,null,1735.6374000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27035,null,"See CPT",null,2069.8026,null,2069.8026,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[27036,null,"See CPT",null,1820.6652000000001,null,1820.6652000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27040,null,"See CPT",null,626.70839999999998,null,353.19240000000002,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[27041,null,"See CPT",null,1268.8764000000001,null,1268.8764000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27043,null,"See CPT",null,838.38599999999997,null,838.38599999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27045,null,"See CPT",null,1309.9038,null,1309.9038,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27047,null,"See CPT",null,910.92720000000008,null,647.51940000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27048,null,"See CPT",null,1089.9017999999999,null,1089.9017999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27049,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[27050,null,"See CPT",null,734.92560000000003,null,734.92560000000003,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R"]
[27052,null,"See CPT",null,1041.7392,null,1041.7392,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27054,null,"See CPT",null,1236.768,null,1236.768,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27057,null,"See CPT",null,1801.0434,null,1801.0434,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27059,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[27060,null,"See CPT",null,841.35900000000004,null,841.35900000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27062,null,"See CPT",null,822.33180000000004,null,822.33180000000004,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27065,null,"See CPT",null,950.17079999999999,null,950.17079999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27066,null,"See CPT",null,1462.1214,null,1462.1214,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27067,null,"See CPT",null,1850.9898000000001,null,1850.9898000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27070,null,"See CPT",null,1606.0146000000002,null,1606.0146000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27071,null,"See CPT",null,1760.0160000000001,null,1760.0160000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27075,null,"See CPT",null,3687.7092000000002,null,3687.7092000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[27076,null,"See CPT",null,4452.3647999999994,null,4452.3647999999994,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[27077,null,"See CPT",null,4963.7208000000001,null,4963.7208000000001,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[27078,null,"See CPT",null,3635.9789999999998,null,3635.9789999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27080,null,"See CPT",null,918.06240000000003,null,918.06240000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[27086,null,"See CPT",null,579.1404,null,303.84060000000005,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R"]
[27087,null,"See CPT",null,1099.4153999999999,null,1099.4153999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27090,null,"See CPT",null,1487.6892,null,1487.6892,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27091,null,"See CPT",null,2827.9176000000002,null,2827.9176000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27093,null,"See CPT",null,449.51759999999996,null,118.92,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[27095,null,"See CPT",null,605.89739999999995,null,145.67700000000002,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[27096,null,"See CPT",null,299.0838,null,145.67700000000002,null,"000",0,0,0,0,2,1,1,0,0,"","R",null,"Y-UR"]
[27097,null,"See CPT",null,1229.6328000000001,null,1229.6328000000001,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27098,null,"See CPT",null,1251.633,null,1251.633,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27100,null,"See CPT",null,1490.0675999999999,null,1490.0675999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27105,null,"See CPT",null,1561.4196000000002,null,1561.4196000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27110,null,"See CPT",null,1738.0158000000001,null,1738.0158000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27111,null,"See CPT",null,1619.0958000000001,null,1619.0958000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27120,null,"See CPT",null,2312.3994000000002,null,2312.3994000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27122,null,"See CPT",null,1969.3151999999998,null,1969.3151999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27125,null,"See CPT",null,2015.694,null,2015.694,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27130,null,"See CPT",null,2280.8856000000001,null,2280.8856000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27132,null,"See CPT",null,2963.4864000000002,null,2963.4864000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27134,null,"See CPT",null,3371.3820000000001,null,3371.3820000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27137,null,"See CPT",null,2598.9965999999999,null,2598.9965999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27138,null,"See CPT",null,2700.6732000000002,null,2700.6732000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27140,null,"See CPT",null,1598.2847999999999,null,1598.2847999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27146,null,"See CPT",null,2279.1017999999999,null,2279.1017999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27147,null,"See CPT",null,2598.9965999999999,null,2598.9965999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27151,null,"See CPT",null,2807.1066000000001,null,2807.1066000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27156,null,"See CPT",null,3022.9464000000003,null,3022.9464000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27158,null,"See CPT",null,2488.9956000000002,null,2488.9956000000002,null,"090",0.1,0.69,0.21,0,2,2,2,0,0,"","R"]
[27161,null,"See CPT",null,2175.6414000000004,null,2175.6414000000004,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27165,null,"See CPT",null,2455.1034,null,2455.1034,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27170,null,"See CPT",null,2074.5594000000001,null,2074.5594000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27175,null,"See CPT",null,1193.9567999999999,null,1193.9567999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27176,null,"See CPT",null,1651.2041999999999,null,1651.2041999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27177,null,"See CPT",null,1991.3154000000002,null,1991.3154000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27178,null,"See CPT",null,1651.2041999999999,null,1651.2041999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27179,null,"See CPT",null,1751.097,null,1751.097,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27181,null,"See CPT",null,1997.2614000000003,null,1997.2614000000003,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27185,null,"See CPT",null,1290.8766000000001,null,1290.8766000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27187,null,"See CPT",null,1782.6108000000002,null,1782.6108000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27197,null,"See CPT",null,242.5968,null,242.5968,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[27198,null,"See CPT",null,569.6268,null,569.6268,null,"000",0,0,0,0,2,0,0,2,0,"","R"]
[27200,null,"See CPT",null,344.27339999999998,null,345.46260000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[27202,null,"See CPT",null,946.60320000000002,null,946.60320000000002,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[27215,null,"See CPT",null,1076.2260000000001,null,1076.2260000000001,null,"090",0.1,0.69,0.21,9,9,9,9,9,9,"","R"]
[27216,null,"See CPT",null,1589.9603999999999,null,1589.9603999999999,null,"090",0.1,0.69,0.21,9,9,9,9,9,9,"","R"]
[27217,null,"See CPT",null,1494.8244,null,1494.8244,null,"090",0.1,0.69,0.21,9,9,9,9,9,9,"","R"]
[27218,null,"See CPT",null,2048.3970000000004,null,2048.3970000000004,null,"090",0.1,0.69,0.21,9,9,9,9,9,9,"","R"]
[27220,null,"See CPT",null,756.33120000000008,null,743.84460000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27222,null,"See CPT",null,1760.0160000000001,null,1760.0160000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27226,null,"See CPT",null,1881.3144,null,1881.3144,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27227,null,"See CPT",null,2927.8104000000003,null,2927.8104000000003,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27228,null,"See CPT",null,3325.0032000000001,null,3325.0032000000001,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27230,null,"See CPT",null,883.57560000000001,null,865.73760000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27232,null,"See CPT",null,1314.066,null,1314.066,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27235,null,"See CPT",null,1622.6633999999999,null,1622.6633999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27236,null,"See CPT",null,2125.1004000000003,null,2125.1004000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27238,null,"See CPT",null,846.71040000000005,null,846.71040000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27240,null,"See CPT",null,1714.8263999999999,null,1714.8263999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27244,null,"See CPT",null,2185.7496000000001,null,2185.7496000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27245,null,"See CPT",null,2183.9657999999999,null,2183.9657999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27246,null,"See CPT",null,709.3578,null,699.8442,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27248,null,"See CPT",null,1335.4716000000001,null,1335.4716000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27250,null,"See CPT",null,313.94880000000001,null,313.94880000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[27252,null,"See CPT",null,1352.1204,null,1352.1204,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27253,null,"See CPT",null,1681.5288,null,1681.5288,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27254,null,"See CPT",null,2264.8314,null,2264.8314,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27256,null,"See CPT",null,551.19420000000002,null,420.38220000000001,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R"]
[27257,null,"See CPT",null,642.16800000000001,null,642.16800000000001,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R"]
[27258,null,"See CPT",null,1984.1801999999998,null,1984.1801999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27259,null,"See CPT",null,2741.1060000000002,null,2741.1060000000002,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27265,null,"See CPT",null,742.65539999999999,null,742.65539999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27266,null,"See CPT",null,1054.2257999999999,null,1054.2257999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27267,null,"See CPT",null,798.54779999999994,null,798.54779999999994,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27268,null,"See CPT",null,981.68460000000016,null,981.68460000000016,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27269,null,"See CPT",null,2204.1822000000002,null,2204.1822000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27275,null,"See CPT",null,329.40840000000003,null,329.40840000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[27279,null,"See CPT",null,1490.6622,null,1490.6622,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27280,null,"See CPT",null,2408.13,null,2408.13,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27282,null,"See CPT",null,1542.3924000000002,null,1542.3924000000002,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[27284,null,"See CPT",null,2843.3771999999999,null,2843.3771999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27286,null,"See CPT",null,2914.1345999999999,null,2914.1345999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27290,null,"See CPT",null,2887.3776000000003,null,2887.3776000000003,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[27295,null,"See CPT",null,2242.2366000000002,null,2242.2366000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27299,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,1,1,"","N"]
[27301,null,"See CPT",null,1231.4166,null,910.92720000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27303,null,"See CPT",null,1147.578,null,1147.578,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27305,null,"See CPT",null,872.87279999999998,null,872.87279999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27306,null,"See CPT",null,613.0326,null,613.0326,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27307,null,"See CPT",null,755.14199999999994,null,755.14199999999994,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R"]
[27310,null,"See CPT",null,1315.2552000000001,null,1315.2552000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27323,null,"See CPT",null,503.62620000000004,null,311.57040000000001,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[27324,null,"See CPT",null,733.7364,null,733.7364,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27325,null,"See CPT",null,1020.3336,null,1020.3336,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM"]
[27326,null,"See CPT",null,946.0086,null,946.0086,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[27327,null,"See CPT",null,934.71120000000008,null,566.65379999999993,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27328,null,"See CPT",null,1114.2803999999999,null,1114.2803999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27329,null,"See CPT",null,1851.5844,null,1851.5844,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27330,null,"See CPT",null,764.65559999999994,null,764.65559999999994,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[27331,null,"See CPT",null,860.98080000000004,null,860.98080000000004,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27332,null,"See CPT",null,1163.0375999999999,null,1163.0375999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27333,null,"See CPT",null,1063.1448,null,1063.1448,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27334,null,"See CPT",null,1233.7950000000001,null,1233.7950000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27335,null,"See CPT",null,1375.3098,null,1375.3098,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27337,null,"See CPT",null,752.16899999999998,null,752.16899999999998,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27339,null,"See CPT",null,1347.9582,null,1347.9582,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27340,null,"See CPT",null,680.81700000000001,null,680.81700000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[27345,null,"See CPT",null,878.2242,null,878.2242,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27347,null,"See CPT",null,949.57620000000009,null,949.57620000000009,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27350,null,"See CPT",null,1179.0917999999999,null,1179.0917999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27355,null,"See CPT",null,1097.037,null,1097.037,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27356,null,"See CPT",null,1329.5255999999999,null,1329.5255999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27357,null,"See CPT",null,1472.2296000000001,null,1472.2296000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27358,null,"See CPT",null,483.40980000000008,null,483.40980000000008,null,"000",0,0,0,0,0,0,2,0,0,"","R",null,"Y-UR"]
[27360,null,"See CPT",null,1636.9338,null,1636.9338,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27364,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[27365,null,"See CPT",null,3633.6006000000002,null,3633.6006000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27369,null,"See CPT",null,330.5976,null,70.162800000000004,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[27372,null,"See CPT",null,1093.4694,null,724.22280000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27380,null,"See CPT",null,1133.9022,null,1133.9022,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27381,null,"See CPT",null,1485.3108,null,1485.3108,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27385,null,"See CPT",null,1106.5506,null,1106.5506,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27386,null,"See CPT",null,1551.9060000000002,null,1551.9060000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27390,null,"See CPT",null,812.81820000000005,null,812.81820000000005,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[27391,null,"See CPT",null,1003.6848,null,1003.6848,null,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R",null,"Y-UR"]
[27392,null,"See CPT",null,1281.9576,null,1281.9576,null,"090",0.1,0.69,0.21,0,2,2,2,1,0,"","R",null,"Y-UR"]
[27393,null,"See CPT",null,906.17039999999997,null,906.17039999999997,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27394,null,"See CPT",null,1178.4972,null,1178.4972,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-UR"]
[27395,null,"See CPT",null,1580.4467999999999,null,1580.4467999999999,null,"090",0.1,0.69,0.21,0,2,2,2,1,0,"","R",null,"Y-UR"]
[27396,null,"See CPT",null,1114.2803999999999,null,1114.2803999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27397,null,"See CPT",null,1638.123,null,1638.123,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[27400,null,"See CPT",null,1252.2275999999999,null,1252.2275999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27403,null,"See CPT",null,1161.2538000000002,null,1161.2538000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27405,null,"See CPT",null,1218.3353999999999,null,1218.3353999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27407,null,"See CPT",null,1431.7967999999998,null,1431.7967999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27409,null,"See CPT",null,1731.4752000000001,null,1731.4752000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27412,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[27415,null,"See CPT",null,2444.4005999999999,null,2444.4005999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27416,null,"See CPT",null,1751.097,null,1751.097,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR"]
[27418,null,"See CPT",null,1491.2567999999999,null,1491.2567999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27420,null,"See CPT",null,1333.6877999999999,null,1333.6877999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27422,null,"See CPT",null,1334.2824000000001,null,1334.2824000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27424,null,"See CPT",null,1344.9852000000001,null,1344.9852000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27425,null,"See CPT",null,822.33180000000004,null,822.33180000000004,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[27427,null,"See CPT",null,1277.2008000000001,null,1277.2008000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27428,null,"See CPT",null,1997.8560000000002,null,1997.8560000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27429,null,"See CPT",null,2248.7772,null,2248.7772,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27430,null,"See CPT",null,1334.2824000000001,null,1334.2824000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27435,null,"See CPT",null,1446.0672,null,1446.0672,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27437,null,"See CPT",null,1187.4161999999999,null,1187.4161999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[27438,null,"See CPT",null,1504.9325999999999,null,1504.9325999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27440,null,"See CPT",null,1430.6076,null,1430.6076,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27441,null,"See CPT",null,1476.3917999999999,null,1476.3917999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27442,null,"See CPT",null,1558.4466,null,1558.4466,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27443,null,"See CPT",null,1462.7160000000001,null,1462.7160000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27445,null,"See CPT",null,2233.3176000000003,null,2233.3176000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27446,null,"See CPT",null,2051.37,null,2051.37,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27447,null,"See CPT",null,2278.5072,null,2278.5072,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27448,null,"See CPT",null,1449.6348,null,1449.6348,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27450,null,"See CPT",null,1808.7732000000001,null,1808.7732000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27454,null,"See CPT",null,2301.6966000000002,null,2301.6966000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27455,null,"See CPT",null,1724.9346,null,1724.9346,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27457,null,"See CPT",null,1716.0155999999999,null,1716.0155999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27465,null,"See CPT",null,2221.4256,null,2221.4256,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27466,null,"See CPT",null,2112.6138000000001,null,2112.6138000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27468,null,"See CPT",null,2387.319,null,2387.319,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27470,null,"See CPT",null,2103.1001999999999,null,2103.1001999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27472,null,"See CPT",null,2250.5610000000001,null,2250.5610000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27475,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","X"]
[27477,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","X"]
[27479,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","X"]
[27485,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","X"]
[27486,null,"See CPT",null,2494.9416000000001,null,2494.9416000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27487,null,"See CPT",null,3107.9742000000001,null,3107.9742000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27488,null,"See CPT",null,2136.9924000000001,null,2136.9924000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27495,null,"See CPT",null,2015.694,null,2015.694,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27496,null,"See CPT",null,991.19820000000016,null,991.19820000000016,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27497,null,"See CPT",null,1045.3067999999998,null,1045.3067999999998,null,"090",0.1,0.69,0.21,0,2,1,0,2,0,"","R"]
[27498,null,"See CPT",null,1183.2539999999999,null,1183.2539999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27499,null,"See CPT",null,1261.1466,null,1261.1466,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27500,null,"See CPT",null,946.60320000000002,null,867.52139999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27501,null,"See CPT",null,918.06240000000003,null,899.62980000000005,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27502,null,"See CPT",null,1357.4718,null,1357.4718,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27503,null,"See CPT",null,1432.3914,null,1432.3914,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27506,null,"See CPT",null,2381.373,null,2381.373,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27507,null,"See CPT",null,1724.9346,null,1724.9346,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27508,null,"See CPT",null,956.1167999999999,null,904.38660000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27509,null,"See CPT",null,1229.6328000000001,null,1229.6328000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27510,null,"See CPT",null,1216.5516,null,1216.5516,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27511,null,"See CPT",null,1773.0971999999999,null,1773.0971999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27513,null,"See CPT",null,2196.4523999999997,null,2196.4523999999997,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27514,null,"See CPT",null,1721.9616000000001,null,1721.9616000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27516,null,"See CPT",null,946.0086,null,881.79179999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27517,null,"See CPT",null,1240.3355999999999,null,1240.3355999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27519,null,"See CPT",null,1589.3658,null,1589.3658,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27520,null,"See CPT",null,599.35680000000002,null,552.97800000000007,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27524,null,"See CPT",null,1352.7149999999999,null,1352.7149999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27530,null,"See CPT",null,569.03219999999999,null,533.35620000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27532,null,"See CPT",null,1124.9832000000001,null,1046.4960000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27535,null,"See CPT",null,1599.4739999999999,null,1599.4739999999999,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27536,null,"See CPT",null,2114.3976000000002,null,2114.3976000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27538,null,"See CPT",null,890.71080000000006,null,825.30480000000011,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27540,null,"See CPT",null,1459.1484,null,1459.1484,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27550,null,"See CPT",null,938.27879999999993,null,859.197,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27552,null,"See CPT",null,1144.605,null,1144.605,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27556,null,"See CPT",null,1564.3925999999999,null,1564.3925999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27557,null,"See CPT",null,1861.6925999999999,null,1861.6925999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27558,null,"See CPT",null,2114.3976000000002,null,2114.3976000000002,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27560,null,"See CPT",null,676.06020000000001,null,614.22180000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27562,null,"See CPT",null,888.92700000000002,null,888.92700000000002,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27566,null,"See CPT",null,1597.0955999999999,null,1597.0955999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27570,null,"See CPT",null,275.2998,null,275.2998,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[27580,null,"See CPT",null,2639.4294,null,2639.4294,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27590,null,"See CPT",null,1387.7963999999999,null,1387.7963999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27591,null,"See CPT",null,1723.1508000000001,null,1723.1508000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27592,null,"See CPT",null,1185.0378000000001,null,1185.0378000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27594,null,"See CPT",null,906.76499999999999,null,906.76499999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[27596,null,"See CPT",null,1267.0925999999999,null,1267.0925999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[27598,null,"See CPT",null,1242.1194,null,1242.1194,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27599,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,1,1,"","N",null,"Y-UR"]
[27600,null,"See CPT",null,721.84440000000006,null,721.84440000000006,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27601,null,"See CPT",null,803.89919999999995,null,803.89919999999995,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27602,null,"See CPT",null,849.68340000000001,null,849.68340000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27603,null,"See CPT",null,973.95479999999998,null,705.79019999999991,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27604,null,"See CPT",null,819.95339999999999,null,576.16739999999993,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27605,null,"See CPT",null,610.05960000000005,null,326.43540000000002,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R"]
[27606,null,"See CPT",null,487.57199999999995,null,487.57199999999995,null,"010",0.1,0.8,0.1,0,2,1,1,1,0,"","R"]
[27607,null,"See CPT",null,1069.6853999999998,null,1069.6853999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27610,null,"See CPT",null,1162.443,null,1162.443,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[27612,null,"See CPT",null,1003.0902000000001,null,1003.0902000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27613,null,"See CPT",null,464.38259999999997,null,287.1918,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[27614,null,"See CPT",null,1064.9286,null,739.68240000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27615,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","X"]
[27616,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","X"]
[27618,null,"See CPT",null,906.76499999999999,null,550.59960000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27619,null,"See CPT",null,825.89940000000001,null,825.89940000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27620,null,"See CPT",null,810.4398000000001,null,810.4398000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27625,null,"See CPT",null,1029.2526,null,1029.2526,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27626,null,"See CPT",null,1079.1989999999998,null,1079.1989999999998,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[27630,null,"See CPT",null,993.5766000000001,null,645.14099999999996,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27632,null,"See CPT",null,737.89859999999999,null,737.89859999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27634,null,"See CPT",null,1205.8488,null,1205.8488,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27635,null,"See CPT",null,1041.1446000000001,null,1041.1446000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27637,null,"See CPT",null,1318.2282,null,1318.2282,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27638,null,"See CPT",null,1344.3905999999999,null,1344.3905999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27640,null,"See CPT",null,1488.2838000000002,null,1488.2838000000002,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27641,null,"See CPT",null,1167.1997999999999,null,1167.1997999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27645,null,"See CPT",null,3132.3528000000001,null,3132.3528000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27646,null,"See CPT",null,2725.0517999999997,null,2725.0517999999997,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27647,null,"See CPT",null,1760.6106,null,1760.6106,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27648,null,"See CPT",null,412.65240000000006,null,89.784599999999998,null,"000",0,0,0,0,2,1,0,0,0,"","R"]
[27650,null,"See CPT",null,1183.8486,null,1183.8486,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27652,null,"See CPT",null,1178.4972,null,1178.4972,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[27654,null,"See CPT",null,1277.2008000000001,null,1277.2008000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27656,null,"See CPT",null,1008.4416000000001,null,634.43820000000005,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27658,null,"See CPT",null,662.97900000000004,null,662.97900000000004,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[27659,null,"See CPT",null,842.54819999999995,null,842.54819999999995,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[27664,null,"See CPT",null,657.62760000000003,null,657.62760000000003,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,"Y-UR"]
[27665,null,"See CPT",null,759.89879999999994,null,759.89879999999994,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[27675,null,"See CPT",null,882.38639999999998,null,882.38639999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27676,null,"See CPT",null,1090.4964,null,1090.4964,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[27680,null,"See CPT",null,750.97980000000007,null,750.97980000000007,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-UR"]
[27681,null,"See CPT",null,913.30560000000003,null,913.30560000000003,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[27685,null,"See CPT",null,1195.7406000000001,null,833.03459999999995,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27686,null,"See CPT",null,954.33300000000008,null,954.33300000000008,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[27687,null,"See CPT",null,814.60199999999998,null,814.60199999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27690,null,"See CPT",null,1149.9564,null,1149.9564,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27691,null,"See CPT",null,1334.2824000000001,null,1334.2824000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27692,null,"See CPT",null,177.1908,null,177.1908,null,"000",0,0,0,0,0,0,2,1,0,"","R"]
[27695,null,"See CPT",null,862.17,null,862.17,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[27696,null,"See CPT",null,982.27919999999995,null,982.27919999999995,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[27698,null,"See CPT",null,1140.4428,null,1140.4428,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27700,null,"See CPT",null,1097.037,null,1097.037,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27702,null,"See CPT",null,1718.394,null,1718.394,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27703,null,"See CPT",null,1975.2611999999999,null,1975.2611999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR"]
[27704,null,"See CPT",null,1025.0903999999998,null,1025.0903999999998,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[27705,null,"See CPT",null,1359.2556,null,1359.2556,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27707,null,"See CPT",null,730.76339999999993,null,730.76339999999993,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[27709,null,"See CPT",null,2035.9104000000002,null,2035.9104000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27712,null,"See CPT",null,1966.3422,null,1966.3422,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27715,null,"See CPT",null,1915.8011999999999,null,1915.8011999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27720,null,"See CPT",null,1566.1764000000001,null,1566.1764000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27722,null,"See CPT",null,1603.0416,null,1603.0416,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27724,null,"See CPT",null,2228.5607999999997,null,2228.5607999999997,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27725,null,"See CPT",null,2166.7224000000001,null,2166.7224000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27726,null,"See CPT",null,1711.2588000000001,null,1711.2588000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27727,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[27730,null,"See CPT",null,1061.3610000000001,null,1061.3610000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-CM"]
[27732,null,"See CPT",null,821.14260000000002,null,821.14260000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM"]
[27734,null,"See CPT",null,1184.4432000000002,null,1184.4432000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM"]
[27740,null,"See CPT",null,1272.444,null,1272.444,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM"]
[27742,null,"See CPT",null,1394.337,null,1394.337,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[27745,null,"See CPT",null,1358.0663999999999,null,1358.0663999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27750,null,"See CPT",null,638.60040000000004,null,591.62699999999995,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27752,null,"See CPT",null,974.54939999999999,null,889.52160000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27756,null,"See CPT",null,1045.9014,null,1045.9014,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27758,null,"See CPT",null,1605.42,null,1605.42,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27759,null,"See CPT",null,1780.827,null,1780.827,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27760,null,"See CPT",null,611.84339999999997,null,564.27539999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27762,null,"See CPT",null,881.19720000000007,null,794.98019999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27766,null,"See CPT",null,1089.9017999999999,null,1089.9017999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27767,null,"See CPT",null,538.70760000000007,null,533.35620000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27768,null,"See CPT",null,814.00739999999996,null,814.00739999999996,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27769,null,"See CPT",null,1307.5254,null,1307.5254,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27780,null,"See CPT",null,571.41059999999993,null,524.43720000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27781,null,"See CPT",null,797.95320000000004,null,732.54719999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27784,null,"See CPT",null,1271.2547999999999,null,1271.2547999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27786,null,"See CPT",null,578.54579999999999,null,529.78859999999997,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27788,null,"See CPT",null,777.73680000000002,null,701.62800000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27792,null,"See CPT",null,1161.2538000000002,null,1161.2538000000002,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27808,null,"See CPT",null,618.97860000000003,null,563.08620000000008,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27810,null,"See CPT",null,861.57540000000006,null,773.57460000000003,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27814,null,"See CPT",null,1372.3367999999998,null,1372.3367999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27816,null,"See CPT",null,609.46500000000003,null,539.89679999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27818,null,"See CPT",null,891.9,null,793.19640000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27822,null,"See CPT",null,1584.6089999999999,null,1584.6089999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27823,null,"See CPT",null,1776.6648,null,1776.6648,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27824,null,"See CPT",null,582.70800000000008,null,557.73480000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27825,null,"See CPT",null,985.25220000000002,null,885.95400000000006,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27826,null,"See CPT",null,1546.5546000000002,null,1546.5546000000002,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27827,null,"See CPT",null,2019.2616,null,2019.2616,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27828,null,"See CPT",null,2388.5082000000002,null,2388.5082000000002,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27829,null,"See CPT",null,1283.1468,null,1283.1468,null,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R"]
[27830,null,"See CPT",null,717.08760000000007,null,659.41139999999996,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27831,null,"See CPT",null,745.03379999999993,null,745.03379999999993,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27832,null,"See CPT",null,1360.4448,null,1360.4448,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27840,null,"See CPT",null,694.49279999999999,null,694.49279999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27842,null,"See CPT",null,897.846,null,897.846,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27846,null,"See CPT",null,1297.4172000000001,null,1297.4172000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27848,null,"See CPT",null,1415.1480000000001,null,1415.1480000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27860,null,"See CPT",null,297.3,null,297.3,null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R"]
[27870,null,"See CPT",null,1804.6110000000001,null,1804.6110000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27871,null,"See CPT",null,1238.5518,null,1238.5518,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[27880,null,"See CPT",null,1586.9874000000002,null,1586.9874000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27881,null,"See CPT",null,1515.0408,null,1515.0408,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27882,null,"See CPT",null,1045.9014,null,1045.9014,null,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R"]
[27884,null,"See CPT",null,1027.4688000000001,null,1027.4688000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[27886,null,"See CPT",null,1154.7132000000001,null,1154.7132000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27888,null,"See CPT",null,1155.3078,null,1155.3078,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[27889,null,"See CPT",null,1124.3886,null,1124.3886,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[27892,null,"See CPT",null,958.49520000000007,null,958.49520000000007,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27893,null,"See CPT",null,1105.9560000000001,null,1105.9560000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[27894,null,"See CPT",null,1457.9592,null,1457.9592,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[27899,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,0,1,1,"","N"]
[28001,null,"See CPT",null,316.92180000000002,null,170.65020000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[28002,null,"See CPT",null,455.46360000000004,null,249.73200000000003,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[28003,null,"See CPT",null,692.11440000000005,null,461.40960000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[28005,null,"See CPT",null,1021.5228,null,1021.5228,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28008,null,"See CPT",null,778.33140000000003,null,525.03179999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28010,null,"See CPT",null,419.19299999999998,null,370.43580000000003,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28011,null,"See CPT",null,564.27539999999999,null,498.86940000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28020,null,"See CPT",null,1003.6848,null,662.97900000000004,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-UR"]
[28022,null,"See CPT",null,885.35940000000005,null,583.30259999999998,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-UR"]
[28024,null,"See CPT",null,828.27779999999996,null,542.86980000000005,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-UR"]
[28035,null,"See CPT",null,952.54920000000004,null,635.03279999999995,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[28039,null,"See CPT",null,888.33240000000001,null,617.7894,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[28041,null,"See CPT",null,801.52080000000001,null,801.52080000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28043,null,"See CPT",null,696.87120000000004,null,463.1934,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28045,null,"See CPT",null,865.14300000000003,null,614.81640000000004,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28046,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","X"]
[28047,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[28050,null,"See CPT",null,754.54739999999993,null,495.30180000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[28052,null,"See CPT",null,708.16859999999997,null,454.86900000000003,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[28054,null,"See CPT",null,667.14120000000003,null,416.81459999999998,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28055,null,"See CPT",null,680.22239999999999,null,680.22239999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28060,null,"See CPT",null,944.81940000000009,null,645.14099999999996,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28062,null,"See CPT",null,1029.8471999999999,null,712.92539999999997,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[28070,null,"See CPT",null,935.90039999999999,null,620.16779999999994,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28072,null,"See CPT",null,893.08920000000001,null,580.32960000000003,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28080,null,"See CPT",null,968.00880000000006,null,674.87099999999998,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[28086,null,"See CPT",null,978.11699999999996,null,638.00580000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28088,null,"See CPT",null,831.25080000000003,null,515.51819999999998,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28090,null,"See CPT",null,844.33199999999999,null,548.22120000000007,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28092,null,"See CPT",null,761.68260000000009,null,481.62599999999998,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28100,null,"See CPT",null,1119.0372,null,752.16899999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28102,null,"See CPT",null,1101.1992,null,1101.1992,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[28103,null,"See CPT",null,689.73599999999999,null,689.73599999999999,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[28104,null,"See CPT",null,951.95460000000014,null,629.68140000000005,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[28106,null,"See CPT",null,757.5204,null,757.5204,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[28107,null,"See CPT",null,913.30560000000003,null,615.41099999999994,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R"]
[28108,null,"See CPT",null,789.03419999999994,null,513.73440000000005,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28110,null,"See CPT",null,837.19680000000005,null,519.08580000000006,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[28111,null,"See CPT",null,872.87279999999998,null,572.59980000000007,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[28112,null,"See CPT",null,879.41339999999991,null,558.32940000000008,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[28113,null,"See CPT",null,1058.9826,null,759.30420000000004,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR"]
[28114,null,"See CPT",null,1926.5039999999999,null,1494.8244,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28116,null,"See CPT",null,1395.5262,null,1041.1446000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[28118,null,"See CPT",null,1094.6586,null,752.16899999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28119,null,"See CPT",null,954.33300000000008,null,649.30320000000006,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[28120,null,"See CPT",null,1220.7138,null,888.33240000000001,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[28122,null,"See CPT",null,1068.4962,null,780.11519999999996,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28124,null,"See CPT",null,863.35919999999999,null,594.00540000000001,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[28126,null,"See CPT",null,708.16859999999997,null,441.7878,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28130,null,"See CPT",null,1094.6586,null,1094.6586,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28140,null,"See CPT",null,1039.3607999999999,null,764.06100000000004,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R"]
[28150,null,"See CPT",null,757.5204,null,495.30180000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28153,null,"See CPT",null,741.46620000000007,null,472.70699999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28160,null,"See CPT",null,748.60140000000001,null,478.05839999999995,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28171,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","X"]
[28173,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","X"]
[28175,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","X"]
[28190,null,"See CPT",null,446.5446,null,236.05620000000002,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[28192,null,"See CPT",null,836.60220000000004,null,554.16719999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28193,null,"See CPT",null,946.0086,null,652.27620000000002,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28200,null,"See CPT",null,903.19740000000002,null,585.68100000000004,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-UR"]
[28202,null,"See CPT",null,1076.2260000000001,null,761.08800000000008,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR"]
[28208,null,"See CPT",null,878.81880000000001,null,571.41059999999993,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-UR"]
[28210,null,"See CPT",null,1060.7664,null,746.22300000000007,null,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-UR"]
[28220,null,"See CPT",null,817.57500000000005,null,542.86980000000005,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[28222,null,"See CPT",null,943.03559999999993,null,641.57339999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[28225,null,"See CPT",null,755.14199999999994,null,472.11240000000004,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[28226,null,"See CPT",null,1133.3075999999999,null,718.87139999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[28230,null,"See CPT",null,785.46660000000008,null,506.00459999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR"]
[28232,null,"See CPT",null,689.14139999999998,null,429.89580000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-UR"]
[28234,null,"See CPT",null,743.84460000000001,null,478.05839999999995,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-UR"]
[28238,null,"See CPT",null,1212.9839999999999,null,871.08900000000006,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28240,null,"See CPT",null,808.65599999999995,null,523.84260000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28250,null,"See CPT",null,1051.8474000000001,null,723.62819999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28260,null,"See CPT",null,1283.1468,null,939.46800000000007,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28261,null,"See CPT",null,2173.2629999999999,null,1676.1774,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28262,null,"See CPT",null,2515.1579999999999,null,2005.5857999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28264,null,"See CPT",null,1632.7716,null,1236.768,null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R"]
[28270,null,"See CPT",null,883.57560000000001,null,595.19460000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28272,null,"See CPT",null,696.87120000000004,null,446.5446,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28280,null,"See CPT",null,927.57600000000002,null,620.16779999999994,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28285,null,"See CPT",null,973.36020000000008,null,684.97919999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[28286,null,"See CPT",null,802.11540000000002,null,528.59940000000006,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28288,null,"See CPT",null,1097.6316000000002,null,776.54759999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28289,null,"See CPT",null,1248.6600000000001,null,818.16959999999995,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28291,null,"See CPT",null,1282.5522000000001,null,872.27819999999997,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28292,null,"See CPT",null,1258.7682000000002,null,857.41319999999996,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28295,null,"See CPT",null,2002.0182000000002,null,1102.9829999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28296,null,"See CPT",null,1625.0418,null,911.52179999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28297,null,"See CPT",null,1896.1794,null,1077.4152000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28298,null,"See CPT",null,1518.0138000000002,null,894.87300000000005,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28299,null,"See CPT",null,1839.0978,null,1047.6852000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28300,null,"See CPT",null,1160.6592000000001,null,1160.6592000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28302,null,"See CPT",null,1286.1197999999999,null,1286.1197999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28304,null,"See CPT",null,1494.8244,null,1090.4964,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28305,null,"See CPT",null,1210.0110000000002,null,1210.0110000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28306,null,"See CPT",null,1099.4153999999999,null,719.46600000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28307,null,"See CPT",null,1437.1482000000001,null,930.54899999999998,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28308,null,"See CPT",null,1035.7932000000001,null,688.54679999999996,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28309,null,"See CPT",null,1586.9874000000002,null,1586.9874000000002,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28310,null,"See CPT",null,988.81979999999999,null,643.95180000000005,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[28312,null,"See CPT",null,943.03559999999993,null,586.87019999999995,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R"]
[28313,null,"See CPT",null,957.90059999999994,null,641.57339999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28315,null,"See CPT",null,872.27819999999997,null,583.30259999999998,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R"]
[28320,null,"See CPT",null,1089.3072,null,1089.3072,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28322,null,"See CPT",null,1420.4994000000002,null,1029.8471999999999,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[28340,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","X"]
[28341,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","X"]
[28344,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","X"]
[28345,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","X"]
[28360,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","X"]
[28400,null,"See CPT",null,453.08519999999999,null,419.19299999999998,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28405,null,"See CPT",null,708.16859999999997,null,635.62739999999997,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28406,null,"See CPT",null,1024.4958000000001,null,1024.4958000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28415,null,"See CPT",null,2020.4507999999998,null,2020.4507999999998,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28420,null,"See CPT",null,2332.0212000000001,null,2332.0212000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28430,null,"See CPT",null,441.19319999999999,null,385.30080000000004,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28435,null,"See CPT",null,676.65480000000002,null,597.57300000000009,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28436,null,"See CPT",null,909.14339999999993,null,909.14339999999993,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28445,null,"See CPT",null,1825.422,null,1825.422,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28446,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","X"]
[28450,null,"See CPT",null,387.08459999999997,null,349.03020000000004,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28455,null,"See CPT",null,530.38319999999999,null,470.32859999999999,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[28456,null,"See CPT",null,684.97919999999999,null,684.97919999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28465,null,"See CPT",null,1145.7942,null,1145.7942,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28470,null,"See CPT",null,399.57119999999998,null,375.19259999999997,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28475,null,"See CPT",null,464.97720000000004,null,407.30099999999999,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28476,null,"See CPT",null,712.92539999999997,null,712.92539999999997,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[28485,null,"See CPT",null,1012.6038000000001,null,1012.6038000000001,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R"]
[28490,null,"See CPT",null,258.65100000000001,null,226.54259999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28495,null,"See CPT",null,326.43540000000002,null,269.94839999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28496,null,"See CPT",null,830.65620000000001,null,443.57159999999999,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28505,null,"See CPT",null,1195.7406000000001,null,891.9,null,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R"]
[28510,null,"See CPT",null,218.81280000000001,null,216.43440000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28515,null,"See CPT",null,297.89459999999997,null,258.65100000000001,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28525,null,"See CPT",null,1034.604,null,726.60120000000006,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[28530,null,"See CPT",null,206.92080000000001,null,178.38,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28531,null,"See CPT",null,603.51900000000001,null,322.86779999999999,null,"090",0.1,0.69,0.21,0,2,1,1,2,0,"","R"]
[28540,null,"See CPT",null,354.38159999999999,null,316.92180000000002,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28545,null,"See CPT",null,567.84300000000007,null,494.7072,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28546,null,"See CPT",null,1086.3342,null,638.60040000000004,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28555,null,"See CPT",null,1556.6628000000001,null,1176.7133999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28570,null,"See CPT",null,431.08499999999998,null,358.54380000000003,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28575,null,"See CPT",null,692.70900000000006,null,618.38400000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28576,null,"See CPT",null,694.49279999999999,null,694.49279999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R"]
[28585,null,"See CPT",null,1597.0955999999999,null,1243.9032000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R"]
[28600,null,"See CPT",null,395.40900000000005,null,335.3544,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[28605,null,"See CPT",null,627.303,null,556.54559999999992,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[28606,null,"See CPT",null,683.79,null,683.79,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28615,null,"See CPT",null,1489.473,null,1489.473,null,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R"]
[28630,null,"See CPT",null,277.6782,null,196.8126,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[28635,null,"See CPT",null,315.13799999999998,null,237.24540000000002,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[28636,null,"See CPT",null,572.59980000000007,null,356.76,null,"010",0.1,0.8,0.1,0,2,0,1,2,0,"","R"]
[28645,null,"See CPT",null,1176.7133999999999,null,865.73760000000004,null,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R"]
[28660,null,"See CPT",null,222.97499999999999,null,165.89340000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[28665,null,"See CPT",null,271.73220000000003,null,225.35339999999999,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[28666,null,"See CPT",null,320.48939999999999,null,320.48939999999999,null,"010",0.1,0.8,0.1,0,2,0,1,2,0,"","R"]
[28675,null,"See CPT",null,1048.8744000000002,null,737.30400000000009,null,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R"]
[28705,null,"See CPT",null,2172.6684,null,2172.6684,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28715,null,"See CPT",null,1681.5288,null,1681.5288,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28725,null,"See CPT",null,1390.1748,null,1390.1748,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28730,null,"See CPT",null,1309.3091999999999,null,1309.3091999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28735,null,"See CPT",null,1395.5262,null,1395.5262,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28737,null,"See CPT",null,1224.8760000000002,null,1224.8760000000002,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28740,null,"See CPT",null,1498.9866000000002,null,1102.9829999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28750,null,"See CPT",null,1422.2832000000001,null,1035.1985999999999,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR"]
[28755,null,"See CPT",null,922.81920000000002,null,598.16759999999999,null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR"]
[28760,null,"See CPT",null,1378.2828,null,1011.4146000000001,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28800,null,"See CPT",null,942.44100000000003,null,942.44100000000003,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[28805,null,"See CPT",null,1258.1736000000001,null,1258.1736000000001,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR"]
[28810,null,"See CPT",null,755.14199999999994,null,755.14199999999994,null,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R"]
[28820,null,"See CPT",null,545.2482,null,314.54340000000002,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[28825,null,"See CPT",null,535.14,null,305.62439999999998,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[28890,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","X"]
[28899,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,"","N"]
[29000,null,"See CPT",null,630.87059999999997,null,346.05720000000002,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29010,null,"See CPT",null,488.76120000000003,null,283.02960000000002,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29015,null,"See CPT",null,525.03179999999998,null,318.7056,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29035,null,"See CPT",null,459.62580000000003,null,253.2996,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29040,null,"See CPT",null,523.84260000000006,null,304.43520000000001,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29044,null,"See CPT",null,513.73440000000005,null,294.327,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29046,null,"See CPT",null,563.08620000000008,null,331.78680000000003,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29049,null,"See CPT",null,177.78540000000001,null,123.6768,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29055,null,"See CPT",null,398.97660000000002,null,242.5968,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29058,null,"See CPT",null,220.00200000000001,null,165.2988,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29065,null,"See CPT",null,173.02860000000001,null,121.2984,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29075,null,"See CPT",null,155.7852,null,110.001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29085,null,"See CPT",null,171.2448,null,119.51459999999999,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29086,null,"See CPT",null,137.3526,null,88.000799999999998,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29105,null,"See CPT",null,146.27160000000001,null,72.541200000000003,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29125,null,"See CPT",null,118.3254,null,70.757400000000004,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29126,null,"See CPT",null,139.13639999999998,null,87.406199999999998,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29130,null,"See CPT",null,73.730400000000003,null,51.730200000000004,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29131,null,"See CPT",null,94.54140000000001,null,60.6492,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29200,null,"See CPT",null,60.054600000000001,null,33.297600000000003,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[29240,null,"See CPT",null,54.703200000000002,null,32.703000000000003,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29260,null,"See CPT",null,53.514000000000003,null,33.892199999999995,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29280,null,"See CPT",null,52.919400000000003,null,35.081400000000002,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29305,null,"See CPT",null,442.38240000000002,null,279.46199999999999,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29325,null,"See CPT",null,488.16660000000007,null,312.75959999999998,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[29345,null,"See CPT",null,242.00220000000002,null,176.0016,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29355,null,"See CPT",null,253.2996,null,187.89360000000002,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29358,null,"See CPT",null,286.59720000000004,null,181.94759999999999,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29365,null,"See CPT",null,220.00200000000001,null,154.596,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29405,null,"See CPT",null,142.70400000000001,null,102.86580000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29425,null,"See CPT",null,134.9742,null,95.73060000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29435,null,"See CPT",null,200.97479999999999,null,140.92020000000002,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29440,null,"See CPT",null,75.514200000000002,null,49.351799999999997,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29445,null,"See CPT",null,229.51560000000001,null,175.40700000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29450,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,1,0,0,"","X"]
[29505,null,"See CPT",null,156.9744,null,90.973799999999997,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29515,null,"See CPT",null,127.24440000000001,null,86.811599999999999,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29520,null,"See CPT",null,64.216800000000006,null,32.703000000000003,null,"000",0,0,0,0,2,1,0,0,0,"","R"]
[29530,null,"See CPT",null,54.703200000000002,null,32.108400000000003,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29540,null,"See CPT",null,49.946399999999997,null,30.9192,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29550,null,"See CPT",null,34.486799999999995,null,19.6218,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29580,null,"See CPT",null,117.1362,null,46.973400000000005,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29581,null,"See CPT",null,165.2988,null,48.162600000000005,null,"000",0,0,0,0,2,1,0,0,0,"","R"]
[29584,null,"See CPT",null,153.4068,null,27.946199999999997,null,"000",0,0,0,0,2,1,0,0,0,"","R"]
[29700,null,"See CPT",null,110.5956,null,58.270800000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[29705,null,"See CPT",null,112.97399999999999,null,78.487200000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[29710,null,"See CPT",null,217.029,null,145.08240000000001,null,"000",0,0,0,0,2,1,0,0,0,"","R"]
[29720,null,"See CPT",null,151.62299999999999,null,75.514200000000002,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[29730,null,"See CPT",null,113.5686,null,77.892600000000002,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[29740,null,"See CPT",null,176.0016,null,121.89299999999999,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[29750,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,1,0,0,0,"","X"]
[29799,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,"","N"]
[29800,null,"See CPT",null,954.33300000000008,null,954.33300000000008,null,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM"]
[29804,null,"See CPT",null,1079.7936,null,1079.7936,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM"]
[29806,null,"See CPT",null,1893.2064,null,1893.2064,null,"090",0.1,0.69,0.21,0,3,1,1,1,0,29805,"R",null,"Y-UR"]
[29828,null,"See CPT",null,1638.7175999999999,null,1638.7175999999999,null,"090",0.1,0.69,0.21,0,3,1,2,1,0,29805,"R",null,"Y-UR"]
[29847,null,"See CPT",null,978.71160000000009,null,978.71160000000009,null,"090",0.1,0.69,0.21,0,3,1,2,0,0,29840,"R"]
[29860,null,"See CPT",null,1153.5239999999999,null,1153.5239999999999,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[29876,null,"See CPT",null,1172.5511999999999,null,1172.5511999999999,null,"090",0.1,0.69,0.21,0,3,1,1,0,0,29870,"R",null,"Y-UR"]
[29880,null,"See CPT",null,1010.82,null,1010.82,null,"090",0.1,0.69,0.21,0,3,1,0,1,0,29870,"R",null,"Y-UR"]
[29887,null,"See CPT",null,1350.9312,null,1350.9312,null,"090",0.1,0.69,0.21,0,3,1,2,1,0,29870,"R",null,"Y-UR"]
[29898,null,"See CPT",null,1004.2794,null,1004.2794,null,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR"]
[29914,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.69,0.21,0,3,1,2,1,0,29860,"X"]
[30124,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.76,0.14000000000000001,0,2,0,1,0,0,"","X"]
[30400,null,"See CPT",null,2283.2640000000001,null,2283.2640000000001,null,"090",0.1,0.76,0.14000000000000001,0,2,0,0,0,0,"","R"]
[30460,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,2,0,"","X"]
[30801,null,"See CPT",null,411.46320000000003,null,284.21880000000004,null,"010",0.1,0.8,0.1,0,2,2,1,0,0,"","R"]
[30903,null,"See CPT",null,460.815,null,134.9742,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[31000,null,"See CPT",null,341.30040000000002,null,197.40719999999999,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[31075,null,"See CPT",null,1523.9597999999999,null,1523.9597999999999,null,"090",0.1,0.76,0.14000000000000001,0,2,1,2,1,0,"","R"]
[31201,null,"See CPT",null,1470.4458,null,1470.4458,null,"090",0.1,0.76,0.14000000000000001,0,2,1,1,0,0,"","R"]
[31253,null,"See CPT",null,881.79179999999997,null,881.79179999999997,null,"000",0,0,0,0,3,1,1,0,0,31231,"R",null,"Y-CM"]
[31292,null,"See CPT",null,1780.827,null,1780.827,null,"010",0.1,0.8,0.1,0,3,1,0,0,0,31231,"R"]
[31298,null,"See CPT",null,6123.1908000000003,null,450.70679999999999,null,"000",0,0,0,0,3,1,0,0,0,31231,"R",null,"Y-CM"]
[31395,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","X"]
[31511,null,"See CPT",null,388.27379999999999,null,233.08320000000001,null,"000",0,0,0,0,3,0,1,0,0,31505,"R"]
[31515,null,"See CPT",null,394.81439999999998,null,196.8126,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[31535,null,"See CPT",null,332.38139999999999,null,332.38139999999999,null,"000",0,0,0,0,3,0,1,0,0,31525,"R"]
[31554,null,"See CPT",null,3057.4331999999999,null,3057.4331999999999,null,"090",0.1,0.76,0.14000000000000001,0,2,0,0,1,0,"","R",null,"Y-UR"]
[31579,null,"See CPT",null,362.70599999999996,null,210.48840000000001,null,"000",0,0,0,0,3,0,1,0,0,31575,"R"]
[31610,null,"See CPT",null,1743.9617999999998,null,1743.9617999999998,null,"090",0.1,0.76,0.14000000000000001,0,2,0,1,0,0,"","R"]
[31622,null,"See CPT",null,454.86900000000003,null,231.29940000000002,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[31634,null,"See CPT",null,3034.8384000000001,null,335.3544,null,"000",0,0,0,0,3,0,2,0,0,31622,"R"]
[31643,null,"See CPT",null,308.00279999999998,null,308.00279999999998,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[31647,null,"See CPT",null,362.1114,null,362.1114,null,"000",0,0,0,0,3,0,1,0,0,31622,"R"]
[31717,null,"See CPT",null,548.22120000000007,null,187.89360000000002,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[31775,null,"See CPT",null,2436.0762,null,2436.0762,null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,0,0,"","R"]
[32036,null,"See CPT",null,1396.7153999999998,null,1396.7153999999998,null,"090",0.1,0.76,0.14000000000000001,0,2,1,2,1,0,"","R"]
[32160,null,"See CPT",null,1396.7153999999998,null,1396.7153999999998,null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","R"]
[32320,null,"See CPT",null,2804.1335999999997,null,2804.1335999999997,null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM"]
[32501,null,"See CPT",null,418.00380000000001,null,418.00380000000001,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM"]
[32550,null,"See CPT",null,1531.6896000000002,null,357.94919999999996,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[32562,null,"See CPT",null,151.62299999999999,null,104.64960000000001,null,"000",0,0,0,0,2,0,2,0,0,"","R"]
[32607,null,"See CPT",null,533.95080000000007,null,533.95080000000007,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[32654,null,"See CPT",null,2035.9104000000002,null,2035.9104000000002,null,"090",0.1,0.76,0.14000000000000001,0,2,1,2,1,0,"","R",null,"Y-CM"]
[32668,null,"See CPT",null,271.73220000000003,null,271.73220000000003,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM"]
[32800,null,"See CPT",null,1653.5826,null,1653.5826,null,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM"]
[32856,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,2,1,0,"","N",null,"Y-CM"]
[33018,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,1,0,0,"","X"]
[33120,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","X"]
[33211,null,"See CPT",null,294.92160000000001,null,294.92160000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[33215,null,"See CPT",null,547.62660000000005,null,547.62660000000005,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,"","R",null,"Y-CM"]
[33223,null,"See CPT",null,726.60120000000006,null,726.60120000000006,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,0,0,0,"","R",null,"Y-CM"]
[33236,null,"See CPT",null,1375.9044000000001,null,1375.9044000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,0,2,0,"","R",null,"Y-CM"]
[33250,null,"See CPT",null,2534.1851999999999,null,2534.1851999999999,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[33263,null,"See CPT",null,687.95220000000006,null,687.95220000000006,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,"","R",null,"Y-CM"]
[33285,null,"See CPT",null,8616.9431999999997,null,153.4068,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-UR"]
[33320,null,"See CPT",null,1839.6924000000001,null,1839.6924000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[33365,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,2,1,"","X"]
[33404,null,"See CPT",null,3040.7844,null,3040.7844,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[33410,null,"See CPT",null,4404.7968000000001,null,4404.7968000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[33425,null,"See CPT",null,4735.3944000000001,null,4735.3944000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[33465,null,"See CPT",null,4771.665,null,4771.665,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[33501,null,"See CPT",null,1947.3150000000001,null,1947.3150000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,"","R",null,"Y-CM"]
[33513,null,"See CPT",null,4302.5255999999999,null,4302.5255999999999,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,"","R",null,"Y-CM"]
[33522,null,"See CPT",null,1263.5250000000001,null,1263.5250000000001,null,"000",0,0,0,0,0,0,2,0,0,"","R",null,"Y-CM"]
[33572,null,"See CPT",null,397.19279999999998,null,397.19279999999998,null,"000",0,0,0,0,0,0,2,0,0,"","R",null,"Y-CM"]
[33615,null,"See CPT",null,3468.8964000000001,null,3468.8964000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[33620,null,"See CPT",null,2857.6476000000002,null,2857.6476000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[33681,null,"See CPT",null,3209.0562,null,3209.0562,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[33710,null,"See CPT",null,3553.3296,null,3553.3296,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,"","R",null,"Y-CM"]
[33745,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,2,0,0,"","X"]
[33775,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,"","X"]
[33782,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","X"]
[33822,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","X"]
[33859,null,"See CPT",null,4223.4438,null,4223.4438,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-UR"]
[33866,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,0,0,1,"","X",null,"Y-CM"]
[33891,null,"See CPT",null,1647.0419999999999,null,1647.0419999999999,null,"000",0,0,0,0,2,1,2,2,0,"","R"]
[33920,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","X"]
[33944,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,2,1,0,"","X"]
[33952,null,"See CPT",null,740.27699999999993,null,740.27699999999993,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[33966,null,"See CPT",null,409.08479999999997,null,409.08479999999997,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[33968,null,"See CPT",null,57.676200000000001,null,57.676200000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM"]
[33985,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,1,1,"","X"]
[33988,null,"See CPT",null,1340.2284,null,1340.2284,null,"000",0,0,0,0,2,0,0,1,1,"","R",null,"Y-CM"]
[34051,null,"See CPT",null,1737.4212,null,1737.4212,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[34451,null,"See CPT",null,2467.59,null,2467.59,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[34705,null,"See CPT",null,2632.8888000000002,null,2632.8888000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,"","R",null,"Y-UR"]
[34712,null,"See CPT",null,1133.3075999999999,null,1133.3075999999999,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,"","R",null,"Y-UR"]
[34831,null,"See CPT",null,3310.7328000000002,null,3310.7328000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,"","R",null,"Y-CM"]
[34833,null,"See CPT",null,671.89800000000002,null,671.89800000000002,null,"000",0,0,0,0,0,1,2,2,0,"","R",null,"Y-CM"]
[35021,null,"See CPT",null,2197.6415999999999,null,2197.6415999999999,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[35081,null,"See CPT",null,2980.1351999999997,null,2980.1351999999997,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[35131,null,"See CPT",null,2358.1835999999998,null,2358.1835999999998,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[35184,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","X"]
[35236,null,"See CPT",null,1740.9888000000001,null,1740.9888000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R"]
[35271,null,"See CPT",null,2406.9407999999999,null,2406.9407999999999,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R"]
[35331,null,"See CPT",null,2502.6714000000002,null,2502.6714000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[35351,null,"See CPT",null,2221.4256,null,2221.4256,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[35515,null,"See CPT",null,2281.4802,null,2281.4802,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[35521,null,"See CPT",null,2112.0192000000002,null,2112.0192000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[35538,null,"See CPT",null,4005.2256000000002,null,4005.2256000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[35566,null,"See CPT",null,2870.1342000000004,null,2870.1342000000004,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[35621,null,"See CPT",null,1893.2064,null,1893.2064,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[35636,null,"See CPT",null,2739.3222000000001,null,2739.3222000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[35665,null,"See CPT",null,2021.64,null,2021.64,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[35671,null,"See CPT",null,1969.3151999999998,null,1969.3151999999998,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[35820,null,"See CPT",null,3490.3020000000001,null,3490.3020000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[35870,null,"See CPT",null,2147.1006000000002,null,2147.1006000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[35907,null,"See CPT",null,3283.3811999999998,null,3283.3811999999998,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM"]
[36014,null,"See CPT",null,1525.7436,null,262.21860000000004,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[36223,null,"See CPT",null,3049.7033999999999,null,557.73480000000006,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[36248,null,"See CPT",null,218.81280000000001,null,83.8386,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[36400,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,1,0,0,"","X"]
[36425,null,"See CPT",null,70.757400000000004,null,70.757400000000004,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[36473,null,"See CPT",null,2368.2918,null,310.38119999999998,null,"000",0,0,0,0,2,1,1,0,0,"","R",null,"Y-CM"]
[36476,null,"See CPT",null,531.57240000000002,null,232.48860000000002,null,"000",0,0,0,0,0,1,1,0,0,"","R",null,"Y-CM"]
[36556,null,"See CPT",null,400.7604,null,147.46080000000001,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[36560,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","X"]
[36576,null,"See CPT",null,651.68160000000012,null,325.84080000000006,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[36590,null,"See CPT",null,405.5172,null,336.54360000000003,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[36620,null,"See CPT",null,77.298000000000002,null,77.298000000000002,null,"000",0,0,0,0,0,0,1,0,0,"","R"]
[36815,null,"See CPT",null,232.48860000000002,null,232.48860000000002,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[36838,null,"See CPT",null,1973.4774,null,1973.4774,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[36901,null,"See CPT",null,1353.3096,null,292.54320000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[37183,null,"See CPT",null,11489.4558,null,648.11400000000003,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[37186,null,"See CPT",null,2298.7235999999998,null,419.7876,null,"000",0,0,0,0,0,2,1,2,0,"","R"]
[37214,null,"See CPT",null,209.8938,null,209.8938,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[37224,null,"See CPT",null,5708.7546000000002,null,764.06100000000004,null,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM"]
[37233,null,"See CPT",null,1965.7476000000001,null,557.73480000000006,null,"000",0,0,0,0,0,1,0,0,0,"","R",null,"Y-CM"]
[37241,null,"See CPT",null,9144.9480000000003,null,744.43920000000003,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[37565,null,"See CPT",null,1285.5252,null,1285.5252,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,0,1,0,"","R"]
[37606,null,"See CPT",null,1292.6604,null,1292.6604,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,"","R"]
[37761,null,"See CPT",null,937.08960000000002,null,937.08960000000002,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM"]
[37780,null,"See CPT",null,411.46320000000003,null,411.46320000000003,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,1,1,0,"","R",null,"Y-CM"]
[38102,null,"See CPT",null,457.24740000000003,null,457.24740000000003,null,"000",0,0,0,0,0,0,2,1,0,"","R"]
[38213,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[38241,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,"","X"]
[38381,null,"See CPT",null,1406.8235999999999,null,1406.8235999999999,null,"090",0.11,0.73,0.16,0,2,0,2,1,0,"","R",null,"Y-CM"]
[38562,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.73,0.16,0,2,2,2,1,0,"","X"]
[38571,null,"See CPT",null,1166.0106000000001,null,1166.0106000000001,null,"010",0.1,0.8,0.1,0,3,2,2,2,0,49320,"R",null,"Y-CM"]
[38790,null,"See CPT",null,143.29860000000002,null,143.29860000000002,null,"000",0,0,0,0,2,1,1,0,0,"","R",null,"Y-CM"]
[38900,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,1,2,1,0,"","X"]
[39402,null,"See CPT",null,699.8442,null,699.8442,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[40525,null,"See CPT",null,988.81979999999999,null,988.81979999999999,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[40720,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,1,0,0,0,"","X"]
[40806,null,"See CPT",null,186.10980000000001,null,50.540999999999997,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[40816,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","X"]
[41005,null,"See CPT",null,400.7604,null,196.21799999999999,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R"]
[41105,null,"See CPT",null,346.65180000000004,null,196.8126,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[41112,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","X"]
[41153,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","X"]
[41520,null,"See CPT",null,677.24940000000004,null,453.08519999999999,null,"090",0.09,0.81,0.1,0,2,0,0,0,0,"","R",null,"Y-CM"]
[41827,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","X"]
[41899,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,"","N"]
[42107,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","X"]
[42226,null,"See CPT",null,1650.0150000000001,null,1650.0150000000001,null,"090",0.09,0.81,0.1,0,2,0,2,0,0,"","R",null,"Y-CM"]
[42335,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","X"]
[42405,null,"See CPT",null,552.97800000000007,null,404.92259999999999,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[42505,null,"See CPT",null,1048.8744000000002,null,827.08860000000004,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R"]
[42660,null,"See CPT",null,211.083,null,155.19059999999999,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[42815,null,"See CPT",null,973.95479999999998,null,973.95479999999998,null,"090",0.09,0.81,0.1,0,2,1,2,1,0,"","R",null,"Y-CM"]
[42835,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,0,0,0,"","X"]
[42860,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,0,0,0,"","X"]
[42971,null,"See CPT",null,814.00739999999996,null,814.00739999999996,null,"090",0.09,0.81,0.1,0,2,0,2,0,0,"","R"]
[43113,null,"See CPT",null,7535.9603999999999,null,7535.9603999999999,null,"090",0.09,0.81,0.1,0,2,0,2,2,0,"","R",null,"Y-CM"]
[43118,null,"See CPT",null,6289.0842000000002,null,6289.0842000000002,null,"090",0.09,0.81,0.1,0,2,0,2,2,0,"","R",null,"Y-CM"]
[43194,null,"See CPT",null,339.51659999999998,null,339.51659999999998,null,"000",0,0,0,0,3,0,1,0,0,43191,"R"]
[43202,null,"See CPT",null,688.54679999999996,null,181.94759999999999,null,"000",0,0,0,0,3,0,1,0,0,43200,"R",null,"Y-CM"]
[43213,null,"See CPT",null,2407.5354000000002,null,455.46360000000004,null,"000",0,0,0,0,3,0,1,0,0,43200,"R"]
[43235,null,"See CPT",null,562.49160000000006,null,216.43440000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[43240,null,"See CPT",null,689.14139999999998,null,689.14139999999998,null,"000",0,0,0,0,3,0,1,0,0,43235,"R"]
[43253,null,"See CPT",null,462.59880000000004,null,462.59880000000004,null,"000",0,0,0,0,3,0,1,0,0,43235,"R"]
[43270,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,3,0,1,0,0,43235,"X"]
[43275,null,"See CPT",null,661.78980000000001,null,661.78980000000001,null,"000",0,0,0,0,3,0,1,0,0,43260,"R"]
[43286,null,"See CPT",null,5562.4830000000002,null,5562.4830000000002,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-UR"]
[43312,null,"See CPT",null,2758.944,null,2758.944,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[43330,null,"See CPT",null,2371.2648000000004,null,2371.2648000000004,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[43352,null,"See CPT",null,1872.3953999999999,null,1872.3953999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[43410,null,"See CPT",null,1836.7194,null,1836.7194,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R"]
[43510,null,"See CPT",null,1691.6369999999999,null,1691.6369999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R"]
[43635,null,"See CPT",null,196.8126,null,196.8126,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM"]
[43645,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","X"]
[43653,null,"See CPT",null,1036.3878,null,1036.3878,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[43771,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","X"]
[43820,null,"See CPT",null,2381.9675999999999,null,2381.9675999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[43880,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","X"]
[44010,null,"See CPT",null,1524.5544,null,1524.5544,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R"]
[44100,null,"See CPT",null,187.89360000000002,null,187.89360000000002,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[44135,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,0,0,0,0,0,"","N"]
[44140,null,"See CPT",null,2375.4270000000001,null,2375.4270000000001,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[44146,null,"See CPT",null,3712.6824000000001,null,3712.6824000000001,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[44188,null,"See CPT",null,2160.1817999999998,null,2160.1817999999998,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R"]
[44208,null,"See CPT",null,3477.8154,null,3477.8154,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[44345,null,"See CPT",null,1861.6925999999999,null,1861.6925999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[44369,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,3,0,0,0,0,44360,"X"]
[44379,null,"See CPT",null,720.65519999999992,null,720.65519999999992,null,"000",0,0,0,0,3,0,0,0,0,44376,"R",null,"Y-CM"]
[44394,null,"See CPT",null,823.52099999999996,null,397.19279999999998,null,"000",0,0,0,0,3,0,1,0,0,44388,"R",null,"Y-CM"]
[44404,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,3,0,1,0,0,44388,"X"]
[44500,null,"See CPT",null,33.892199999999995,null,33.892199999999995,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[44661,null,"See CPT",null,2721.4842000000003,null,2721.4842000000003,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R"]
[44721,null,"See CPT",null,671.30340000000001,null,671.30340000000001,null,"000",0,0,0,0,2,0,2,1,0,"","R"]
[45100,null,"See CPT",null,542.27519999999993,null,542.27519999999993,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[45111,null,"See CPT",null,1928.2878000000001,null,1928.2878000000001,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[45136,null,"See CPT",null,3155.5421999999999,null,3155.5421999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[45315,null,"See CPT",null,429.89580000000001,null,186.70440000000002,null,"000",0,0,0,0,3,0,1,0,0,45300,"R",null,"Y-CM"]
[45327,null,"See CPT",null,205.73160000000001,null,205.73160000000001,null,"000",0,0,0,0,3,0,1,0,0,45300,"R",null,"Y-CM"]
[45334,null,"See CPT",null,957.90059999999994,null,207.51540000000003,null,"000",0,0,0,0,3,0,1,0,0,45330,"R",null,"Y-CM"]
[45378,53,"See CPT",null,316.92180000000002,null,162.32580000000002,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[45386,null,"See CPT",null,1171.9566,null,371.625,null,"000",0,0,0,0,3,0,1,0,0,45378,"R",null,"Y-CM"]
[45505,null,"See CPT",null,1085.145,null,1085.145,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[45541,null,"See CPT",null,1683.3126,null,1683.3126,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[45915,null,"See CPT",null,654.65459999999996,null,413.84160000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[46200,null,"See CPT",null,883.57560000000001,null,614.22180000000003,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R"]
[46250,null,"See CPT",null,889.52160000000003,null,577.35660000000007,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R"]
[46261,null,"See CPT",null,951.36,null,951.36,null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R"]
[46604,null,"See CPT",null,1311.6876,null,117.7308,null,"000",0,0,0,0,3,0,1,0,0,46600,"R",null,"Y-CM"]
[46614,null,"See CPT",null,318.11099999999999,null,112.37939999999999,null,"000",0,0,0,0,3,0,1,0,0,46600,"R",null,"Y-CM"]
[46746,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","X"]
[46751,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","X"]
[46940,null,"See CPT",null,491.73419999999999,null,256.86720000000003,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[46999,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,"","N"]
[47140,null,"See CPT",null,6306.3276000000005,null,6306.3276000000005,null,"090",0.09,0.81,0.1,0,2,0,2,1,2,"","R",null,"Y-CM"]
[47143,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,2,1,0,"","N",null,"Y-CM"]
[47383,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","X"]
[47531,null,"See CPT",null,824.71019999999999,null,122.4876,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[47537,null,"See CPT",null,954.92759999999998,null,167.6772,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[47544,null,"See CPT",null,1626.231,null,269.35380000000004,null,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-UR"]
[47600,null,"See CPT",null,1900.3416,null,1900.3416,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R"]
[47701,null,"See CPT",null,3087.7577999999999,null,3087.7577999999999,null,"090",0.09,0.81,0.1,0,2,0,0,0,0,"","R",null,"Y-CM"]
[47800,null,"See CPT",null,2731.5924,null,2731.5924,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[47900,null,"See CPT",null,2424.7788,null,2424.7788,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[48154,null,"See CPT",null,5141.5061999999998,null,5141.5061999999998,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[48545,null,"See CPT",null,2392.0758000000001,null,2392.0758000000001,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R"]
[48554,null,"See CPT",null,4640.8530000000001,null,4640.8530000000001,null,"090",0.09,0.81,0.1,0,2,0,2,2,2,"","R",null,"Y-CM"]
[49014,null,"See CPT",null,666.54660000000001,null,666.54660000000001,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-UR"]
[49205,null,"See CPT",null,3080.0279999999998,null,3080.0279999999998,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[49322,null,"See CPT",null,667.14120000000003,null,667.14120000000003,null,"010",0.1,0.8,0.1,0,3,0,2,2,0,49320,"R",null,"Y-CM"]
[49411,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,2,0,0,0,0,"","X"]
[49419,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","X"]
[49450,null,"See CPT",null,1160.6592000000001,null,113.5686,null,"000",0,0,0,0,2,0,0,0,0,"","R"]
[49496,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.81,0.1,0,2,1,2,1,0,"","X"]
[49521,null,"See CPT",null,1276.6061999999999,null,1276.6061999999999,null,"090",0.09,0.81,0.1,0,2,1,2,1,0,"","R"]
[49560,null,"See CPT",null,1313.4713999999999,null,1313.4713999999999,null,"090",0.09,0.81,0.1,0,2,1,2,1,0,"","R"]
[49600,null,"See CPT",null,1313.4713999999999,null,1313.4713999999999,null,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[49651,null,"See CPT",null,1011.4146000000001,null,1011.4146000000001,null,"090",0.09,0.81,0.1,0,2,1,2,1,0,"","R"]
[49999,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,1,1,1,"","N"]
[50040,null,"See CPT",null,1625.6364000000001,null,1625.6364000000001,null,"090",0.08,0.83,0.09,0,2,1,1,1,0,"","R"]
[50225,null,"See CPT",null,2109.0461999999998,null,2109.0461999999998,null,"090",0.08,0.83,0.09,0,2,1,2,1,0,"","R"]
[50300,null,"See CPT",null,3992.8060396224,null,3992.8060396224,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
[50329,null,"See CPT",null,315.13799999999998,null,315.13799999999998,null,"000",0,0,0,0,2,0,2,1,0,"","R",null,"Y-CM"]
[50384,null,"See CPT",null,1655.3664000000001,null,393.03060000000005,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[50432,null,"See CPT",null,1745.7456,null,355.57080000000002,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[50500,null,"See CPT",null,2207.1551999999997,null,2207.1551999999997,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R"]
[50548,null,"See CPT",null,2348.67,null,2348.67,null,"090",0.08,0.83,0.09,0,2,1,2,1,0,"","R",null,"Y-CM"]
[50553,null,"See CPT",null,687.35760000000005,null,545.84280000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[50600,null,"See CPT",null,1645.2582000000002,null,1645.2582000000002,null,"090",0.08,0.83,0.09,0,2,1,2,1,0,"","R"]
[50620,null,"See CPT",null,1584.6089999999999,null,1584.6089999999999,null,"090",0.08,0.83,0.09,0,2,1,2,1,0,"","R",null,"Y-CM"]
[50725,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","X"]
[50740,null,"See CPT",null,2175.6414000000004,null,2175.6414000000004,null,"090",0.08,0.83,0.09,0,2,1,2,1,0,"","R",null,"Y-CM"]
[50800,null,"See CPT",null,1625.0418,null,1625.0418,null,"090",0.08,0.83,0.09,0,2,1,2,1,0,"","R",null,"Y-CM"]
[50920,null,"See CPT",null,1549.5275999999999,null,1549.5275999999999,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,"Y-CM"]
[50970,null,"See CPT",null,643.95180000000005,null,643.95180000000005,null,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM"]
[50976,null,"See CPT",null,808.65599999999995,null,808.65599999999995,null,"000",0,0,0,0,3,1,0,0,0,50970,"R",null,"Y-CM"]
[51520,null,"See CPT",null,1052.442,null,1052.442,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,"Y-CM"]
[51550,null,"See CPT",null,1693.4208000000001,null,1693.4208000000001,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R"]
[51702,null,"See CPT",null,114.1632,null,44.594999999999999,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[51710,null,"See CPT",null,249.13740000000001,null,139.73099999999999,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[51726,26,"See CPT",null,147.46080000000001,null,147.46080000000001,null,"000",0,0,0,1,2,0,1,0,0,"","R"]
[51736,null,"See CPT",null,23.784000000000002,null,23.784000000000002,null,"000",0,0,0,1,2,0,0,0,0,"","R"]
[51792,null,"See CPT",null,511.35599999999999,null,511.35599999999999,null,"000",0,0,0,1,2,0,0,0,0,"","R"]
[51797,null,"See CPT",null,369.2466,null,369.2466,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[51925,null,"See CPT",null,1933.6392000000003,null,1933.6392000000003,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,"Y-CM"]
[51990,null,"See CPT",null,1312.2822000000001,null,1312.2822000000001,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,"Y-CM"]
[52265,null,"See CPT",null,702.81720000000007,null,283.02960000000002,null,"000",0,0,0,0,3,0,1,0,0,52000,"R"]
[52276,null,"See CPT",null,459.03120000000001,null,459.03120000000001,null,"000",0,0,0,0,3,0,1,0,0,52000,"R"]
[52300,null,"See CPT",null,485.78820000000002,null,485.78820000000002,null,"000",0,0,0,0,3,2,0,0,0,52000,"R",null,"Y-CM"]
[52330,null,"See CPT",null,1130.9292,null,457.24740000000003,null,"000",0,0,0,0,3,1,1,0,0,52000,"R"]
[52354,null,"See CPT",null,723.62819999999999,null,723.62819999999999,null,"000",0,0,0,0,3,1,1,0,0,52351,"R",null,"Y-CM"]
[52450,null,"See CPT",null,838.38599999999997,null,838.38599999999997,null,"090",0.08,0.83,0.09,0,2,0,1,0,0,"","R"]
[53010,null,"See CPT",null,526.81560000000002,null,526.81560000000002,null,"090",0.08,0.83,0.09,0,2,0,1,0,0,"","R"]
[53060,null,"See CPT",null,338.32740000000001,null,293.73240000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[53405,null,"See CPT",null,1534.6625999999999,null,1534.6625999999999,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,"Y-CM"]
[53420,null,"See CPT",null,1478.7702000000002,null,1478.7702000000002,null,"090",0.08,0.83,0.09,0,2,0,1,1,0,"","R",null,"Y-CM"]
[53446,null,"See CPT",null,1135.0914,null,1135.0914,null,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,"Y-CM"]
[53500,null,"See CPT",null,1321.7958000000001,null,1321.7958000000001,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM"]
[53661,null,"See CPT",null,134.37959999999998,null,70.162800000000004,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[54000,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","X"]
[54105,null,"See CPT",null,497.68019999999996,null,374.59800000000001,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[54115,null,"See CPT",null,814.00739999999996,null,755.73660000000007,null,"090",0.1,0.8,0.1,0,2,0,2,0,0,"","R"]
[54235,null,"See CPT",null,156.9744,null,127.839,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[54240,null,"See CPT",null,189.67740000000001,null,189.67740000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[54308,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,0,2,1,0,"","X"]
[54348,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,0,2,1,0,"","X"]
[54411,null,"See CPT",null,1810.557,null,1810.557,null,"090",0.1,0.8,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[54437,null,"See CPT",null,1196.9297999999999,null,1196.9297999999999,null,"090",0.1,0.8,0.1,0,2,0,2,1,0,"","R",null,"Y-CM"]
[54550,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,1,2,0,0,"","X"]
[54620,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","X"]
[54900,null,"See CPT",null,1409.7966000000001,null,1409.7966000000001,null,"090",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,"Y-CM"]
[54901,null,"See CPT",null,1860.5034000000001,null,1860.5034000000001,null,"090",0.1,0.8,0.1,0,2,2,0,0,0,"","R",null,"Y-CM"]
[55150,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,0,2,1,0,"","X"]
[55550,null,"See CPT",null,760.49339999999995,null,760.49339999999995,null,"090",0.1,0.8,0.1,0,2,1,2,1,0,"","R"]
[55810,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,0,2,1,0,"","X"]
[55845,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,2,2,2,1,0,"","X"]
[55899,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,0,0,1,1,"","N"]
[55980,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[56634,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,2,0,"","X"]
[56637,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,2,0,"","X"]
[56821,null,"See CPT",null,304.43520000000001,null,200.3802,null,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM"]
[57109,null,"See CPT",null,3083.0010000000002,null,3083.0010000000002,null,"090",0.12,0.74,0.14000000000000001,0,2,2,2,1,0,"","R",null,"Y-CM"]
[57200,null,"See CPT",null,603.51900000000001,null,603.51900000000001,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R"]
[57265,null,"See CPT",null,1557.2574000000002,null,1557.2574000000002,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM"]
[57289,null,"See CPT",null,1427.04,null,1427.04,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM"]
[57307,null,"See CPT",null,1943.1528000000001,null,1943.1528000000001,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM"]
[57423,null,"See CPT",null,1657.1502,null,1657.1502,null,"090",0.08,0.83,0.09,0,2,0,2,2,0,"","R",null,"Y-CM"]
[57425,null,"See CPT",null,1735.0427999999999,null,1735.0427999999999,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM"]
[57465,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[57550,null,"See CPT",null,779.52059999999994,null,779.52059999999994,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM"]
[58146,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","X"]
[58260,null,"See CPT",null,1500.7703999999999,null,1500.7703999999999,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM"]
[58294,null,"See CPT",null,2170.8845999999999,null,2170.8845999999999,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM"]
[58345,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,1,2,2,0,"","X"]
[58544,null,"See CPT",null,1617.3119999999999,null,1617.3119999999999,null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,2,0,"","R",null,"Y-CM"]
[58545,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,0,2,2,0,"","X"]
[58558,null,"See CPT",null,2594.2398000000003,null,406.70639999999997,null,"000",0,0,0,0,3,0,1,2,0,58555,"R",null,"Y-CM"]
[58578,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,1,1,"","N"]
[58670,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.8,0.1,0,3,0,1,2,0,49320,"X"]
[58750,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,1,2,1,0,"","X"]
[58940,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,2,2,1,0,"","X"]
[58956,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.12,0.74,0.14000000000000001,0,2,2,2,1,0,"","X"]
[59015,null,"See CPT",null,275.89439999999996,null,227.73180000000002,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[59020,"TC","See CPT",null,62.433000000000007,null,62.433000000000007,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[59070,null,"See CPT",null,709.3578,null,535.7346,null,"000",0,0,0,0,2,0,2,0,0,"","R",null,"Y-CM"]
[59160,null,"See CPT",null,503.62620000000004,null,335.94900000000001,null,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,"Y-CM"]
[59412,null,"See CPT",null,178.97459999999998,null,178.97459999999998,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[59610,null,"See CPT",null,4417.2834000000003,null,4417.2834000000003,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM"]
[59850,null,"See CPT",null,692.70900000000006,null,692.70900000000006,null,"090",0.17,0.6,0.23,0,2,0,0,0,0,"","R",null,"Y-CM"]
[59870,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.17,0.6,0.23,0,2,0,2,0,0,"","X"]
[60225,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.82,0.09,0,2,0,2,1,0,"","X"]
[60254,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.82,0.09,0,2,0,2,1,0,"","X"]
[60500,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.09,0.82,0.09,0,2,0,2,1,0,"","X"]
[60659,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,0,0,"","N"]
[61105,null,"See CPT",null,824.71019999999999,null,824.71019999999999,null,"090",0.11,0.76,0.13,0,2,0,0,0,0,"","R"]
[61210,null,"See CPT",null,633.24900000000002,null,633.24900000000002,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
[61321,null,"See CPT",null,3725.7635999999998,null,3725.7635999999998,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R"]
[61345,null,"See CPT",null,3583.6542000000004,null,3583.6542000000004,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R"]
[61518,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","X"]
[61530,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,0,1,2,0,"","X"]
[61534,null,"See CPT",null,2906.9994000000002,null,2906.9994000000002,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R"]
[61548,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,0,2,2,0,"","X"]
[61566,null,"See CPT",null,3926.7384000000006,null,3926.7384000000006,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM"]
[61583,null,"See CPT",null,5189.0742,null,5189.0742,null,"090",0.11,0.76,0.13,0,2,0,2,1,2,"","R",null,"Y-CM"]
[61601,null,"See CPT",null,4340.58,null,4340.58,null,"090",0.11,0.76,0.13,0,2,0,2,1,2,"","R",null,"Y-CM"]
[61615,null,"See CPT",null,5020.8023999999996,null,5020.8023999999996,null,"090",0.11,0.76,0.13,0,2,0,2,1,2,"","R",null,"Y-CM"]
[61642,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[61686,null,"See CPT",null,7817.8007999999991,null,7817.8007999999991,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM"]
[61697,null,"See CPT",null,7355.2020000000002,null,7355.2020000000002,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM"]
[61737,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,1,0,0,0,"","X"]
[61791,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,1,0,0,0,"","X"]
[61864,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,0,0,0,2,1,0,"","X"]
[62117,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","X"]
[62146,null,"See CPT",null,2204.1822000000002,null,2204.1822000000002,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R"]
[62192,null,"See CPT",null,1745.7456,null,1745.7456,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM"]
[62230,null,"See CPT",null,1490.6622,null,1490.6622,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM"]
[62252,"TC","See CPT",null,68.378999999999991,null,68.378999999999991,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[62280,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","X"]
[62292,null,"See CPT",null,1026.2796000000001,null,1026.2796000000001,null,"090",0.11,0.76,0.13,0,2,0,0,0,0,"","R",null,"Y-UR"]
[62326,null,"See CPT",null,255.08340000000001,null,151.0284,null,"000",0,0,0,0,2,9,1,0,0,"","R",null,"Y-UR"]
[62360,null,"See CPT",null,577.95120000000009,null,577.95120000000009,null,"010",0.1,0.8,0.1,0,2,0,0,1,0,"","R",null,"Y-UR"]
[63012,null,"See CPT",null,2113.2084,null,2113.2084,null,"090",0.11,0.76,0.13,0,2,0,2,2,0,"","R",null,"Y-UR"]
[63044,null,"See CPT",null,1199.8840572576003,null,1199.8840572576003,null,"000",0,0,0,0,0,1,2,2,0,"","F",null,"Y-UR"]
[63052,null,"See CPT",null,449.51759999999996,null,449.51759999999996,null,"000",0,0,0,0,0,0,2,2,0,"","R"]
[63056,null,"See CPT",null,2632.2942000000003,null,2632.2942000000003,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-UR"]
[63086,null,"See CPT",null,331.78680000000003,null,331.78680000000003,null,"000",0,0,0,0,0,0,2,2,2,"","R",null,"Y-UR"]
[63103,null,"See CPT",null,510.76139999999998,null,510.76139999999998,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR"]
[63265,null,"See CPT",null,2939.1078000000002,null,2939.1078000000002,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-UR"]
[63273,null,"See CPT",null,3283.3811999999998,null,3283.3811999999998,null,"090",0.11,0.76,0.13,0,2,0,2,0,0,"","R",null,"Y-UR"]
[63295,null,"See CPT",null,567.84300000000007,null,567.84300000000007,null,"000",0,0,0,0,0,2,2,2,0,"","R",null,"Y-UR"]
[63600,null,"See CPT",null,1927.0985999999998,null,1927.0985999999998,null,"090",0.11,0.76,0.13,0,2,0,0,0,0,"","R",null,"Y-CM"]
[63662,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","X"]
[63685,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,0,2,1,0,"","X",null,"Y-UR"]
[63744,null,"See CPT",null,1226.6597999999999,null,1226.6597999999999,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM"]
[64417,null,"See CPT",null,258.0564,null,107.02800000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[64450,null,"See CPT",null,138.54179999999999,null,74.325000000000003,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[64479,null,"See CPT",null,493.51800000000003,null,231.89400000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R",null,"Y-UR"]
[64495,null,"See CPT",null,164.70420000000001,null,91.568399999999997,null,"000",0,0,0,0,0,1,2,0,0,"","R",null,"Y-UR"]
[64568,null,"See CPT",null,1086.9288000000001,null,1086.9288000000001,null,"090",0.11,0.76,0.13,0,2,1,0,0,0,"","R",null,"Y-UR"]
[64583,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.11,0.76,0.13,0,2,1,0,1,1,"","X"]
[64590,null,"See CPT",null,485.1936,null,286.00259999999997,null,"010",0.1,0.8,0.1,0,2,0,1,1,0,"","R",null,"Y-UR"]
[64624,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","X"]
[64634,null,"See CPT",null,488.16660000000007,null,117.7308,null,"000",0,0,0,0,0,1,1,0,0,"","R",null,"Y-UR"]
[64680,null,"See CPT",null,653.46540000000005,null,286.00259999999997,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM"]
[64714,null,"See CPT",null,1351.5258000000001,null,1351.5258000000001,null,"090",0.11,0.76,0.13,0,2,1,2,1,0,"","R",null,"Y-CM"]
[64742,null,"See CPT",null,878.2242,null,878.2242,null,"090",0.11,0.76,0.13,0,2,1,2,0,0,"","R",null,"Y-CM"]
[64776,null,"See CPT",null,705.79019999999991,null,705.79019999999991,null,"090",0.11,0.76,0.13,0,2,0,0,0,0,"","R"]
[64788,null,"See CPT",null,727.79039999999998,null,727.79039999999998,null,"090",0.11,0.76,0.13,0,2,0,1,0,0,"","R",null,"Y-CM"]
[64802,null,"See CPT",null,1502.5542,null,1502.5542,null,"090",0.11,0.76,0.13,0,2,1,2,1,0,"","R",null,"Y-CM"]
[64840,null,"See CPT",null,1716.0155999999999,null,1716.0155999999999,null,"090",0.11,0.76,0.13,0,2,1,2,0,0,"","R"]
[64858,null,"See CPT",null,2088.2352000000001,null,2088.2352000000001,null,"090",0.11,0.76,0.13,0,2,1,2,1,0,"","R"]
[64886,null,"See CPT",null,2283.2640000000001,null,2283.2640000000001,null,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R"]
[64902,null,"See CPT",null,1205.8488,null,1205.8488,null,"000",0,0,0,0,0,0,2,1,0,"","R"]
[65091,null,"See CPT",null,1365.2016000000001,null,1365.2016000000001,null,"090",0.1,0.7,0.2,0,2,1,0,1,0,"","R"]
[65114,null,"See CPT",null,2843.3771999999999,null,2843.3771999999999,null,"090",0.1,0.7,0.2,0,2,1,2,1,0,"","R"]
[65235,null,"See CPT",null,1300.9848,null,1300.9848,null,"090",0.1,0.7,0.2,0,2,1,0,0,0,"","R"]
[65272,null,"See CPT",null,964.44119999999998,null,626.70839999999998,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R"]
[65450,null,"See CPT",null,586.27559999999994,null,571.41059999999993,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R"]
[65730,null,"See CPT",null,2226.1823999999997,null,2226.1823999999997,null,"090",0.1,0.7,0.2,0,2,1,2,1,0,"","R"]
[65778,null,"See CPT",null,2564.5098000000003,null,93.94680000000001,null,"000",0,0,0,0,2,1,0,0,0,"","R"]
[65850,null,"See CPT",null,1496.0136,null,1496.0136,null,"090",0.1,0.7,0.2,0,2,1,1,1,0,"","R"]
[65920,null,"See CPT",null,1406.229,null,1406.229,null,"090",0.1,0.7,0.2,0,2,1,1,1,0,"","R"]
[66160,null,"See CPT",null,1749.9078,null,1749.9078,null,"090",0.1,0.7,0.2,0,2,1,1,1,0,"","R"]
[66500,null,"See CPT",null,715.30380000000002,null,715.30380000000002,null,"090",0.1,0.7,0.2,0,2,1,1,1,0,"","R"]
[66625,null,"See CPT",null,759.89879999999994,null,759.89879999999994,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R"]
[66821,null,"See CPT",null,599.95140000000004,null,555.35640000000001,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R"]
[66840,null,"See CPT",null,1225.4705999999999,null,1225.4705999999999,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R"]
[66988,null,"See CPT",null," By Report ",null," By Report ",null,"090",0.1,0.7,0.2,0,2,1,0,1,1,"","N",null,"Y-CM"]
[67028,null,"See CPT",null,202.16399999999999,null,161.13659999999999,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[67043,null,"See CPT",null,2122.7220000000002,null,2122.7220000000002,null,"090",0.1,0.7,0.2,0,2,1,2,1,0,"","R"]
[67115,null,"See CPT",null,881.79179999999997,null,881.79179999999997,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R"]
[67228,null,"See CPT",null,603.51900000000001,null,534.54539999999997,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,"Y-CM"]
[67299,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,0,1,1,"","N"]
[67346,null,"See CPT",null,334.75979999999998,null,334.75979999999998,null,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM"]
[67405,null,"See CPT",null,1647.6366,null,1647.6366,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R"]
[67599,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,0,2,1,2,1,1,"","N"]
[67805,null,"See CPT",null,364.4898,null,288.97560000000004,null,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R"]
[67850,null,"See CPT",null,396.59820000000002,null,230.11020000000002,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[67903,null,"See CPT",null,1091.6856,null,849.08879999999999,null,"090",0.1,0.7,0.2,0,2,1,1,1,0,"","R"]
[67922,null,"See CPT",null,566.65379999999993,null,354.38159999999999,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R"]
[67935,null,"See CPT",null,1083.9558,null,775.95300000000009,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R"]
[68115,null,"See CPT",null,614.81640000000004,null,322.86779999999999,null,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R"]
[68200,null,"See CPT",null,74.919600000000003,null,60.054600000000001,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[68505,null,"See CPT",null,1899.1524000000002,null,1899.1524000000002,null,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,"Y-CM"]
[68550,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","X"]
[68770,null,"See CPT",null,1107.7398000000001,null,1107.7398000000001,null,"090",0.1,0.7,0.2,0,2,1,0,0,0,"","R"]
[68841,null,"See CPT",null,67.784399999999991,null,57.081600000000002,null,"000",0,0,0,0,2,1,1,0,0,"","R"]
[69090,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[69210,null,"See CPT",null,85.027799999999999,null,58.270800000000001,null,"000",0,0,0,0,2,2,1,0,0,"","R"]
[69440,null,"See CPT",null,1268.8764000000001,null,1268.8764000000001,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,"","R"]
[69502,null,"See CPT",null,1714.2318,null,1714.2318,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,"","R",null,"Y-CM"]
[69604,null,"See CPT",null,2028.7751999999998,null,2028.7751999999998,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,"","R",null,"Y-CM"]
[69635,null,"See CPT",null,2333.2103999999999,null,2333.2103999999999,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,"","R"]
[69662,null,"See CPT",null,2103.1001999999999,null,2103.1001999999999,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,"","R"]
[69706,null,"See CPT",null,5499.4553999999998,null,428.70659999999998,null,"000",0,0,0,0,3,2,0,0,0,31231,"R",null,"Y-CM"]
[69719,null,"See CPT",null,1092.2802000000001,null,1092.2802000000001,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,"","R"]
[69910,null,"See CPT",null,1795.0974000000001,null,1795.0974000000001,null,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,"","R",null,"Y-CM"]
[70015,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[70030,"TC","See CPT",null,44.594999999999999,null,44.594999999999999,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[70130,"TC","See CPT",null,87.406199999999998,null,87.406199999999998,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[70140,"TC","See CPT",null,42.2166,null,42.2166,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[70190,"TC","See CPT",null,51.730200000000004,null,51.730200000000004,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[70210,26,"See CPT",null,14.865,null,14.865,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[70240,26,"See CPT",null,16.054200000000002,null,16.054200000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[70310,26,"See CPT",null,13.675800000000001,null,13.675800000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[70332,26,"See CPT",null,46.973400000000005,null,46.973400000000005,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[70336,26,"See CPT",null,125.4606,null,125.4606,null,"000",0,0,0,1,4,3,0,0,0,"","R"]
[70370,26,"See CPT",null,26.757000000000001,null,26.757000000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[70380,26,"See CPT",null,14.2704,null,14.2704,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[70460,null,"See CPT",null,285.40800000000002,null,285.40800000000002,null,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-UR"]
[70482,null,"See CPT",null,410.86860000000001,null,410.86860000000001,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[70487,null,"See CPT",null,292.54320000000001,null,292.54320000000001,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[70492,null,"See CPT",null,429.30119999999999,null,429.30119999999999,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[70542,null,"See CPT",null,527.41019999999992,null,527.41019999999992,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[70543,null,"See CPT",null,664.76279999999997,null,664.76279999999997,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[70547,null,"See CPT",null,420.97680000000003,null,420.97680000000003,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[70549,null,"See CPT",null,674.27639999999997,null,674.27639999999997,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[70552,"TC","See CPT",null,375.19259999999997,null,375.19259999999997,null,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-UR"]
[70557,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[70559,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[71048,"TC","See CPT",null,58.865400000000001,null,58.865400000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[71111,"TC","See CPT",null,70.162800000000004,null,70.162800000000004,null,"000",0,0,0,1,0,2,0,0,0,"","R"]
[71130,null,"See CPT",null,77.298000000000002,null,77.298000000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[71271,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,4,0,0,0,0,"","X"]
[71275,"TC","See CPT",null,389.46300000000002,null,389.46300000000002,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[71551,26,"See CPT",null,147.46080000000001,null,147.46080000000001,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[72052,null,"See CPT",null,115.3524,null,115.3524,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[72072,"TC","See CPT",null,53.514000000000003,null,53.514000000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[72080,26,"See CPT",null,17.838000000000001,null,17.838000000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[72084,26,"See CPT",null,36.270600000000002,null,36.270600000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[72110,"TC","See CPT",null,73.135800000000003,null,73.135800000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[72126,26,"See CPT",null,103.46040000000001,null,103.46040000000001,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[72127,26,"See CPT",null,108.21720000000001,null,108.21720000000001,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[72130,null,"See CPT",null,385.30080000000004,null,385.30080000000004,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[72142,"TC","See CPT",null,387.08459999999997,null,387.08459999999997,null,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-UR"]
[72147,26,"See CPT",null,151.62299999999999,null,151.62299999999999,null,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-UR"]
[72156,null,"See CPT",null,624.92459999999994,null,624.92459999999994,null,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-UR"]
[72170,null,"See CPT",null,51.730200000000004,null,51.730200000000004,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[72190,26,"See CPT",null,22.0002,null,22.0002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[72195,null,"See CPT",null,451.3014,null,451.3014,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[72196,null,"See CPT",null,528.00480000000005,null,528.00480000000005,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[72198,"TC","See CPT",null,507.78839999999997,null,507.78839999999997,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[72255,26,"See CPT",null,80.271000000000001,null,80.271000000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[72265,"TC","See CPT",null,132.5958,null,132.5958,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[73000,"TC","See CPT",null,45.189599999999999,null,45.189599999999999,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[73040,"TC","See CPT",null,199.78559999999999,null,199.78559999999999,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[73060,null,"See CPT",null,58.865400000000001,null,58.865400000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[73090,"TC","See CPT",null,39.838200000000001,null,39.838200000000001,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[73092,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,3,0,0,0,"","X"]
[73110,26,"See CPT",null,14.865,null,14.865,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[73201,null,"See CPT",null,391.24680000000001,null,391.24680000000001,null,"000",0,0,0,1,4,3,0,0,0,"","R"]
[73201,26,"See CPT",null,98.108999999999995,null,98.108999999999995,null,"000",0,0,0,1,4,3,0,0,0,"","R"]
[73219,26,"See CPT",null,138.54179999999999,null,138.54179999999999,null,"000",0,0,0,1,4,3,0,0,0,"","R",null,"Y-UR"]
[73223,26,"See CPT",null,183.13679999999999,null,183.13679999999999,null,"000",0,0,0,1,4,3,0,0,0,"","R",null,"Y-UR"]
[73501,"TC","See CPT",null,44.000399999999999,null,44.000399999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[73522,26,"See CPT",null,25.567799999999998,null,25.567799999999998,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[73523,26,"See CPT",null,26.757000000000001,null,26.757000000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[73562,null,"See CPT",null,76.108800000000002,null,76.108800000000002,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[73564,26,"See CPT",null,19.6218,null,19.6218,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[73590,null,"See CPT",null,58.270800000000001,null,58.270800000000001,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[73615,null,"See CPT",null,250.32660000000001,null,250.32660000000001,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[73630,"TC","See CPT",null,49.351799999999997,null,49.351799999999997,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[73701,null,"See CPT",null,321.67860000000002,null,321.67860000000002,null,"000",0,0,0,1,4,3,0,0,0,"","R"]
[73719,null,"See CPT",null,516.11279999999999,null,516.11279999999999,null,"000",0,0,0,1,4,3,0,0,0,"","R",null,"Y-UR"]
[73721,"TC","See CPT",null,276.48900000000003,null,276.48900000000003,null,"000",0,0,0,1,4,3,0,0,0,"","R",null,"Y-UR"]
[73725,"TC","See CPT",null,504.81540000000001,null,504.81540000000001,null,"000",0,0,0,1,4,3,0,0,0,"","R"]
[74019,null,"See CPT",null,68.378999999999991,null,68.378999999999991,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74022,"TC","See CPT",null,65.406000000000006,null,65.406000000000006,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74174,"TC","See CPT",null,556.54559999999992,null,556.54559999999992,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[74176,26,"See CPT",null,148.05540000000002,null,148.05540000000002,null,"000",0,0,0,1,4,0,9,0,0,"","R"]
[74182,"TC","See CPT",null,448.32839999999999,null,448.32839999999999,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[74210,"TC","See CPT",null,134.37959999999998,null,134.37959999999998,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74221,26,"See CPT",null,59.46,null,59.46,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74240,26,"See CPT",null,68.378999999999991,null,68.378999999999991,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74248,"TC","See CPT",null,97.514399999999995,null,97.514399999999995,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74251,26,"See CPT",null,99.892799999999994,null,99.892799999999994,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74270,26,"See CPT",null,88.000799999999998,null,88.000799999999998,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74290,null,"See CPT",null,165.2988,null,165.2988,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74328,26,"See CPT",null,41.0274,null,41.0274,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74355,26,"See CPT",null,65.406000000000006,null,65.406000000000006,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74400,null,"See CPT",null,258.0564,null,258.0564,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74420,null,"See CPT",null,142.10940000000002,null,142.10940000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74425,26,"See CPT",null,42.2166,null,42.2166,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74445,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,"","N"]
[74485,null,"See CPT",null,222.38040000000001,null,222.38040000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[74712,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,4,0,0,0,0,"","X"]
[74775,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM"]
[75563,null,"See CPT",null,843.73739999999998,null,843.73739999999998,null,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-CM"]
[75571,"TC","See CPT",null,140.92020000000002,null,140.92020000000002,null,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-CM"]
[75600,26,"See CPT",null,42.2166,null,42.2166,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[75625,"TC","See CPT",null,114.1632,null,114.1632,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[75635,26,"See CPT",null,200.3802,null,200.3802,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[75716,"TC","See CPT",null,134.9742,null,134.9742,null,"000",0,0,0,1,6,2,0,0,0,"","R"]
[75733,26,"See CPT",null,108.81180000000001,null,108.81180000000001,null,"000",0,0,0,1,6,2,0,0,0,"","R"]
[75746,26,"See CPT",null,94.54140000000001,null,94.54140000000001,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[75803,26,"See CPT",null,99.298199999999994,null,99.298199999999994,null,"000",0,0,0,1,0,2,0,0,0,"","R"]
[75807,26,"See CPT",null,93.94680000000001,null,93.94680000000001,null,"000",0,0,0,1,0,2,0,0,0,"","R"]
[75809,26,"See CPT",null,41.0274,null,41.0274,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[75831,null,"See CPT",null,219.4074,null,219.4074,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[75833,null,"See CPT",null,270.54300000000001,null,270.54300000000001,null,"000",0,0,0,1,6,2,0,0,0,"","R"]
[75860,null,"See CPT",null,231.89400000000001,null,231.89400000000001,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[75880,null,"See CPT",null,199.78559999999999,null,199.78559999999999,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[75891,null,"See CPT",null,228.32640000000001,null,228.32640000000001,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[75901,null,"See CPT",null,449.51759999999996,null,449.51759999999996,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[75956,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,"","N"]
[75957,null,"See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,"","N"]
[75989,"TC","See CPT",null,111.78479999999999,null,111.78479999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76000,"TC","See CPT",null,52.324800000000003,null,52.324800000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76098,"TC","See CPT",null,47.568000000000005,null,47.568000000000005,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[76125,"TC","See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,"","N"]
[76380,26,"See CPT",null,81.460200000000015,null,81.460200000000015,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76497,"TC","See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,"","N"]
[76499,"TC","See CPT",null," By Report ",null," By Report ",null,"000",0,0,0,1,0,0,0,0,0,"","N"]
[76506,26,"See CPT",null,54.703200000000002,null,54.703200000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76516,null,"See CPT",null,85.027799999999999,null,85.027799999999999,null,"000",0,0,0,1,7,2,0,0,0,"","R"]
[76519,null,"See CPT",null,122.4876,null,122.4876,null,"000",0,0,0,1,7,2,0,0,0,"","R"]
[76604,null,"See CPT",null,107.02800000000001,null,107.02800000000001,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[76700,null,"See CPT",null,218.81280000000001,null,218.81280000000001,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[76775,null,"See CPT",null,106.43340000000001,null,106.43340000000001,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[76800,"TC","See CPT",null,165.2988,null,165.2988,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76810,null,"See CPT",null,161.7312,null,161.7312,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76811,null,"See CPT",null,319.30020000000002,null,319.30020000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76816,"TC","See CPT",null,130.81200000000001,null,130.81200000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[76817,"TC","See CPT",null,108.21720000000001,null,108.21720000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76820,26,"See CPT",null,42.811199999999999,null,42.811199999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76826,"TC","See CPT",null,225.35339999999999,null,225.35339999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76831,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,4,0,0,0,0,"","X"]
[76870,null,"See CPT",null,188.48820000000001,null,188.48820000000001,null,"000",0,0,0,1,4,0,0,0,0,"","R"]
[76881,"TC","See CPT",null,53.514000000000003,null,53.514000000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76882,"TC","See CPT",null,62.433000000000007,null,62.433000000000007,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76937,26,"See CPT",null,23.784000000000002,null,23.784000000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[76940,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[76948,26,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[76965,"TC","See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[76979,26,"See CPT",null,72.541200000000003,null,72.541200000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[76983,"TC","See CPT",null,69.56819999999999,null,69.56819999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[77001,26,"See CPT",null,32.108400000000003,null,32.108400000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[77002,26,"See CPT",null,48.162600000000005,null,48.162600000000005,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[77021,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,9,0,0,"","X"]
[77021,26,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,9,0,0,"","X"]
[77053,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,9,0,0,"","X"]
[77054,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,9,0,0,"","X"]
[77065,null,"See CPT",null,233.67780000000002,null,233.67780000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[77067,26,"See CPT",null,64.811400000000006,null,64.811400000000006,null,"000",0,0,0,1,0,2,0,0,0,"","R",null,"Y-CM"]
[77074,26,"See CPT",null,37.459800000000001,null,37.459800000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[77075,26,"See CPT",null,47.568000000000005,null,47.568000000000005,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[77084,null,"See CPT",null,627.303,null,627.303,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[77084,26,"See CPT",null,136.1634,null,136.1634,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[77280,26,"See CPT",null,67.189799999999991,null,67.189799999999991,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[77285,26,"See CPT",null,101.08199999999999,null,101.08199999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[77299,"TC","See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM"]
[77306,"TC","See CPT",null,134.37959999999998,null,134.37959999999998,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[77317,26,"See CPT",null,171.2448,null,171.2448,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[77331,null,"See CPT",null,115.947,null,115.947,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[77336,null,"See CPT",null,151.62299999999999,null,151.62299999999999,null,"000",0,0,0,3,0,0,0,0,0,"","R",null,"Y-CM"]
[77338,"TC","See CPT",null,432.27420000000001,null,432.27420000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[77417,null,"See CPT",null,23.189400000000003,null,23.189400000000003,null,"000",0,0,0,3,0,0,0,0,0,"","R",null,"Y-CM"]
[77425,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[77520,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,3,0,0,0,0,0,"","N",null,"Y-CM"]
[77605,"TC","See CPT",null,1682.1233999999999,null,1682.1233999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[77620,26,"See CPT",null,146.86620000000002,null,146.86620000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[77762,null,"See CPT",null,980.4953999999999,null,980.4953999999999,null,"090",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[77770,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[77770,26,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[77799,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM"]
[78012,null,"See CPT",null,149.24459999999999,null,149.24459999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78015,"TC","See CPT",null,349.03020000000004,null,349.03020000000004,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78020,null,"See CPT",null,146.27160000000001,null,146.27160000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78075,null,"See CPT",null,789.03419999999994,null,789.03419999999994,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78102,"TC","See CPT",null,260.4348,null,260.4348,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78111,"TC","See CPT",null,120.70379999999999,null,120.70379999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78120,null,"See CPT",null,132.00120000000001,null,132.00120000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78185,"TC","See CPT",null,277.08359999999999,null,277.08359999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78191,"TC","See CPT",null,186.70440000000002,null,186.70440000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78201,26,"See CPT",null,36.270600000000002,null,36.270600000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78216,"TC","See CPT",null,190.27200000000002,null,190.27200000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78231,"TC","See CPT",null,156.9744,null,156.9744,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78258,26,"See CPT",null,59.46,null,59.46,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78265,26,"See CPT",null,81.460200000000015,null,81.460200000000015,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[78266,"TC","See CPT",null,690.92520000000002,null,690.92520000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[78299,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM"]
[78300,null,"See CPT",null,404.32799999999997,null,404.32799999999997,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[78315,"TC","See CPT",null,527.41019999999992,null,527.41019999999992,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[78399,"TC","See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM"]
[78430,26,"See CPT",null,134.9742,null,134.9742,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-UR"]
[78433,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-UR"]
[78452,null,"See CPT",null,837.79139999999995,null,837.79139999999995,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-UR"]
[78454,null,"See CPT",null,767.62860000000001,null,767.62860000000001,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-UR"]
[78459,null,"See CPT",null,3288.8155034592005,null,3288.8155034592005,null,"000",0,0,0,1,0,0,0,0,0,"","F",null,"Y-UR"]
[78466,null,"See CPT",null,344.86799999999999,null,344.86799999999999,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM"]
[78472,"TC","See CPT",null,321.67860000000002,null,321.67860000000002,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM"]
[78483,null,"See CPT",null,429.30119999999999,null,429.30119999999999,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM"]
[78496,null,"See CPT",null,77.298000000000002,null,77.298000000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-UR"]
[78579,"TC","See CPT",null,290.75939999999997,null,290.75939999999997,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78598,"TC","See CPT",null,467.35560000000004,null,467.35560000000004,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78600,"TC","See CPT",null,288.97560000000004,null,288.97560000000004,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[78608,26,"See CPT",null,121.89299999999999,null,121.89299999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78609,null,"See CPT",null,130.2174,null,130.2174,null,"000",0,0,0,1,9,9,9,9,9,"","R",null,"Y-CM"]
[78635,26,"See CPT",null,52.324800000000003,null,52.324800000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[78660,"TC","See CPT",null,284.8134,null,284.8134,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[78707,"TC","See CPT",null,331.78680000000003,null,331.78680000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[78725,"TC","See CPT",null,176.0016,null,176.0016,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[78761,"TC","See CPT",null,315.13799999999998,null,315.13799999999998,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[78800,26,"See CPT",null,54.703200000000002,null,54.703200000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78804,26,"See CPT",null,83.8386,null,83.8386,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78811,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[78813,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[78830,"TC","See CPT",null,736.11480000000006,null,736.11480000000006,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[78832,26,"See CPT",null,173.02860000000001,null,173.02860000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[79200,26,"See CPT",null,142.10940000000002,null,142.10940000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[79440,26,"See CPT",null,142.10940000000002,null,142.10940000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[79999,"TC","See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM"]
[80143,null,"See CPT",null,26.655200000000001,null,26.655200000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[80151,null,"See CPT",null,26.655200000000001,null,26.655200000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[80161,null,"See CPT",null,26.655200000000001,null,26.655200000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[80176,null,"See CPT",null,21.006699999999999,null,21.006699999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[80184,null,"See CPT",null,21.879000000000001,null,21.879000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[80200,null,"See CPT",null,23.065899999999999,null,23.065899999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[80280,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[80321,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[80333,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[80336,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[80342,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[80354,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[80361,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[80375,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[80414,null,"See CPT",null,73.845199999999991,null,73.845199999999991,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[80424,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[80505,null,"See CPT",null,169.46100000000001,null,158.75819999999999,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[81001,null,"See CPT",null,4.5331000000000001,null,4.5331000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[81020,null,"See CPT",null,6.7210000000000001,null,6.7210000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[81120,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81166,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81181,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81190,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81202,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81207,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81223,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81226,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81238,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81249,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81256,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81263,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81275,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81283,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81296,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81299,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81311,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81322,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81329,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81336,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81348,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81353,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81375,null,"See CPT",null,315.65820000000002,null,315.65820000000002,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[81378,null,"See CPT",null,494.1651,null,494.1651,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[81406,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81419,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81431,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81438,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81471,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81503,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81520,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81523,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[81595,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[82017,null,"See CPT",null,24.124100000000002,null,24.124100000000002,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82045,null,"See CPT",null,48.534199999999991,null,48.534199999999991,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82105,null,"See CPT",null,23.981099999999998,null,23.981099999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82143,null,"See CPT",null,13.370499999999998,null,13.370499999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82163,null,"See CPT",null,29.343599999999999,null,29.343599999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82270,null,"See CPT",null,6.2633999999999999,null,6.2633999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82274,null,"See CPT",null,22.765599999999999,null,22.765599999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82373,null,"See CPT",null,25.825799999999997,null,25.825799999999997,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82379,null,"See CPT",null,24.124100000000002,null,24.124100000000002,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82441,null,"See CPT",null,8.5942999999999987,null,8.5942999999999987,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82523,null,"See CPT",null,26.712399999999999,null,26.712399999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82550,null,"See CPT",null,9.3092999999999986,null,9.3092999999999986,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82608,null,"See CPT",null,20.477599999999999,null,20.477599999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82657,null,"See CPT",null,31.703100000000003,null,31.703100000000003,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82668,null,"See CPT",null,26.869699999999998,null,26.869699999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82726,null,"See CPT",null,28.2425,null,28.2425,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82747,null,"See CPT",null,25.239499999999996,null,25.239499999999996,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82805,null,"See CPT",null,112.64109999999999,null,112.64109999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82945,null,"See CPT",null,5.6199000000000003,null,5.6199000000000003,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[82955,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[83003,null,"See CPT",null,23.838100000000001,null,23.838100000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[83026,null,"See CPT",null,5.7342999999999993,null,5.7342999999999993,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[83036,null,"See CPT",null,13.885300000000001,null,13.885300000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[83150,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[83505,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[83570,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[83630,null,"See CPT",null,28.170999999999999,null,28.170999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[83663,null,"See CPT",null,27.0413,null,27.0413,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[83721,null,"See CPT",null,15.014999999999999,null,15.014999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[83872,null,"See CPT",null,8.3797999999999995,null,8.3797999999999995,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[83876,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[83950,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[83993,null,"See CPT",null,28.070899999999998,null,28.070899999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[84119,null,"See CPT",null,19.104799999999997,null,19.104799999999997,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[84132,null,"See CPT",null,6.8067999999999991,null,6.8067999999999991,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[84144,null,"See CPT",null,29.829799999999999,null,29.829799999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[84163,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[84207,null,"See CPT",null,40.183,null,40.183,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[84228,null,"See CPT",null,16.6309,null,16.6309,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[84300,null,"See CPT",null,7.2357999999999993,null,7.2357999999999993,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[84315,null,"See CPT",null,4.6903999999999995,null,4.6903999999999995,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[84439,null,"See CPT",null,12.898599999999998,null,12.898599999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[84466,null,"See CPT",null,18.2468,null,18.2468,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[84484,null,"See CPT",null,17.832100000000001,null,17.832100000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[84525,null,"See CPT",null,7.3358999999999996,null,7.3358999999999996,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[84590,null,"See CPT",null,16.6023,null,16.6023,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[84681,null,"See CPT",null,29.758299999999998,null,29.758299999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[85014,null,"See CPT",null,3.3891,null,3.3891,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[85027,null,"See CPT",null,9.2520999999999987,null,9.2520999999999987,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[85230,null,"See CPT",null,25.596999999999998,null,25.596999999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[85270,null,"See CPT",null,25.596999999999998,null,25.596999999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[85300,null,"See CPT",null,16.945499999999999,null,16.945499999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[85335,null,"See CPT",null,18.4041,null,18.4041,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[85384,null,"See CPT",null,13.8996,null,13.8996,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[85400,null,"See CPT",null,11.0253,null,11.0253,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[85530,null,"See CPT",null,18.718699999999998,null,18.718699999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[85547,null,"See CPT",null,12.297999999999998,null,12.297999999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[85670,null,"See CPT",null,8.2510999999999992,null,8.2510999999999992,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86001,null,"See CPT",null,11.182600000000001,null,11.182600000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86022,null,"See CPT",null,26.269100000000002,null,26.269100000000002,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86052,null,"See CPT",null,"Not Covered",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[86152,null,"See CPT",null,"Not Covered ",null,"Not Covered ",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[86161,null,"See CPT",null,17.16,null,17.16,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86256,null,"See CPT",null,17.2315,null,17.2315,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86280,null,"See CPT",null,11.711699999999999,null,11.711699999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86327,null,"See CPT",null,42.785600000000002,null,42.785600000000002,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86335,null,"See CPT",null,41.970500000000001,null,41.970500000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86335,26,"See CPT",null,32.108400000000003,null,32.108400000000003,null,"000",0,0,0,6,0,0,0,0,0,"","R"]
[86359,null,"See CPT",null,53.95389999999999,null,53.95389999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86403,null,"See CPT",null,16.502199999999998,null,16.502199999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86431,null,"See CPT",null,8.1081000000000003,null,8.1081000000000003,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86602,null,"See CPT",null,14.557399999999999,null,14.557399999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86609,null,"See CPT",null,18.418400000000002,null,18.418400000000002,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86645,null,"See CPT",null,24.095500000000001,null,24.095500000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86664,null,"See CPT",null,21.864699999999999,null,21.864699999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86665,null,"See CPT",null,25.940200000000001,null,25.940200000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86694,null,"See CPT",null,20.5777,null,20.5777,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86705,null,"See CPT",null,16.831099999999999,null,16.831099999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86723,null,"See CPT",null,18.861699999999999,null,18.861699999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86759,null,"See CPT",null,26.068899999999999,null,26.068899999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86768,null,"See CPT",null,18.861699999999999,null,18.861699999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86800,null,"See CPT",null,22.751300000000001,null,22.751300000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86806,null,"See CPT",null,68.053700000000006,null,68.053700000000006,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86821,null,"See CPT",null,52.280799999999999,null,52.280799999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86850,null,"See CPT",null,13.971099999999998,null,13.971099999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86900,null,"See CPT",null,4.2757000000000005,null,4.2757000000000005,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[86922,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
[86970,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
[86985,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
[87075,null,"See CPT",null,13.5421,null,13.5421,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87084,null,"See CPT",null,38.710099999999997,null,38.710099999999997,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87107,null,"See CPT",null,14.7576,null,14.7576,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87154,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[87176,null,"See CPT",null,8.4084000000000003,null,8.4084000000000003,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87205,null,"See CPT",null,6.1060999999999988,null,6.1060999999999988,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87255,null,"See CPT",null,48.419799999999995,null,48.419799999999995,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87272,null,"See CPT",null,17.131399999999999,null,17.131399999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87285,null,"See CPT",null,17.417399999999997,null,17.417399999999997,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87301,null,"See CPT",null,17.131399999999999,null,17.131399999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87332,null,"See CPT",null,17.131399999999999,null,17.131399999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87390,null,"See CPT",null,34.405799999999999,null,34.405799999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87430,null,"See CPT",null,24.038299999999996,null,24.038299999999996,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87483,null,"See CPT",null,595.9953999999999,null,595.9953999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[87500,null,"See CPT",null,50.178699999999999,null,50.178699999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87510,null,"See CPT",null,28.671499999999998,null,28.671499999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87527,null,"See CPT",null,59.716799999999992,null,59.716799999999992,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87531,null,"See CPT",null,82.94,null,82.94,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87538,null,"See CPT",null,50.178699999999999,null,50.178699999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87561,null,"See CPT",null,50.178699999999999,null,50.178699999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87592,null,"See CPT",null,61.261200000000002,null,61.261200000000002,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[87637,null,"See CPT",null,203.96089999999998,null,203.96089999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[87799,null,"See CPT",null,61.261200000000002,null,61.261200000000002,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87807,null,"See CPT",null,18.732999999999997,null,18.732999999999997,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87902,null,"See CPT",null,368.15349999999995,null,368.15349999999995,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[87906,null,"See CPT",null,184.08389999999997,null,184.08389999999997,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[88012,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[88040,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
[88106,26,"See CPT",null,33.297600000000003,null,33.297600000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[88121,26,"See CPT",null,84.433199999999999,null,84.433199999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[88152,null,"See CPT",null,39.525199999999998,null,39.525199999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[88161,"TC","See CPT",null,89.784599999999998,null,89.784599999999998,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[88172,"TC","See CPT",null,35.676000000000002,null,35.676000000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[88177,26,"See CPT",null,38.054400000000001,null,38.054400000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[88182,"TC","See CPT",null,200.97479999999999,null,200.97479999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[88230,null,"See CPT",null,166.58069999999998,null,166.58069999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[88248,null,"See CPT",null,247.63309999999998,null,247.63309999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[88275,null,"See CPT",null,73.201699999999988,null,73.201699999999988,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[88302,26,"See CPT",null,11.892000000000001,null,11.892000000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[88307,null,"See CPT",null,522.65339999999992,null,522.65339999999992,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[88312,26,"See CPT",null,46.378800000000005,null,46.378800000000005,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[88319,null,"See CPT",null,256.86720000000003,null,256.86720000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[88321,null,"See CPT",null,171.83940000000001,null,146.86620000000002,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[88332,26,"See CPT",null,53.514000000000003,null,53.514000000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[88341,null,"See CPT",null,161.13659999999999,null,161.13659999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[88348,null,"See CPT",null,836.60220000000004,null,836.60220000000004,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[88358,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[88361,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[88365,26,"See CPT",null,76.703400000000002,null,76.703400000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[88368,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[88369,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[88374,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[88380,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[88399,26,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N"]
[89049,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[89250,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[89268,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[89310,null,"See CPT",null,12.312299999999999,null,12.312299999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
[89322,null,"See CPT",null,22.164999999999999,null,22.164999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
[89346,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[90284,null,"See CPT",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
[90386,null,"See CPT",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
[90473,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[90630,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
[90654,null,"See CPT",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
[90662,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
[90667,null,"See CPT",null,0,null,0,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
[90689,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
[90694,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
[90723,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[90744,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[90792,null,"See CPT",null,349.62479999999999,null,305.02980000000002,null,"000",0,0,0,0,0,0,9,0,0,"","R",null,"Y-CM"]
[90849,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[90870,null,"See CPT",null,312.75959999999998,null,186.70440000000002,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[90880,null,"See CPT",null,187.29900000000001,null,156.9744,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[90952,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[90955,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[90967,null,"See CPT",null,31.513800000000003,null,31.513800000000003,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[91010,"TC","See CPT",null,305.62439999999998,null,305.62439999999998,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[91022,"TC","See CPT",null,190.27200000000002,null,190.27200000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[91037,"TC","See CPT",null,232.48860000000002,null,232.48860000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[91040,26,"See CPT",null,87.406199999999998,null,87.406199999999998,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[91065,26,"See CPT",null,18.432600000000001,null,18.432600000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[91122,null,"See CPT",null,511.35599999999999,null,511.35599999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[91132,null,"See CPT",null,881.19720000000007,null,881.19720000000007,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[91300,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
[92012,null,"See CPT",null,161.7312,null,89.784599999999998,null,"000",0,0,0,0,0,2,0,0,0,"","R"]
[92060,null,"See CPT",null,113.5686,null,113.5686,null,"000",0,0,0,1,7,2,0,0,0,"","R"]
[92072,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,2,0,0,0,"","X"]
[92132,26,"See CPT",null,28.540800000000001,null,28.540800000000001,null,"000",0,0,0,1,7,2,0,0,0,"","R"]
[92133,26,"See CPT",null,38.054400000000001,null,38.054400000000001,null,"000",0,0,0,1,7,2,0,0,0,"","R"]
[92228,26,"See CPT",null,31.513800000000003,null,31.513800000000003,null,"000",0,0,0,1,7,2,0,0,0,"","R"]
[92230,null,"See CPT",null,178.97459999999998,null,57.676200000000001,null,"000",0,0,0,0,0,3,0,0,0,"","R"]
[92250,26,"See CPT",null,36.865200000000002,null,36.865200000000002,null,"000",0,0,0,1,7,2,0,0,0,"","R"]
[92274,null,"See CPT",null,158.1636,null,158.1636,null,"000",0,0,0,1,7,2,0,0,0,"","R"]
[92285,26,"See CPT",null,5.3513999999999999,null,5.3513999999999999,null,"000",0,0,0,1,7,2,0,0,0,"","R"]
[92312,null,"See CPT",null,224.16419999999999,null,107.62260000000001,null,"000",0,0,0,0,0,2,0,0,0,"","R"]
[92354,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
[92355,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
[92519,null,"See CPT",null,193.245,null,110.5956,null,"000",0,0,0,0,0,2,0,0,0,"","R",null,"Y-CM"]
[92522,null,"See CPT",null,200.3802,null,200.3802,null,"000",0,0,0,7,5,0,0,0,0,"","R"]
[92538,null,"See CPT",null,41.0274,null,41.0274,null,"000",0,0,0,1,0,2,0,0,0,"","R"]
[92541,26,"See CPT",null,36.865200000000002,null,36.865200000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[92546,"TC","See CPT",null,204.54239999999999,null,204.54239999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[92549,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[92567,null,"See CPT",null,30.3246,null,19.027200000000001,null,"000",0,0,0,7,0,2,0,0,0,"","R"]
[92568,null,"See CPT",null,27.946199999999997,null,27.351600000000001,null,"000",0,0,0,7,0,2,0,0,0,"","R"]
[92588,"TC","See CPT",null,10.1082,null,10.1082,null,"000",0,0,0,1,0,2,0,0,0,"","R"]
[92592,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
[92606,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled",null,"Y-CM"]
[92613,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,0,0,0,0,0,0,"","Bundled",null,"Y-CM"]
[92633,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
[92920,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,0,0,0,"","X"]
[92950,null,"See CPT",null,601.73519999999996,null,322.27319999999997,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[92953,null,"See CPT",null,1.7838000000000001,null,1.7838000000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[92987,null,"See CPT",null,2386.7244000000001,null,2386.7244000000001,null,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,0,0,0,"","R",null,"Y-CM"]
[92998,null,"See CPT",null,550.005,null,550.005,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[93025,null,"See CPT",null,221.19120000000001,null,221.19120000000001,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM"]
[93224,null,"See CPT",null,138.54179999999999,null,138.54179999999999,null,"000",0,0,0,4,6,0,0,0,0,"","R"]
[93247,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,3,6,0,0,0,0,"","N",null,"Y-CM"]
[93261,"TC","See CPT",null,66.000600000000006,null,66.000600000000006,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM"]
[93280,26,"See CPT",null,67.189799999999991,null,67.189799999999991,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM"]
[93282,null,"See CPT",null,151.0284,null,151.0284,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM"]
[93286,null,"See CPT",null,88.000799999999998,null,88.000799999999998,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM"]
[93287,null,"See CPT",null,101.67659999999999,null,101.67659999999999,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM"]
[93290,26,"See CPT",null,37.459800000000001,null,37.459800000000001,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM"]
[93293,null,"See CPT",null,87.406199999999998,null,87.406199999999998,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[93304,"TC","See CPT",null,229.51560000000001,null,229.51560000000001,null,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM"]
[93307,26,"See CPT",null,77.892600000000002,null,77.892600000000002,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[93315,26,"See CPT",null,222.97499999999999,null,222.97499999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[93318,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,6,0,0,0,0,"","N"]
[93325,26,"See CPT",null,5.3513999999999999,null,5.3513999999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[93351,null,"See CPT",null,432.27420000000001,null,432.27420000000001,null,"000",0,0,0,1,6,0,9,9,9,"","R"]
[93453,26,"See CPT",null,547.62660000000005,null,547.62660000000005,null,"000",0,0,0,1,2,0,0,0,0,"","R",null,"Y-CM"]
[93454,26,"See CPT",null,415.62540000000001,null,415.62540000000001,null,"000",0,0,0,1,2,0,0,0,0,"","R",null,"Y-CM"]
[93458,26,"See CPT",null,511.35599999999999,null,511.35599999999999,null,"000",0,0,0,1,2,0,0,0,0,"","R",null,"Y-CM"]
[93462,null,"See CPT",null,365.67900000000003,null,365.67900000000003,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[93505,26,"See CPT",null,395.40900000000005,null,395.40900000000005,null,"000",0,0,0,1,2,0,0,0,0,"","R"]
[93571,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N"]
[93592,null,"See CPT",null,686.16839999999991,null,686.16839999999991,null,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR"]
[93594,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,2,0,0,0,0,"","X"]
[93598,26,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[93600,26,"See CPT",null,205.73160000000001,null,205.73160000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[93609,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM"]
[93616,26,"See CPT",null,103.46040000000001,null,103.46040000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[93620,"TC","See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM"]
[93622,26,"See CPT",null,298.48919999999998,null,298.48919999999998,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[93640,26,"See CPT",null,310.38119999999998,null,310.38119999999998,null,"000",0,0,0,1,2,0,0,0,0,"","R",null,"Y-CM"]
[93642,null,"See CPT",null,595.19460000000004,null,595.19460000000004,null,"000",0,0,0,1,2,0,0,0,0,"","R",null,"Y-CM"]
[93660,"TC","See CPT",null,125.4606,null,125.4606,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[93662,26,"See CPT",null,162.92040000000003,null,162.92040000000003,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[93740,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[93799,26,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N"]
[93886,null,"See CPT",null,504.81540000000001,null,504.81540000000001,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[93890,"TC","See CPT",null,425.73360000000002,null,425.73360000000002,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[93922,"TC","See CPT",null,131.4066,null,131.4066,null,"000",0,0,0,1,6,2,0,0,0,"","R"]
[93923,26,"See CPT",null,38.649000000000001,null,38.649000000000001,null,"000",0,0,0,1,6,2,0,0,0,"","R"]
[93931,"TC","See CPT",null,190.86660000000001,null,190.86660000000001,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[93970,"TC","See CPT",null,293.73240000000004,null,293.73240000000004,null,"000",0,0,0,1,6,2,0,0,0,"","R"]
[93975,26,"See CPT",null,98.108999999999995,null,98.108999999999995,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[93981,26,"See CPT",null,36.865200000000002,null,36.865200000000002,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[93990,"TC","See CPT",null,234.86700000000002,null,234.86700000000002,null,"000",0,0,0,1,6,0,0,0,0,"","R"]
[94010,null,"See CPT",null,48.757199999999997,null,48.757199999999997,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[94070,null,"See CPT",null,112.37939999999999,null,112.37939999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[94150,"TC","See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,1,9,9,9,9,9,"","Bundled"]
[94453,null,"See CPT",null,122.4876,null,122.4876,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[94610,null,"See CPT",null,97.514399999999995,null,97.514399999999995,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[94645,null,"See CPT",null,29.73,null,29.73,null,"000",0,0,0,5,0,0,0,0,0,"","R"]
[94669,null,"See CPT",null,34.486799999999995,null,34.486799999999995,null,"000",0,0,0,5,0,0,0,0,0,"","R"]
[94726,26,"See CPT",null,21.4056,null,21.4056,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[94729,null,"See CPT",null,108.21720000000001,null,108.21720000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[94772,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
[95004,null,"See CPT",null,7.1352000000000002,null,7.1352000000000002,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[95070,null,"See CPT",null,66.000600000000006,null,66.000600000000006,null,"000",0,0,0,3,0,0,0,0,0,"","R"]
[95115,null,"See CPT",null,17.243399999999998,null,17.243399999999998,null,"000",0,0,0,5,0,0,0,0,0,"","R",null,"Y-CM"]
[95147,null,"See CPT",null,112.97399999999999,null,5.3513999999999999,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[95199,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,"","N"]
[95707,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,"","N",null,"Y-CM"]
[95719,null,"See CPT",null,278.27279999999996,null,275.89439999999996,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[95725,null,"See CPT",null,522.05880000000002,null,510.16680000000002,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[95801,"TC","See CPT",null,92.757600000000011,null,92.757600000000011,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[95807,"TC","See CPT",null,594.00540000000001,null,594.00540000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[95808,"TC","See CPT",null,1083.9558,null,1083.9558,null,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM"]
[95813,"TC","See CPT",null,640.38419999999996,null,640.38419999999996,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95819,"TC","See CPT",null,731.35800000000006,null,731.35800000000006,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95824,26,"See CPT",null,68.97359999999999,null,68.97359999999999,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95861,null,"See CPT",null,302.65140000000002,null,302.65140000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95864,null,"See CPT",null,442.38240000000002,null,442.38240000000002,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95868,null,"See CPT",null,265.19159999999999,null,265.19159999999999,null,"000",0,0,0,1,0,2,0,0,0,"","R"]
[95873,null,"See CPT",null,141.51480000000001,null,141.51480000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95875,"TC","See CPT",null,149.83920000000001,null,149.83920000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95887,null,"See CPT",null,159.3528,null,159.3528,null,"000",0,0,0,1,0,3,0,0,0,"","R"]
[95907,null,"See CPT",null,167.6772,null,167.6772,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95909,26,"See CPT",null,141.51480000000001,null,141.51480000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95913,26,"See CPT",null,331.19220000000001,null,331.19220000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95922,"TC","See CPT",null,102.86580000000001,null,102.86580000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95926,"TC","See CPT",null,247.3536,null,247.3536,null,"000",0,0,0,1,0,2,0,0,0,"","R"]
[95930,"TC","See CPT",null,88.000799999999998,null,88.000799999999998,null,"000",0,0,0,1,0,2,0,0,0,"","R"]
[95937,26,"See CPT",null,61.2438,null,61.2438,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95941,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
[95955,26,"See CPT",null,94.54140000000001,null,94.54140000000001,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95961,null,"See CPT",null,592.81620000000009,null,592.81620000000009,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
[95967,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM"]
[95973,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[96000,null,"See CPT",null,151.62299999999999,null,151.62299999999999,null,"000",0,0,0,7,0,2,0,0,0,"","R"]
[96113,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[96130,null,"See CPT",null,211.67760000000001,null,189.67740000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[96136,null,"See CPT",null,79.676400000000001,null,41.622,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
[96167,null,"See CPT",null,124.2714,null,109.4064,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[96366,null,"See CPT",null,38.054400000000001,null,38.054400000000001,null,"000",0,0,0,5,0,0,0,0,0,"","R"]
[96374,null,"See CPT",null,71.946600000000004,null,71.946600000000004,null,"000",0,0,0,5,0,0,0,0,0,"","R"]
[96411,null,"See CPT",null,105.83880000000001,null,105.83880000000001,null,"000",0,0,0,5,0,0,0,0,0,"","R"]
[96521,null,"See CPT",null,256.86720000000003,null,256.86720000000003,null,"000",0,0,0,5,0,0,0,0,0,"","R"]
[96904,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,5,0,0,0,0,0,"","X"]
[96921,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,1,0,0,"","X"]
[96933,null,"See CPT",null,78.487200000000001,null,78.487200000000001,null,"000",0,0,0,2,0,0,0,0,0,"","R"]
[97026,null,"See CPT",null,11.892000000000001,null,11.892000000000001,null,"000",0,0,0,7,5,0,0,0,0,"","R"]
[97039,null,"See CPT",null,20.725329081600002,null,20.725329081600002,null,"000",0,0,0,7,0,0,0,0,0,"","F"]
[97139,null,"See CPT",null,28.740709483200003,null,28.740709483200003,null,"000",0,0,0,7,0,0,0,0,0,"","F"]
[97158,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[97172,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[97606,null,"See CPT",null,"Bundled",null,"Bundled",null,"000",0,0,0,0,0,0,0,0,0,"","Bundled",null,"Y-CM"]
[97755,null,"See CPT",null,68.378999999999991,null,68.378999999999991,null,"000",0,0,0,7,5,0,0,0,0,"","R"]
[97799,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,7,0,0,0,0,0,"","N"]
[98929,null,"See CPT",null,151.0284,null,124.86600000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[98962,null,"See CPT",null,19.027200000000001,null,19.027200000000001,null,"000",0,0,0,9,9,9,9,9,9,"","R"]
[98976,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[99050,null,"See CPT",null,52.137832032000013,null,49.466038564800002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
[99082,null,"See CPT",null,19.535461545600004,null,19.535461545600004,null,"000",0,0,0,0,0,0,0,0,0,"","F"]
[99170,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,1,0,0,"","X"]
[99177,null,"See CPT",null,8.9190000000000005,null,8.9190000000000005,null,"000",0,0,0,9,9,9,9,9,9,"","R"]
[99190,null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
[99219,null,"See CPT",null,230.70480000000001,null,230.70480000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[99222,null,"See CPT",null,235.4616,null,235.4616,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[99234,null,"See CPT",null,226.54259999999999,null,226.54259999999999,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[99251,null,"See CPT",null,84.433199999999999,null,84.433199999999999,null,"000",0,0,0,9,9,9,9,9,9,"","R"]
[99292,null,"See CPT",null,214.6506,null,190.86660000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[99325,null,"See CPT",null,137.94719999999998,null,137.94719999999998,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[99335,null,"See CPT",null,166.488,null,166.488,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
[99340,null,"See CPT",null,188.48820000000001,null,188.48820000000001,null,"000",0,0,0,9,9,9,9,9,9,"","R"]
[99360,null,"See CPT",null,105.83880000000001,null,105.83880000000001,null,"000",0,0,0,9,9,9,9,9,9,"","R"]
[99380,null,"See CPT",null,181.35299999999998,null,151.62299999999999,null,"000",0,0,0,9,9,9,9,9,9,"","R"]
[99385,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[99395,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[99412,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[99424,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[99447,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[99450,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[99467,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[99477,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[99484,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
[99492,null,"See CPT",null,272.32679999999999,null,164.1096,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-ONC"]
[99504,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
[99512,null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0004A",null,"See CPT",null,41.2,null,41.2,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["0007U",null,"See CPT",null,163.63490000000002,null,163.63490000000002,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
["0015M",null,"See CPT",null,1866.6790999999998,null,1866.6790999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-ONC"]
["0021U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0041A",null,"See CPT",null,41.2,null,41.2,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["0072T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0087U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0094A",null,"See CPT",null,41.2,null,41.2,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["0101T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0102U",null,"See CPT",null,1679.1363769248001,null,1679.1363769248001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC"]
["0114U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0123U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0132U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0135U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0147U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0154U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0163T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0174T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,"","N"]
["0209U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0214T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,1,0,0,0,"","N",null,"Y-UR"]
["0218U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0220T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,"","N",null,"Y-UR"]
["0226U",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["0234T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,"","N"]
["0241U",null,"See CPT",null,203.96089999999998,null,203.96089999999998,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
["0264T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0287U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0290U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0303U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0305U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0330T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0347T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0378R",null,"Stand alone job analysis, non-voc",null,10.0922401008,null,10.0922401008,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["0390R",null,"Vocational evaluation - non voc, ea 6 minutes, work eval",null,10.0922401008,null,10.0922401008,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["0402T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0404T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0414T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0416T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0425T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0433T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0444T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,0,0,0,0,0,"","N",null,"Y-CM"]
["0469T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0480T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,0,9,9,9,9,"","X"]
["0484T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,0,2,1,"","X"]
["0500F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["0501T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,4,9,9,9,9,9,"","X"]
["0509T",null,"See CPT",null,136.75799999999998,null,136.75799999999998,null,"000",0,0,0,1,7,2,0,0,0,"","R"]
["0516F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["0522T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,1,9,9,9,9,9,"","N",null,"Y-CM"]
["0527T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,1,0,0,"","X"]
["0535T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,9,9,9,9,9,"","X"]
["0538T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["0554T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0556F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["0563T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0570T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0580T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0584T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0620T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,1,0,0,0,"","X"]
["0623T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,4,0,0,0,0,0,"","X"]
["0639T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["0672T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,1,0,0,"","X"]
["0679T",null,"See CPT",null,"By Report",null,"By Report",null,"000",0,0,0,0,2,0,1,0,0,"","N"]
["0691T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,0,0,0,0,0,"","X"]
["0703T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,2,0,0,0,0,0,"","X"]
["0711T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,3,9,9,9,9,9,"","X"]
["0811V",null,"Assessment services - intern",null,8.6860330127999994,null,8.6860330127999994,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["0831V",null,"Plan development services-intern",null,8.6860330127999994,null,8.6860330127999994,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["0895V",null,"Air travel, vrc, intern, or forensic vrc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["0897V",null,"Hotel charges (voc) [out-of-state only]",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["1005F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["1026M",null,"AP final report at request of insurer",null,29.368094184,null,29.368094184,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["1039F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["1052F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["1066M",null,"Provider review of video materials with report",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["1071F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["1089M",null,"HEALTH SERVICES COORDINATOR-Top Tier",null,9.68,null,9.68,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["1091F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["1108M",null,"Ime-standard, single",null,700.56,null,700.56,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["1123M",null,"Ime - communication issues",null,233.14,null,233.14,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["1127F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["1142M",null,"IME Rare add'l provider",null,1269.76,null,1269.76,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["1152M",null,"Coord of hlth svcs, pt present, initial",null,"Contracted",null,"Contracted",null,"000",0,0,0,9,9,9,9,9,9,"","C"]
["1158F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["1190M",null,"Comprehensive hearing loss exam",null,700.56,null,700.56,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["1192M",null,"Impairment rating by a/p, complex",null,875.69,null,875.69,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["1215M",null,"Ur contracted - retrospective audit/review",null,"Contracted",null,"Contracted",null,"000",0,0,0,9,9,9,9,9,9,"","C"]
["1245M",null,"Utilization review physical medicine",null,"Contracted",null,"Contracted",null,"000",0,0,0,9,9,9,9,9,9,"","C"]
["1278M",null,"CCM, VALUE BASE-INITIAL PHASE",null,"Contracted",null,"Contracted",null,"000",0,0,0,9,9,9,9,9,9,"","C"]
["1302W",null,"Stay at work tools & equipment",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["1460F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["1501F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["1505F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["2004F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["2015M",null,"Pain clinic follow-up services: not face-to face/hr",null,1.3521222000000004,null,1.3521222000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["2028F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["2051A",null,"See CPT",null,61.981281648,null,61.981281648,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["3006F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3023F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3040F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3048F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3075F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3079F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3095F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3120F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3155F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3265F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3272F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3279F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3316F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3319F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3342F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3372F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3388F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3476F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3496F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3502F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3570F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3650F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["3760F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4005F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4016F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4035F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4050F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4054F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4075F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4084F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4133F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4144F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4164F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4174F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4190F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4210F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4248F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4256F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4279F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4305F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4510F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["4552F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["5010F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["5094V",null,"Hearing aid domes/tubes replacement, bilateral",null,25,null,25,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["6015F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["6040F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["8881H",null,"Nursing facility rehab - very high (per",null,731.22,null,731.22,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["8887H",null,"Nursing facility clinically complex (per",null,511.6,null,511.6,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["8917H",null,"Home/vehicle modification mileage, lodging, airfare, car rental",null,"State Rate",null,"State Rate",null,"000",0,0,0,9,9,9,9,9,9,"","S"]
["9001F",null,"See CPT",null,"Tracking",null,"Tracking",null,"000",0,0,0,9,9,9,9,9,9,"","T"]
["9974M",null,"INTERPRETER SYSTEM PER MINUTE",null,1.0302,null,1.0302,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["9997M",null,"Document translation at insurer request",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["A0130",null,"Noner transport wheelch van",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["A0170",null,"Transport parking fees/tolls",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["A0396",null,"Als esophageal intub suppls",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A0426",null,"Als 1",null,744.53502798870636,null,744.53502798870636,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A0998",null,"Ambulance response/treatment",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["A2006",null,"Novosorb synpath per sq cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["A4211",null,"Supp for self-adm injections",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4216",null,"Sterile water/saline, 10 ml",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4232",null,"Syringe w/needle insulin 3cc",null,4.1499999999999995,null,4.1499999999999995,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A4235",null,"Lithium batt for glucose mon",null,3.7267000000000001,null,3.7267000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A4256",null,"Calibrator solution/chips",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4263",null,"Permanent tear duct plug",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4284",null,"Replcmnt breast pump shield",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["A4306",null,"Drug delivery system <=50 ml",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4330",null,"Stool collection pouch",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4334",null,"Urinary cath leg strap",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4354",null,"Cath insertion tray w/bag",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4360",null,"Disposable ext urethral dev",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4376",null,"Drainable rubber pch w fcplt",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4379",null,"Urinary plastic pouch w fcpl",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4392",null,"Urinary pouch w st wear barr",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4406",null,"Pectin based ostomy paste",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4413",null,"2 pc drainable ost pouch",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4420",null,"Ost pch clsd for bar w lk fl",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4432",null,"Os pch urine w bar/fange/tap",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4437",null,"Irr supply sleev disp per mo",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,null,"N"]
["A4480",null,"Vabra aspirator",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4490",null,"Above knee surgical stocking",null,34.162799999999997,null,34.162799999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A4565",null,"Slings",null,9.7026000000000003,null,9.7026000000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A4600",null,"Sleeve, inter limb comp dev",null,40.993699999999997,null,40.993699999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A4611",null,"Heavy duty battery",null,313.68955160160004,null,313.68955160160004,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A4618",null,"Breathing circuits",null,32.283240230399997,null,32.283240230399997,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A4634",null,"Replacement bulb th lightbox",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["A4639",null,"Infrared ht sys replcmnt pad",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["A4670",null,"Automatic bp monitor, dial",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A4673",null,"Ext line w easy lock connect",null,11.7113,null,11.7113,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A4726",null,"Dialys sol fld vol > 5999cc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["A4755",null,"Comb art/venous blood tubing",null,122.00999999999999,null,122.00999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A4773",null,"Occult blood test strips",null,234.25919999999999,null,234.25919999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A4913",null,"Misc dialysis supplies noc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["A5055",null,"Stoma cap",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A5063",null,"Drain ostomy pouch w/flange",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A5120",null,"Skin barrier, wipe or swab",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A5126",null,"Disk/foam pad +or- adhesive",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6010",null,"Collagen based wound filler",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6154",null,"Wound pouch each",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6205",null,"Composite drsg > 48 sq in",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6212",null,"Foam drg <=16 sq in w/border",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6224",null,"Gauze > 48 in no w/sal w/o b",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6232",null,"Hydrogel dsg>16<=48 sq in",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6245",null,"Hydrogel drg <= 16 in w/bdr",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6248",null,"Hydrogel drsg gel filler",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6262",null,"Wound filler dry form / gram",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6407",null,"Packing strips, non-impreg",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6448",null,"Lt compres band <3\"/yd",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6455",null,"Self-adher band >=5\"/yd",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["A6503",null,"Compres burngarment facehood",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["A6530",null,"Compression stocking bk18-30",null,85.979699999999994,null,85.979699999999994,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A6544",null,"Gc stocking garter belt",null,105.4183,null,105.4183,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A6550",null,"Neg pres wound ther drsg set",null,29.797900000000002,null,29.797900000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC"]
["A7013",null,"Disposable compressor filter",null,1.9504999999999999,null,1.9504999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A7018",null,"Water distilled w/nebulizer",null,0.43259999999999998,null,0.43259999999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A7030",null,"Cpap full face mask",null,249.84659999999997,null,249.84659999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A7044",null,"Pap oral interface",null,190.33559999999997,null,190.33559999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A7503",null,"Hmes filter holder or cap",null,14.296400000000002,null,14.296400000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A7524",null,"Tracheostoma stent/stud/bttn",null,97.551299999999998,null,97.551299999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A9155",null,"Artificial saliva",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["A9272",null,"Disp wound suct, drsg/access",null,143.73109999999997,null,143.73109999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A9285",null,"Inversion eversion cor devic",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["A9501",null,"Technetium tc-99m teboroxime",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["A9509",null,"Iodine i-123 sod iodide mil",null,1057.8615,null,1057.8615,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A9528",null,"Iodine i-131 iodide cap, dx",null,257.66519999999997,null,257.66519999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A9538",null,"Tc99m pyrophosphate",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["A9552",null,"F18 fdg",null,659.2192,null,659.2192,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["A9564",null,"P32 chromic phosphate",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["A9572",null,"Indium in-111 pentetreotide",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["A9582",null,"Iodine i-123 iobenguane",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["A9587",null,"Gallium ga-68",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["A9594",null,"Gallium ga-68 psma-11, ucla",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["A9901",null,"Delivery/set up/dispensing",null,117.13789999999999,null,117.13789999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["B4083",null,"Enteral stomach tube levine",null,2.4308000000000001,null,2.4308000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["B4153",null,"Ef hydrolyzed/amino acids",null,1.8437000000000001,null,1.8437000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["B4176",null,"Parenteral sol amino acid 7-",null,62.747600000000006,null,62.747600000000006,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["B4197",null,"Parenteral sol 74-100 gm pro",null,365.9178,null,365.9178,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["B9002","NU","Enter nutr inf pump any type",null,1089.1426000000001,null,1089.1426000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["B9006","RR","Parenteral infus pump statio",null,522.66319999999996,null,522.66319999999996,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["C1715",null,"Brachytherapy needle",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C1727",null,"Cath, bal tis dis, non-vas",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C1754",null,"Catheter, intradiscal",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C1761",null,"Cath, trans intra litho/coro",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["C1773",null,"Ret dev, insertable",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C1781",null,"Mesh (implantable)",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C1816",null,"Receiver/transmitter, neuro",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C1819",null,"Tissue localization-excision",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C1830",null,"Power bone marrow bx needle",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C1875",null,"Stent, coated/cov w/o del sy",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C1885",null,"Cath, translumin angio laser",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C1898",null,"Lead, pmkr, other than trans",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C2620",null,"Pmkr, single, non rate-resp",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C2626",null,"Infusion pump, non-prog,temp",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C2640",null,"Brachytx, stranded, p-103",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["C2643",null,"Brachytx, non-stranded,c-131",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["C5273",null,"Low cost skin substitute app",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["C8903",null,"Mri w/cont, breast,  uni",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C8914",null,"Mra w/o fol w/cont, lwr ext",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C8929",null,"Tte w or wo fol wcon,doppler",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C9046",null,"Cocaine hcl nasal solution",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["C9057",null,"Inj cetirizine hydrochloride",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["C9113",null,"Inj pantoprazole sodium, via",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["C9250",null,"Artiss fibrin sealant",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["C9353",null,"Neurawrap nerve protector,cm",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C9363",null,"Integra meshed bil wound mat",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["C9485",null,"Injection, olaratumab",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["C9607",null,"Perc d-e cor revasc chro sin",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["C9754",null,"Perc av fistula, direct",null,"Facility Only",null,10158.293424000001,null,"000",0,0,0,9,9,9,9,9,9,"","O",null,"Y-ONC"]
["C9760",null,"Non-blind interatrial shunt",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["C9772",null,"Revasc lithotrip tibi/perone",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["C9779",null,"Esd endoscopy or colonoscopy",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["C9782",null,"Blind myocar trpl bon marrow",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D0160",null,"Extensv oral eval prob focus",null,177.98400000000001,null,177.98400000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D0240",null,"Intraoral occlusal film",null,46.968000000000004,null,46.968000000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D0330",null,"Panoramic image",null,135.13600000000002,null,135.13600000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D0368",null,"Cone beam ct interprete tmj",null,423.53600000000006,null,423.53600000000006,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D0386",null,"Max ultrasound image capture",null,507.584,null,507.584,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D0419",null,"Assess of salivary flow",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D0472",null,"Gross exam, prep & report",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D0482",null,"Direct immunofluorescence",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D0486",null,"Access of transep cytol samp",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D0605",null,"Antibody test pub hlth path",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D1110",null,"Dental prophylaxis adult",null,108.768,null,108.768,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D1351",null,"Dental sealant per tooth",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D1527",null,"Remove bilat space main, man",null,531.48,null,531.48,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D1705",null,"AstraZeneca Covid-19 vaccine administration - first dose",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D2161",null,"Amalgam 4 or > surfaces perm",null,316.41600000000005,null,316.41600000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D2410",null,"Dental gold foil one surface",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D2520",null,"Dental inlay metallic 2 surf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D2630",null,"Dental onlay porc 3/more sur",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D2720",null,"Crown resin w/ high noble me",null,1209.6320000000001,null,1209.6320000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D2780",null,"Crown 3/4 cast hi noble met",null,1292.856,null,1292.856,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D2915",null,"Recement cast or prefab post",null,140.08000000000001,null,140.08000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D2949",null,"Restorative foundation",null,253.792,null,253.792,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D2957",null,"Each addtnl prefab post",null,243.90400000000002,null,243.90400000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D2990",null,"Resin infiltration of lesion",null,215.88800000000003,null,215.88800000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D3220",null,"Therapeutic pulpotomy",null,252.96800000000002,null,252.96800000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D3330",null,"End thxpy, molar tooth",null,1219.52,null,1219.52,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D3357",null,"Pulpal regeneration complete",null,666.6160000000001,null,666.6160000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D3431",null,"Biological materials",null,653.43200000000013,null,653.43200000000013,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D3503",null,"Surg exp root surf molar",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-ONC"]
["D4240",null,"Gingival flap proc w/ planin",null,922.05600000000004,null,922.05600000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D4264",null,"Bone replce graft each add",null,665.79200000000014,null,665.79200000000014,null,"000",0,0,0,0,0,0,0,0,0,"","F",null,"Y-CM"]
["D4277",null,"Soft tissue graft firsttooth",null,1207.9839999999999,null,1207.9839999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D4346",null,"Scaling gingiv inflammation",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["D4910",null,"Periodontal maint procedures",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D5221",null,"Immed max part denture resin",null,1792.2,null,1792.2,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D5282",null,"Remove unil part denture,max",null,1348.0640000000001,null,1348.0640000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D5520",null,"Replace denture teeth complt",null,233.19200000000001,null,233.19200000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D5711",null,"Dentures rebase cmplt mand",null,696.28,null,696.28,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D5741",null,"Denture reln part mand chr",null,443.31200000000007,null,443.31200000000007,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D5751",null,"Denture reln cmplt mand lab",null,555.37600000000009,null,555.37600000000009,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D5875",null,"Prosthesis modification",null,556.20000000000005,null,556.20000000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D5911",null,"Facial moulage sectional",null,570.20800000000008,null,570.20800000000008,null,"000",0,0,0,0,0,0,0,0,0,"","F",null,"Y-CM"]
["D5925",null,"Facial augmentation implant",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["D5934",null,"Mandibular flange prosthesis",null,5844.3805463472008,null,5844.3805463472008,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D5982",null,"Surgical stent",null,528.18399999999997,null,528.18399999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D5991",null,"Vesiculobullous disease carr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D6051",null,"Interim abutment",null,687.21600000000001,null,687.21600000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D6056",null,"Prefabricated abutment",null,869.32,null,869.32,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D6072",null,"Abutment supported retainer",null,1669.4240000000002,null,1669.4240000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D6075",null,"Implant supported retainer",null,1712.2720000000002,null,1712.2720000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D6088",null,"Imp crown titanium alloys",null,1798.7920000000001,null,1798.7920000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC"]
["D6097",null,"Abut crown porc to titanium",null,1610.92,null,1610.92,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC"]
["D6114",null,"Implnt/abut fixed dent max",null,12105.384000000002,null,12105.384000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D6121",null,"Retain metal fpd base alloys",null,1765.0080000000003,null,1765.0080000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC"]
["D6211",null,"Bridge base metal cast",null,1220.3440000000001,null,1220.3440000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D6214",null,"Pontic titanium",null,1285.44,null,1285.44,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D6603",null,"Cst hgh nble mtl inlay >=3sr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D6606",null,"Cast noble metal inlay 2 sur",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D6624",null,"Inlay titanium",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D6751",null,"Crown porcelain base metal",null,1236.8240000000001,null,1236.8240000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D6794",null,"Crown titanium",null,1242.5920000000001,null,1242.5920000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D6999",null,"Fixed prosthodontic proc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["D7270",null,"Tooth reimplantation",null,663.32,null,663.32,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D7280",null,"Exposure of unerupted tooth",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D7299",null,"Rem anchorage device w/flap",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["D7311",null,"Alveoloplasty w/extract 1-3",null,370.8,null,370.8,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D7415",null,"Excision malig les complicat",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D7471",null,"Rem exostosis any site",null,929.47200000000009,null,929.47200000000009,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D7560",null,"Maxillary sinusotomy",null,2116.0320000000002,null,2116.0320000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D7670",null,"Closd rductn splint alveolus",null,1926.5120000000002,null,1926.5120000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D7810",null,"Tmj open reduct-dislocation",null,5168.9520000000011,null,5168.9520000000011,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D7830",null,"Tmj manipulation under anest",null,1142.0640000000001,null,1142.0640000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D7877",null,"Tmj arthroscopy debridement",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["D7899",null,"Tmj unspecified therapy",null,647.6640000000001,null,647.6640000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D7949",null,"Reconstruct midface w/graft",null,15575.248000000001,null,15575.248000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D7952",null,"Sinus augmentation vertical",null,2217.3840000000005,null,2217.3840000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D7982",null,"Sialodochoplasty",null,1929.8080000000002,null,1929.8080000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D7998",null,"Intraoral place of fix dev",null,2647.5120000000002,null,2647.5120000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D8210",null,"Orthodontic rem appliance tx",null,977.26400000000012,null,977.26400000000012,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D8670",null,"Periodic orthodontc tx visit",null,323.83200000000005,null,323.83200000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["D9210",null,"Dent anesthesia w/o surgery",null,90.64,null,90.64,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D9215",null,"Local anesthesia",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["D9610",null,"Dent therapeutic drug inject",null,123.60000000000001,null,123.60000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D9630",null,"Drugs/meds disp for home use",null,56.032000000000011,null,56.032000000000011,null,"000",0,0,0,0,0,0,0,0,0,"","F"]
["D9943",null,"Occlusal guard adjustment",null,155.73600000000002,null,155.73600000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["D9952",null,"Complete occlusal adjustment",null,780.32800000000009,null,780.32800000000009,null,"000",0,0,0,0,0,0,0,0,0,"","F",null,"Y-CM"]
["D9986",null,"Missed appointment",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["D9995",null,"Teledentistry real-time",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["E0117","NU","Underarm springassist crutch",null,303.49779999999998,null,303.49779999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0130","RR","Walker rigid adjust/fixed ht",null,10.9901,null,10.9901,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0149","NU","Heavy duty wheeled walker",null,190.55,null,190.55,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0153","RR","Forearm crutch platform atta",null,8.652000000000001,null,8.652000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0159","RR","Brake for wheeled walker",null,1.8746,null,1.8746,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0171","NU","Commode chair non-electric",null,310.05784592640003,null,310.05784592640003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0184","RR","Dry pressure mattress",null,24.998100000000001,null,24.998100000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0188","NU","Synthetic sheepskin pad",null,31.239899999999999,null,31.239899999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0199","NU","Dry pressure pad for mattres",null,38.223300000000002,null,38.223300000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0203",null,"Therapeutic lightbox tabletp",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["E0240","NU","Bath/shower chair",null,143.76429999999999,null,143.76429999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0243","NU","Toilet rail",null,76.162339281599998,null,76.162339281599998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0250","NU","Hosp bed fixed ht w/ mattres",null,865.19999999999993,null,865.19999999999993,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E0266","NU","Hosp bed total elec w/o matt",null,1658.0939999999998,null,1658.0939999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E0274","NU","Over-bed table",null,138.4357,null,138.4357,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0290","RR","Hosp bed fx ht w/o rails w/m",null,74.335099999999997,null,74.335099999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E0296","RR","Hosp bed total elect w/ matt",null,151.36880000000002,null,151.36880000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E0300",null,"Enclosed ped crib hosp grade",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["E0316","NU","Bed safety enclosure",null,2214.5,null,2214.5,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0326","NU","Urinal female jug-type",null,12.3909,null,12.3909,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0371","NU","Nonpower mattress overlay",null,3552.058,null,3552.058,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0440",null,"Oxygen system liquid station",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["E0455","RR","Oxygen tent excl croup/ped t",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-PHL"]
["E0465","NU","Home vent invasive interface",null,10224.089,null,10224.089,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0470","NU","Rad w/o backup non-inv intfc",null,2039.194,null,2039.194,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E0481","RR","Intrpulmnry percuss vent sys",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["E0565","RR","Compressor air power source",null,57.690300000000001,null,57.690300000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0572","NU","Aerosol compressor adjust pr",null,410.86700000000002,null,410.86700000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0601","NU","Cont airway pressure device",null,852.9430000000001,null,852.9430000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E0607","NU","Blood glucose monitor home",null,84.202500000000001,null,84.202500000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0621","NU","Patient lift sling or seat",null,109.9937,null,109.9937,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0629","RR","Seat lift mech, non-electric",null,36.204500000000003,null,36.204500000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E0636","NU","Pt support & positioning sys",null,12492.046,null,12492.046,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0650","NU","Pneuma compresor non-segment",null,907.55360000000007,null,907.55360000000007,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0660","NU","Pneumatic appliance full leg",null,201.3135,null,201.3135,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0665","RR","Pneumatic appliance full arm",null,17.716000000000001,null,17.716000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0671","NU","Pressure pneum appl full leg",null,523.40480000000002,null,523.40480000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0675","RR","Pneumatic compression device",null,484.57380000000001,null,484.57380000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E0731",null,"Conductive garment for tens/",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["E0748","NU","Elec osteogen stim spinal",null,4902.8206000000009,null,4902.8206000000009,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC"]
["E0760","NU","Osteogen ultrasound stimltor",null,4074.1444000000001,null,4074.1444000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC"]
["E0776","RR","Iv pole",null,19.745100000000001,null,19.745100000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0786","NU","Implantable pump replacement",null,10063.203000000001,null,10063.203000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E0791","NU","Parenteral infusion pump sta",null,3590.5800000000004,null,3590.5800000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0855","RR","Cervical traction equipment",null,63.334700000000005,null,63.334700000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0880","RR","Trac stand free stand extrem",null,24.833300000000001,null,24.833300000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0920","RR","Fracture frame attached to b",null,53.755699999999997,null,53.755699999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0941",null,"Gravity assisted traction de",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["E0947","RR","Fracture frame attachmnts pe",null,78.784700000000001,null,78.784700000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0956","RR","W/c lateral trunk/hip suppor",null,9.8056000000000001,null,9.8056000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0966","RR","Wheelchair head rest extensi",null,8.5696000000000012,null,8.5696000000000012,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0968","NU","Wheelchair commode seat",null,220.11100000000002,null,220.11100000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E0974","RR","W/ch access anti-rollback",null,9.5172000000000008,null,9.5172000000000008,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0982","NU","Back upholstery, replacement",null,52.911099999999998,null,52.911099999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E0985","RR","W/c seat lift mechanism",null,25.348300000000002,null,25.348300000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E1002","NU","Pwr seat tilt",null,4208.8890000000001,null,4208.8890000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E1004","RR","Pwr seat recline mech",null,522.71469999999999,null,522.71469999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E1011",null,"Ped wc modify width adjustm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["E1029","RR","W/c vent tray fixed",null,40.118500000000004,null,40.118500000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E1031","RR","Rollabout chair with casters",null,56.773600000000002,null,56.773600000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E1038","RR","Transport chair pt wt<=300lb",null,19.9099,null,19.9099,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E1084","RR","Hemi-wheelchair detachable a",null,123.6206,null,123.6206,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E1088","NU","Wheelchair lightweight det a",null,1899.9380000000001,null,1899.9380000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E1130","RR","Whlchr stand fxd arm ft rest",null,74.542299999999997,null,74.542299999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E1161","RR","Manual adult wc w tiltinspac",null,298.15410000000003,null,298.15410000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E1180","NU","Wheelchair amputee w/ foot r",null,1085.414,null,1085.414,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E1222","RR","Wheelchair spec size w/ leg",null,85.407600000000002,null,85.407600000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E1224","RR","Wheelchair spec size w/ leg",null,102.25840000000001,null,102.25840000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E1227","NU","Wheelchair spec sz spec ht a",null,349.685,null,349.685,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E1237",null,"Rgd ped wc adjstabl w/o seat",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["E1260","NU","Wheelchair lightwt foot rest",null,532.44499999999994,null,532.44499999999994,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E1297","RR","Wheelchair special seat dept",null,14.646600000000001,null,14.646600000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E1355","RR","Oxygen supplies stand/rack",null,26.0869,null,26.0869,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E1391","RR","Oxygen concentrator, dual",null,155.68450000000001,null,155.68450000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["E1560","RR","Replace blood leak detector",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["E1590","RR","Hemodialysis machine",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["E1615","RR","Deionizer h2o puri system",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["E1700","NU","Jaw motion rehab system",null,369.46100000000001,null,369.46100000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["E1805","RR","Adjust wrist ext/flex device",null,159.21740000000003,null,159.21740000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E1902","RR","Aac non-electronic board",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["E2202","NU","Seat width 24-27 in",null,558.71320000000003,null,558.71320000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2205","RR","Manual wc accessory, handrim",null,4.0582000000000003,null,4.0582000000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2213","NU","Pneumatic prop tire insert",null,36.358999999999995,null,36.358999999999995,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2217","NU","Foam filled caster tire each",null,49.8005,null,49.8005,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2222","NU","Solid caster integ whl, repl",null,26.120799999999999,null,26.120799999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2291",null,"Planar back for ped size wc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["E2301","RR","Pwr standing",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["E2323","RR","Special joystick handle",null,7.4366000000000003,null,7.4366000000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2325","NU","Sip and puff interface",null,1452.8150000000003,null,1452.8150000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2331","NU","Attendant control",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["E2358","NU","Gr 34 nonsealed leadacid",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["E2361","NU","22nf sealed leadacid battery",null,142.52110000000002,null,142.52110000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2363","RR","Gr24 sealed leadacid battery",null,18.54,null,18.54,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2369","RR","Pwr wc drivewheel gear repl",null,46.895900000000005,null,46.895900000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2376","RR","Expandable controller, repl",null,140.19330000000002,null,140.19330000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2382","NU","Tube, pneum wheel drive tire",null,21.145900000000001,null,21.145900000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2385","RR","Tube, pneumatic caster tire",null,5.0675999999999997,null,5.0675999999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2391","RR","Solid caster tire",null,2.1424000000000003,null,2.1424000000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2395","RR","Caster wheel excludes tire",null,5.5002000000000004,null,5.5002000000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2504","NU","Sgd prerec msg>20min <=40min",null,1987.7661000000001,null,1987.7661000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2506","NU","Sgd prerec msg > 40 min",null,2914.6322,null,2914.6322,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2606","NU","Position wc cush wdth>=22 in",null,423.39179999999999,null,423.39179999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2614","NU","Position back cush wd>=22in",null,559.93889999999999,null,559.93889999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2621","NU","Wc planar back cush wd>=22in",null,571.79420000000005,null,571.79420000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["E2628","NU","Mobile arm supports reclinin",null,902.11520000000007,null,902.11520000000007,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["G0027",null,"Semen analysis",null,9.5068999999999999,null,9.5068999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["G0033",null,"2+ benzo seiz",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G0045",null,"Mrs 90 days post stk",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G0048",null,"Pall serv during meas",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G0064",null,"Cert nurse midwife ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G0076",null,"Care manag h vst new pt 20 m",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["G0082",null,"Care man h v ext pt 30 m",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["G0089",null,"Adm subq drug 1st home visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G0109",null,"Diab manage trn ind/group",null,27.946199999999997,null,27.946199999999997,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
["G0121",null,"Colon ca scrn not hi rsk ind",null,635.03279999999995,null,325.24619999999999,null,"000",0,0,0,0,2,0,1,0,0,"","R"]
["G0130",26,"Single energy x-ray study",null,19.6218,null,19.6218,null,"000",0,0,0,1,0,0,0,0,0,"","R"]
["G0144",null,"Scr c/v cyto,thinlayer,rescr",null,62.877099999999999,null,62.877099999999999,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
["G0175",null,"Opps service,sched team conf",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["G0202",null,"Scr mammo bi incl cad",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G0206","TC","Dx mammo incl cad uni",null,192.7909917648,null,192.7909917648,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["G0235",26,"Pet not otherwise specified",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,9,9,9,9,9,"","X"]
["G0252",null,"Pet imaging initial dx",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,1,9,9,9,9,9,"","X"]
["G0259",null,"Inject for sacroiliac joint",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["G0281",null,"Elec stim unattend for press",null,22.0002,null,22.0002,null,"000",0,0,0,7,5,0,0,0,0,"","R",null,"Y-CM"]
["G0288",null,"Recon, cta for surg plan",null,67.189799999999991,null,67.189799999999991,null,"000",0,0,0,3,0,0,0,0,0,"","R"]
["G0333",null,"Dispense fee initial 30 day",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G0372",null,"Md service required for pmd",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["G0383",null,"Lev 4 hosp type b ed visit",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["G0400",null,"Home sleep test/type 4 porta",null,"By Report",null,"By Report",null,"000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM"]
["G0409",null,"Corf related serv 15 mins ea",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,0,0,0,0,0,"","X"]
["G0420",null,"Ed svc ckd ind per session",null,198.59639999999999,null,198.59639999999999,null,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM"]
["G0436",null,"Tobacco-use counsel 3-10 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G0439",null,"Ppps, subseq visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["G0459",null,"Telehealth inpt pharm mgmt",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,9,0,0,"","X"]
["G0465",null,"AUTOLOG PRP DIAB WOUND ULCER ",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,2,0,1,0,0,"","X"]
["G0481",null,"Drug test def 8-14 classes",null,223.9237,null,223.9237,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-ONC"]
["G0495",null,"Rn care train/edu in hh",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G0506",null,"Comp asses care plan ccm svc",null,110.5956,null,79.081800000000001,null,"000",0,0,0,0,0,0,0,0,0,"","R"]
["G0518",null,"Remove w insert drug implant",null,718.27679999999998,null,322.27319999999997,null,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-ONC"]
["G1008",null,"Cdsm cranberry pk",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G1012",null,"Cdsm agilemd",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G1026",null,"Pt hemo > 3mo",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2002",null,"Post-d/c h vst new pt 30 m",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["G2022",null,"Benef refuses service, mod",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2066",null,"Inter devc remote 30d",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,3,0,0,0,0,0,"","X"]
["G2074",null,"Med assist tx no drug",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2086",null,"Off base opioid tx 70min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["G2099",null,"Pt 66+ frailty and adv ill",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2105",null,"Pt 66+ lt ints > 90",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2126",null,"Pt 66+ frailty adv ill",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2136",null,"Bk pain vas 6-20wk = 3",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2152",null,"Res change sc =0",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2169",null,"Svs by ot in home health",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2177",null,"Bronch w rx antibx 30d",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2187",null,"Clin ind img hd trauma",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2199",null,"Not scrn etoh no rsn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2206",null,"Adjv trtmt chemo her2",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G2216",null,"Home supply inject naloxon",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G4000",null,"Dermatology ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G4016",null,"Neurosurgical ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G4019",null,"Oncology/hema ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G4027",null,"Plastic surgery ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G4037",null,"Urology ss",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G6007",null,"Radiation treatment delivery",null,453.08519999999999,null,453.08519999999999,null,"000",0,0,0,3,0,0,0,0,0,"","R",null,"Y-CM"]
["G6014",null,"Radiation treatment delivery",null,446.5446,null,446.5446,null,"000",0,0,0,3,0,0,0,0,0,"","R",null,"Y-CM"]
["G8404",null,"Low extemity neur exam docum",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8415",null,"Eval on foot not performed",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8465",null,"High risk recurrence pro ca",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8473",null,"Ace/arb thxpy rx'd",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8536",null,"No doc elder mal scrn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8560",null,"Pt hx act drain prev 90 days",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8576",null,"No postop ren fail",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8602",null,"No tpa init w/in 3 hrs",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8658",null,"Rafscrs llfai no scor + surv",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8661",null,"Rafscrs lbi no scor",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8721",null,"Pt, pn, hist grade doc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8722",null,"Med reas pt, pn, not doc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8753",null,"Sys bp > or = 140",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8816",null,"Statin med pres at disch",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8843",null,"Doc reas no ahi or rdi",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8852",null,"Pos air press prescribe",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8869",null,"Doc immune hep b antitnf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8877",null,"No brst cncr dx min invasive",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8915",null,"Pt not trans to hosp at d/c",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8916",null,"Pt w iv ab given on time",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8937",null,"No rx ace/arb therapy",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G8963",null,"Csi per asx pt w/pci 2 yrs",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9005",null,"Mccd, risk adj, maintenance",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["G9012",null,"Other specified case mgmt",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["G9057",null,"Onc pract mgmt differs trial",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9060",null,"Onc prac mgmt dif pt comorb",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9077",null,"Onc dx prostate t1no progres",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9078",null,"Onc dx prostate t2no progres",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9088",null,"Onc dx colon metas noevid dx",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9100",null,"Onc dx gastric no recurrence",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9112",null,"Onc dx head/neck ext unknown",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9124",null,"Onc dx cml acceler phase",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9136",null,"Onc dx nhl trans to lg bcell",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9156",null,"Evaluation for wheelchair",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9213",null,"No doc of dsm-iv",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9223",null,"Pjp proph ordered cd4 low",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9242",null,"Doc viral load >=200",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9277",null,"Doc daily aspirin or contra",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9286",null,"Antibio rx w in 10d of sympt",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9295",null,"Non cutaneous loc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9312",null,"Surgical site infection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9319",null,"Image not std nomenclature",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9354",null,"1 or no ct sinus w/in 90d dx",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9357",null,"Pp eval/edu perf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9368",null,">= 2 same hi-rsk med not ord",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9403",null,"Doc reas no 30 day f/u",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9412",null,"Admit w/in 180d req surg rev",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9421",null,"Lung cx bx rpt no doc class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9434",null,"Asth not controlled",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9457",null,"Pt no abd img no doc rsn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9477",null,"Care coord at hospice",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9480",null,"Admission to mccm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9505",null,"Abx pres w/in 10 dys of symp",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9517",null,"No impr vis acuit w/in 90d",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9533",null,"Indic for head ct not valid",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9548",null,"No f/u rec image study",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9593",null,"Low pecarn ped head trauma",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9603",null,"Pt surv improv bsline tx",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9614",null,"Photodoc < 2 cec lndmk",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9621",null,"Scr unheal etoh w/counsel",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9628",null,"Pt bwli srg 30 day pst srg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9646",null,"Pt w/90d mrs 0-2",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9660",null,"Doc med rsn scope pt >85y",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9676",null,"40-75y w/type 1/2 w/ldl-c rs",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9698",null,"Sys rsn no presc bronchdil",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9706",null,"Low recur prost ca",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9717",null,"Doc pt dx dep/bp f/u nt req",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9724",null,"Pt w/doc use anticoag mst yr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9727",null,"Pt unable cmplt knee fs prom",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9741",null,"Pt w/hosp anytime msmt per",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9756",null,"Surg proc w/silicone oil",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9766",null,"Cva stroke dx tx transf fac",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9778",null,"Pts dx w/pregn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9787",null,"Pt alive",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9797",null,"Pt currently on statin",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9811",null,"No pdc 75% w/asth cont med",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9818",null,"Doc sex activity",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9839",null,"Anti-egfr mon anti ther",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9846",null,"Pt died from cancer",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9875",null,"9 em core sessions",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9882",null,"2 em ongoing ms mo 13-15 wl",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9900",null,"Scrn mam perf rslts not doc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9910",null,"Pt 66+ snp or ltc pos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9917",null,"Adv dem crgvr limited",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9920",null,"Scrning perf and negative",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9932",null,"Doc pt rsn no tb scrn recrds",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9946",null,"Bk pain no vas",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9963",null,"Embolization not doc separat",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9975",null,"Doc med rsn no dil mac exam",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["G9997",null,"Doc pt preg dur msrmt pd",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["H0008",null,"Alcohol and/or drug services",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["H0015",null,"Alcohol and/or drug services",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["H0018",null,"Alcohol and/or drug services",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["H0029",null,"Alcohol and/or drug preventi",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["H0036",null,"Comm psy face-face per 15min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["H0048",null,"Spec coll non-blood:a/d test",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["H1004",null,"Follow up home visit/prental",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["H2017",null,"Psysoc rehab svc, per 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["H2027",null,"Psychoed svc, per 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["H2034",null,"A/d halfway house, per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["H2037",null,"Dev delay prev dp ch, 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J0153",null,"Adenosine inj 1mg",null,0.45700000000000002,null,0.45700000000000002,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0190",null,"Inj biperiden lactate/5 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J0224",null,"Inj. lumasiran, 0.5 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J0280",null,"Aminophyllin 250 mg inj",null,11.571,null,11.571,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0360",null,"Hydralazine hcl injection",null,4.4420000000000002,null,4.4420000000000002,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0470",null,"Dimecaprol injection",null,56.42,null,56.42,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0500",null,"Dicyclomine injection",null,26.074999999999999,null,26.074999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0558",null,"Peng benzathine/procaine inj",null,11.782,null,11.782,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0587",null,"Inj, rimabotulinumtoxinb",null,12.170999999999999,null,12.170999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J0592",null,"Buprenorphine hydrochloride",null,4.101,null,4.101,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0620",null,"Calcium glycer & lact/10 ml",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J0691",null,"Inj lefamulin 1 mg",null,0.72399999999999998,null,0.72399999999999998,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0702",null,"Betamethasone acet&sod phosp",null,6.7869999999999999,null,6.7869999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0740",null,"Cidofovir injection",null,546.20299999999997,null,546.20299999999997,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0775",null,"Collagenase, clost hist inj",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J0800",null,"Corticotropin injection",null,3780.6860000000001,null,3780.6860000000001,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0888",null,"Epoetin beta non esrd",null,1.5620000000000001,null,1.5620000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J0895",null,"Deferoxamine mesylate inj",null,7.1980000000000004,null,7.1980000000000004,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J1097",null,"Phenylep ketorolac opth soln",null,116.25,null,116.25,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J1190",null,"Dexrazoxane hcl injection",null,181.21600000000001,null,181.21600000000001,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J1250",null,"Inj dobutamine hcl/250 mg",null,6.0030000000000001,null,6.0030000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J1301",null,"Injection, edaravone, 1 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J1410",null,"Inj estrogen conjugate 25 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J1429",null,"Inj golodirsen 10 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J1451",null,"Fomepizole, 15 mg",null,9.86,null,9.86,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J1454",null,"Inj fosnetupitant, palonoset",null,464.38299999999998,null,464.38299999999998,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J1560",null,"Gamma globulin > 10 cc inj",null,464.27100000000002,null,464.27100000000002,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J1575",null,"Hyqvia 100mg immuneglobulin",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J1626",null,"Granisetron hcl injection",null,0.33500000000000002,null,0.33500000000000002,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J1642",null,"Inj heparin sodium per 10 u",null,1.4E-2,null,1.4E-2,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J1729",null,"Inj hydroxyprogst capoat nos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J1741",null,"Ibuprofen injection",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["J1823",null,"Inj. inebilizumab-cdon, 1 mg",null,462.86700000000002,null,462.86700000000002,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-ONC"]
["J1833",null,"Injection, isavuconazonium",null,0.87,null,0.87,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J1955",null,"Inj levocarnitine per 1 gm",null,22.459,null,22.459,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J2010",null,"Lincomycin injection",null,9.4809999999999999,null,9.4809999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J2182",null,"Injection, mepolizumab, 1mg",null,28.75,null,28.75,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J2265",null,"Minocycline hydrochloride",null,1.62,null,1.62,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J2350",null,"Injection, ocrelizumab, 1 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J2357",null,"Omalizumab injection",null,37.268000000000001,null,37.268000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J2469",null,"Palonosetron hcl",null,1.214,null,1.214,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J2503",null,"Pegaptanib sodium injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J2560",null,"Phenobarbital sodium inj",null,41.725000000000001,null,41.725000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J2675",null,"Inj progesterone per 50 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J2770",null,"Quinupristin/dalfopristin",null,428.32799999999997,null,428.32799999999997,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J2790",null,"Rho d immune globulin inj",null,78.495999999999995,null,78.495999999999995,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J2796",null,"Romiplostim injection",null,83.897000000000006,null,83.897000000000006,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J2850",null,"Inj secretin synthetic human",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J3032",null,"Inj. eptinezumab-jjmr 1 mg",null,16.010999999999999,null,16.010999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-ONC"]
["J3090",null,"Inj tedizolid phosphate",null,1.661,null,1.661,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J3245",null,"Inj., tildrakizumab, 1 mg",null,137.273,null,137.273,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J3280",null,"Thiethylperazine maleate inj",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J3350",null,"Urea injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J3370",null,"Vancomycin hcl injection",null,2.7360000000000002,null,2.7360000000000002,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J3399",null,"Inj onase abepar-xioi treat",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J3475",null,"Inj magnesium sulfate",null,0.76100000000000001,null,0.76100000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J7030",null,"Normal saline solution infus",null,2.5569999999999999,null,2.5569999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J7050",null,"Normal saline solution infus",null,0.63900000000000001,null,0.63900000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J7177",null,"Inj., fibryga, 1 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7183",null,"Wilate injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7196",null,"Antithrombin recombinant",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["J7203",null,"Factor ix recomb gly rebinyn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7210",null,"Inj, afstyla, 1 i.u.",null,1.3839999999999999,null,1.3839999999999999,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J7307",null,"Etonogestrel implant system",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7321",null,"Hyalgan supartz visco-3 dose",null,74.91,null,74.91,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J7324",null,"Orthovisc inj per dose",null,154.749,null,154.749,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J7345",null,"Aminolevulinic acid, 10% gel",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7502",null,"Cyclosporine oral 100 mg",null,2.2290000000000001,null,2.2290000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J7510",null,"Prednisolone oral per 5 mg",null,0.253,null,0.253,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["J7604",null,"Acetylcysteine comp unit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7610",null,"Albuterol comp con",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7629",null,"Bitolterol mesylate comp unt",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7642",null,"Glycopyrrolate comp con",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7645",null,"Ipratropium bromide comp",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7669",null,"Metaproterenol non-comp unit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7681",null,"Terbutaline sulf comp unit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J7799",null,"Non-inhalation drug for dme",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["J8610",null,"Methotrexate oral 2.5 mg",null,0.215,null,0.215,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J9000",null,"Doxorubicin hcl injection",null,3.008,null,3.008,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J9023",null,"Injection, avelumab, 10 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J9042",null,"Brentuximab vedotin inj",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J9050",null,"Carmustine injection",null,801.09500000000003,null,801.09500000000003,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J9130",null,"Dacarbazine 100 mg inj",null,5.5350000000000001,null,5.5350000000000001,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J9150",null,"Daunorubicin injection",null,39.576999999999998,null,39.576999999999998,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J9173",null,"Inj., durvalumab, 10 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J9205",null,"Inj irinotecan liposome 1 mg",null,57.512,null,57.512,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J9212",null,"Interferon alfacon-1 inj",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X",null,"Y-CM"]
["J9219",null,"Leuprolide acetate implant",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J9260",null,"Methotrexate sodium inj",null,2.36,null,2.36,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J9266",null,"Pegaspargase injection",null,21561.046999999999,null,21561.046999999999,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J9299",null,"Injection, nivolumab",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J9303",null,"Panitumumab injection",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J9311",null,"Inj rituximab, hyaluronidase",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J9353",null,"Inj. margetuximab-cmkb, 5 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["J9360",null,"Vinblastine sulfate inj",null,4.0170000000000003,null,4.0170000000000003,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["J9999",null,"Chemotherapy drug",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["K0006","RR","Heavy duty wheelchair",null,116.28700000000001,null,116.28700000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["K0008","RR","Cstm manual wheelchair/base",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["K0014","RR","Other power whlchr base",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["K0017","NU","Detach adjust armrest base",null,53.312800000000003,null,53.312800000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["K0020","RR","Fixed adjust armrest pair",null,5.0263999999999998,null,5.0263999999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["K0044","RR","Ftrst upr hanger brac rep ea",null,1.8128,null,1.8128,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["K0050","NU","Ratchet assembly replacement",null,34.803699999999999,null,34.803699999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["K0053","RR","Elevate footrest articulate",null,10.4442,null,10.4442,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["K0105","RR","Iv hanger",null,12.051,null,12.051,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["K0455","NU","Pump uninterrupted infusion",null,3337.6120000000001,null,3337.6120000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["K0608",null,"Repl garment for aed",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["K0672","NU","Removable soft interface le",null,90.181142251200001,null,90.181142251200001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["K0743","RR","Portable home suction pump",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["K0815","RR","Pwc gp 1 std seat/back",null,462.30520000000001,null,462.30520000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["K0816","RR","Pwc gp 1 std cap chair",null,437.39980000000003,null,437.39980000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["K0825","RR","Pwc gp 2 hd cap chair",null,594.62929999999994,null,594.62929999999994,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["K0829","NU","Pwc gp 2 xtra hd cap chair",null,10307.725,null,10307.725,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["K0837","RR","Pwc gp 2 hd sing pow opt s/b",null,644.17229999999995,null,644.17229999999995,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["K0843","RR","Pwc gp2 hd mult pow opt s/b",null,683.6110000000001,null,683.6110000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["K0849","NU","Pwc gp 3 std cap chair",null,8277.2860000000001,null,8277.2860000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["K0855","RR","Pwc gp 3 xhd cap chair",null,1483.3545000000001,null,1483.3545000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["K0858","NU","Pwc gp3 hd sing pow opt s/b",null,11465.445000000002,null,11465.445000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["K0861","RR","Pwc gp3 std mult pow opt s/b",null,925.57860000000005,null,925.57860000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["K0870","RR","Pwc gp 4 hd seat/back",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["K0879","NU","Pwc gp4 hd sing pow opt s/b",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["K0891","RR","Pwc gp5 ped mult pow opt s/b",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["K1004","NU","Lo freq us diathermy device",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["K1013","NU","Enema tube, any, replac only",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["K1022",null,"Endoskel posit rotat unit",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["K1027",null,"Oral dev without fix mech",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["L0112",null,"Cranial cervical orthosis",null,1772.7252000000001,null,1772.7252000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L0200",null,"Cerv col supp adj bar & thor",null,802.30439999999999,null,802.30439999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L0457",null,"Tlso flex trnk sj-ss pre ots",null,1078.9437,null,1078.9437,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L0480",null,"Tlso rigid plastic custom fa",null,2019.4754999999998,null,2019.4754999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L0625",null,"Lo flex l1-below l5 pre ots",null,59.753399999999999,null,59.753399999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L0632",null,"Lso sag rigid frame cust",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["L0641",null,"Lo rig pos pnl l1-l5 pre ots",null,84.5625,null,84.5625,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L0650",null,"Lso sc r ant/pos pnl pre ots",null,1248.2532000000001,null,1248.2532000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L0859",null,"Mri compatible system",null,1478.1648,null,1478.1648,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L1001",null,"Ctlso infant immobilizer",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["L1050",null,"Sternal pad",null,124.35299999999999,null,124.35299999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L1220",null,"Anterior thoracic extension",null,328.8528,null,328.8528,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L1610",null,"Ho frejka cov only pre cst",null,53.271300000000004,null,53.271300000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L1680",null,"Pelvic & hip control thigh c",null,1971.1979999999999,null,1971.1979999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L1810",null,"Ko elastic with joints",null,138.3381,null,138.3381,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L1832",null,"Ko adj jnt pos r sup pre cst",null,737.6925,null,737.6925,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L1845",null,"Ko double upright pre cst",null,1029.9650999999999,null,1029.9650999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L1907",null,"Afo supramalleolar custom",null,712.68659999999988,null,712.68659999999988,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L1950",null,"Afo spiral molded to pt plas",null,1205.0433,null,1205.0433,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L2020",null,"Kafo dbl solid stirrup band/",null,1889.0585999999998,null,1889.0585999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L2090",null,"Hkafo unilat torsion ball br",null,709.40250000000003,null,709.40250000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L2128",null,"Kafo fem fx cast molded to p",null,2774.1420000000003,null,2774.1420000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L2190",null,"Waist belt",null,105.9645,null,105.9645,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L2230",null,"Split flat caliper stirr & p",null,114.31619999999999,null,114.31619999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L2275",null,"Plastic mod low ext pad/line",null,189.77669999999998,null,189.77669999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L2360",null,"Extended steel shank",null,83.701499999999996,null,83.701499999999996,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L2405",null,"Knee joint drop lock ea jnt",null,110.41709999999999,null,110.41709999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L2550",null,"Thigh/wght bear high roll cu",null,380.22989999999999,null,380.22989999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L2650",null,"Pelv & thor control gluteal",null,194.14320000000001,null,194.14320000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L2760",null,"Extension per extension per",null,75.300600000000003,null,75.300600000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L2785",null,"Drop lock retainer each",null,42.447299999999998,null,42.447299999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3002",null,"Foot insert plastazote or eq",null,204.56129999999999,null,204.56129999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3050",null,"Foot arch supp premold metat",null,59.593500000000006,null,59.593500000000006,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3170",null,"Foot plas heel stabi pre ots",null,64.451999999999998,null,64.451999999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3211",null,"Surgical boot each junior",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["L3230",null,"Custom shoes depth inlay",null,438.94400000000002,null,438.94400000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3320",null,"Shoe lift elev heel/sole cor",null,159.1216,null,159.1216,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3360",null,"Shoe sole wedge outside sole",null,45.104100000000003,null,45.104100000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3390",null,"Shoe outflare wedge",null,62.779199999999996,null,62.779199999999996,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3530",null,"Ortho shoe add half sole",null,40.2333,null,40.2333,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3560",null,"O shoe add horseshoe toe tap",null,29.015699999999999,null,29.015699999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3640",null,"Shoe dennis browne splint bo",null,54.759600000000006,null,54.759600000000006,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3678",null,"So hard plas stabili pre ots",null,149.68799999999999,null,149.68799999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3766",null,"Ewhfo w/joint(s) cf",null,1565.1258,null,1565.1258,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L3912",null,"Hfo flexion glove pre ots",null,150.14609999999999,null,150.14609999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3919",null,"Ho w/o joints cf",null,312.1986,null,312.1986,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L3924",null,"Hfo without joints pre ots",null,113.5167,null,113.5167,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3976",null,"Sewhfo airplane w/o jnts cf",null,1936.6472999999999,null,1936.6472999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L3980",null,"Up ext fx orthos humeral nos",null,367.06889999999999,null,367.06889999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L4020",null,"Replace quadlat socket brim",null,1162.7067,null,1162.7067,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L4090",null,"Repl met band kafo-afo calf/",null,145.97640000000001,null,145.97640000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L4392",null,"Replace afo soft interface",null,29.310899999999997,null,29.310899999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L5010",null,"Mold socket ank hgt w/ toe f",null,1637.76,null,1637.76,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5230",null,"Fem focal defic constant fri",null,6616.8064000000004,null,6616.8064000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5280",null,"Hemipelvect canad sing axis",null,9132.7360000000008,null,9132.7360000000008,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5530",null,"Prep bk ptb thermopls molded",null,2699.6864,null,2699.6864,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5560",null,"Prep ak ischial plast molded",null,2907.8271999999997,null,2907.8271999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5613",null,"Ak 4 bar ling w/hydraul swig",null,3296.7936,null,3296.7936,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5628",null,"Test socket hemipelvectomy",null,813.32479999999998,null,813.32479999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5643",null,"Hip flex inner socket ext fr",null,2403.6480000000001,null,2403.6480000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5651",null,"Ak flex inner socket ext fra",null,1615.5264000000002,null,1615.5264000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5668",null,"Bk molded distal cushion",null,150.9376,null,150.9376,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5672",null,"Bk removable medial brim sus",null,434.0992,null,434.0992,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5694",null,"Ak pelvic control belt pad/l",null,324.1216,null,324.1216,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5696",null,"Ak/knee disartic pelvic join",null,331.86559999999997,null,331.86559999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5710",null,"Kne-shin exo sng axi mnl loc",null,612.08320000000003,null,612.08320000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5724",null,"Knee-shin exo fluid swing ph",null,2160.64,null,2160.64,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5814",null,"Endo knee-shin hydral swg ph",null,4904.6528000000008,null,4904.6528000000008,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L5840",null,"Multi-axial knee/shin system",null,5429.6576000000005,null,5429.6576000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L5920",null,"Endo ak/hip alignable system",null,713.77919999999995,null,713.77919999999995,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5940",null,"Endo bk ultra-light material",null,838.97600000000011,null,838.97600000000011,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5978",null,"Ft prosth multiaxial ankl/ft",null,475.96800000000002,null,475.96800000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L5980",null,"Flex foot system",null,5453.6448,null,5453.6448,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L6100",null,"Elb mold sock flex hinge pad",null,3145.92,null,3145.92,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L6130",null,"Elbow stump activated lock h",null,4643.2767999999996,null,4643.2767999999996,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L6384",null,"Postop dsg cast chg shlder/t",null,2741.6704,null,2741.6704,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L6580",null,"Wrist/elbow bowden cable mol",null,2423.2704000000003,null,2423.2704000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L6615",null,"Disconnect locking wrist uni",null,287.50080000000003,null,287.50080000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L6621",null,"Flex/ext wrist w/wo friction",null,3020.672,null,3020.672,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L6647",null,"Shoulder lock actuator",null,685.70880000000011,null,685.70880000000011,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L6650",null,"Shoulder universal joint",null,459.94239999999996,null,459.94239999999996,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L6690",null,"Frame typ sock interscap-tho",null,1233.3568,null,1233.3568,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L6693",null,"Lockingelbow forearm cntrbal",null,3749.2736,null,3749.2736,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L6711",null,"Ped term dev, hook, vol open",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["L6810",null,"Term dev precision pinch dev",null,269.24799999999999,null,269.24799999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L6905",null,"Hand restoration multiple fi",null,2633.4720000000002,null,2633.4720000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L6940",null,"Elbow disarticulation switch",null,13598.131200000002,null,13598.131200000002,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L7045",null,"Pediatric electric hook",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X","Y"]
["L7180",null,"Electronic elbow sequential",null,49286.720000000001,null,49286.720000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM"]
["L7403",null,"Add ue prost b/e acrylic",null,486.32319999999999,null,486.32319999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L7499",null,"Upper extremity prosthes nos",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N","Y","Y-CM"]
["L8020",null,"Mastectomy form",null,324.096,null,324.096,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L8041",null,"Midfacial prosthesis",null,3979.9935999999998,null,3979.9935999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L8310",null,"Truss double w/ standard pad",null,197.47839999999999,null,197.47839999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L8420",null,"Prosthetic sock multi ply bk",null,26.982399999999998,null,26.982399999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L8505",null,"Artificial larynx, accessory",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["L8509",null,"Trach-esoph voice pros md in",null,144.2176,null,144.2176,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["L8612",null,"Aqueous shunt prosthesis",null,974.29759999999999,null,974.29759999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L8615",null,"Coch implant headset replace",null,595.62239999999997,null,595.62239999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["L8627",null,"Cid ext speech process repl",null,9151.756800000001,null,9151.756800000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["L8659",null,"Interphalangeal joint repl",null,2548.3904000000002,null,2548.3904000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F","Y"]
["L8689",null,"External recharg sys intern",null,2278.0032000000001,null,2278.0032000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["L8696",null,"Ext antenna phren nerve stim",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["M0240",null,"CASIRI AND IMDEV REPEAT",null,463.5,null,463.5,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["M0243",null,"CASIRIVI AND IMDEVI INFUSION",null,463.5,null,463.5,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["M1009",null,"Dc eoc doc med rec",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["M1012",null,"Dc eoc doc med rec",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["M1028",null,"Doc of pt prm hda dx and otr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["M1039",null,"Pt dx lum sp reg inf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["M1057",null,"Aspirin not used, no rsn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["M1070",null,"Pt not scrn fut fall no rsn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["M1116",null,"Start eoc doc med rec",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["M1118",null,"Oc ni pt 1-2 vis",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["M1134",null,"Oc ni pt self dc 1-2 vis",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["M1142",null,"Emerge cases",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["P2033",null,"Blood thymol turbidity",null,7.0785,null,7.0785,null,"000",0,0,0,9,9,9,9,9,9,"","L"]
["P9016",null,"Rbc leukocytes reduced",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["P9034",null,"Platelets, pheresis",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["P9041",null,"Albumin (human),5%, 50ml",null,10.49,null,10.49,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["P9055",null,"Plt, aph/pher, l/r, cmv-neg",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["P9057",null,"Rbc, frz/deg/wsh, l/r, irrad",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["Q0081",null,"Infusion ther other than che",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["Q0085",null,"Chemo by both infusion and o",null,"Facility Only",null,0,null,"000",0,0,0,9,9,9,9,9,9,"","O"]
["Q0144",null,"Azithromycin dihydrate, oral",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q0173",null,"Trimethobenzamide hcl 250mg",null,1.08,null,1.08,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["Q0247",null,"Sotrovimab",null,2465.8200000000002,null,2465.8200000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["Q0482",null,"Microprcsr cu combo vad, rep",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q0494",null,"Emr hd pmp elec/combo, rep",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q0500",null,"Filters elec/combo vad, rep",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q0513",null,"Disp fee inhal drugs/30 days",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q1004",null,"Ntiol category 4",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["Q2034",null,"Agriflu vaccine",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q2054",null,"Lisocabtagene mara car pos t",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["Q4006",null,"Cast sup long arm adult fbrg",null,32.898200000000003,null,32.898200000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["Q4015",null,"Cast sup gauntlet ped plster",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4024",null,"Cast sup sht arm splnt ped f",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4031",null,"Cast sup lng leg ped plaster",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4043",null,"Cast sup lng leg splnt ped p",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4046",null,"Cast sup sht leg splnt fbrgl",null,21.022300000000001,null,21.022300000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["Q4074",null,"Iloprost non-comp unit dose",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4110",null,"Primatrix",null,40.328000000000003,null,40.328000000000003,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["Q4117",null,"Hyalomatrix",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4135",null,"Mediskin",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4145",null,"Epifix, inj, 1mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4152",null,"Dermapure 1 square cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4164",null,"Helicoll, per square cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4167",null,"Truskin, per sq centimeter",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4174",null,"Palingen or promatrx",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4205",null,"Membrane graft or wrap sq cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4213",null,"Ascent, 0.5 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4229",null,"Cogenex amnio memb per sq cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4239",null,"Amnio-maxx or lite per sq cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q4247",null,"Amniotext patch, per sq cm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q5001",null,"Hospice or home hlth in home",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["Q5004",null,"Hospice in snf",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["Q5010",null,"Hospice home care in hospice",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["Q5119",null,"Inj ruxience, 10 mg",null,49.816000000000003,null,49.816000000000003,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-ONC"]
["Q9002",null,"Va chaplain counsel individu",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["Q9962",null,"Hocm 300-349mg/ml iodine,1ml",null,0.18,null,0.18,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["Q9992",null,"Buprenorphine xr over 100 mg",null,1781.309,null,1781.309,null,"000",0,0,0,9,9,9,9,9,9,"","D"]
["R0075",null,"Transport port x-ray multipl",null,32.2778611584,null,32.2778611584,null,"000",0,0,0,3,0,0,0,0,0,"","F"]
["R0398",null,"TRAINING, OPTION 2, JOB PLACEMENT ",null,10.19082,null,10.19082,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["S0013",null,"Esketamine, nasal spray",null,11.58,null,11.58,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-ONC"]
["S0028",null,"Injection, famotidine, 20 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S0088",null,"Imatinib 100 mg",null,3.14,null,3.14,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["S0122",null,"Inj menotropins 75 iu",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S0139",null,"Minoxidil, 10 mg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S0170",null,"Anastrozole 1 mg",null,0.13,null,0.13,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["S0178",null,"Lomustine 10 mg",null,"By report",null,"By report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["S0189",null,"Testosterone pellet 75 mg",null,108.18,null,108.18,null,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM"]
["S0250",null,"Comp geriatr assmt team",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S0260",null,"H&p for surgery",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S0316",null,"Follow-up/reassessment",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S0500",null,"Dispos cont lens",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S0515",null,"Scleral lens liquid bandage",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S0595",null,"New lenses in pts old frame",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S0810",null,"Photorefractive keratectomy",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S1016",null,"Non-pvc intravenous administ",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S2061",null,"Donor lobectomy (lung)",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S2067",null,"Breast \"stacked\" diep/gap",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S2117",null,"Arthroereisis, subtalar",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S2208",null,"Minimally invasive direct co",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S2266",null,"Induced abortion 29-31 wks",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S2348",null,"Decompress disc rf lumbar",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S3000",null,"Bilat dil retinal exam",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S3630",null,"Eosinophil blood count",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S3846",null,"Gene test beta-thalassemia",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S3852",null,"Dna analysis apoe alzheimer",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S4014",null,"Compl zift case rate",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S4027",null,"Store prev froz embryos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S4042",null,"Ovulation mgmt per cycle",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S5000",null,"Prescription drug, generic",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S5108",null,"Homecare train pt 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S5116",null,"Nonfamily hc train/session",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S5150",null,"Unskilled respite care /15m",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S5161",null,"Emer rspns sys serv permonth",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["S5520",null,"Hit picc insert kit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S5553",null,"Insulin long acting 5 u",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8030",null,"Tantalum ring application",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8080",null,"Scintimammography",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8185",null,"Flutter device",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8265",null,"Haberman feeder",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8270",null,"Enuresis alarm",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8301",null,"Infect control supplies nos",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["S8415",null,"Supplies for home delivery",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8420",null,"Custom gradient sleev/glov",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8421",null,"Ready gradient sleev/glov",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8422",null,"Custom grad sleeve med",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8423",null,"Custom grad sleeve heavy",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8424",null,"Ready gradient sleeve",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8425",null,"Custom grad glove med",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8426",null,"Custom grad glove heavy",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8427",null,"Ready gradient glove",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8428",null,"Ready gradient gauntlet",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8429",null,"Gradient pressure wrap",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8430",null,"Padding for comprssn bdg",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8431",null,"Compression bandage",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S8450",null,"Splint digit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8451",null,"Splint wrist or ankle",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8452",null,"Splint elbow",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8460",null,"Camisole post-mast",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8490",null,"100 insulin syringes",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8930",null,"Auricular electrostimulation",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8940",null,"Hippotherapy per session",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8948",null,"Low-level laser trmt 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8950",null,"Complex lymphedema therapy,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8990",null,"Pt or manip for maint",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S8999",null,"Resuscitation bag",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9001",null,"Home uterine monitor with or",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9007",null,"Ultrafiltration monitor",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9024",null,"Paranasal sinus ultrasound",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9025",null,"Omnicardiogram/cardiointegra",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9034",null,"Eswl for gallstones",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9055",null,"Procuren or other growth fac",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9056",null,"Coma stimulation per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9061",null,"Medical supplies and equipme",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9083",null,"Urgent care center global",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9088",null,"Services provided in urgent",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9090",null,"Vertebral axial decompressio",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9097",null,"Home visit wound care",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9098",null,"Home phototherapy visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9110",null,"Telemonitoring/home per mnth",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9117",null,"Back school visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9122",null,"Home health aide or certifie",null,33.051876,null,33.051876,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC"]
["S9123",null,"Nursing care in home rn",null,66.459510374399997,null,66.459510374399997,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC"]
["S9124",null,"Nursing care, in the home; b",null,48.005746588800001,null,48.005746588800001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC"]
["S9125",null,"Respite care, in the home, p",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9126",null,"Hospice care, in the home, p",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9127",null,"Social work visit, in the ho",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9128",null,"Speech therapy, in the home,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9129",null,"Occupational therapy, in the",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9131",null,"Pt in the home per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9140",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9141",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9145",null,"Insulin pump initiation",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9150",null,"Evaluation by ocularist",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9152",null,"Speech therapy, re-eval",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9208",null,"Home mgmt preterm labor",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9209",null,"Home mgmt pprom",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9211",null,"Home mgmt gest hypertension",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9212",null,"Hm postpar hyper per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9213",null,"Hm preeclamp per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9214",null,"Hm gest dm per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9325",null,"Hit pain mgmt per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9326",null,"Hit cont pain per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9327",null,"Hit int pain per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9328",null,"Hit pain imp pump diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9329",null,"Hit chemo per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9330",null,"Hit cont chem diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9331",null,"Hit intermit chemo diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9335",null,"Ht hemodialysis diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9336",null,"Hit cont anticoag diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9338",null,"Hit immunotherapy diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9339",null,"Hit periton dialysis diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9340",null,"Hit enteral per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9341",null,"Hit enteral grav diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9342",null,"Hit enteral pump diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9343",null,"Hit enteral bolus nurs",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9345",null,"Hit anti-hemophil diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9346",null,"Hit alpha-1-proteinas diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9347",null,"Hit longterm infusion diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9348",null,"Hit sympathomim diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9349",null,"Hit tocolysis diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9351",null,"Hit cont antiemetic diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9353",null,"Hit cont insulin diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9355",null,"Hit chelation diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9357",null,"Hit enzyme replace diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9359",null,"Hit anti-tnf per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9361",null,"Hit diuretic infus diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9363",null,"Hit anti-spasmotic diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9364",null,"Hit tpn total diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9365",null,"Hit tpn 1 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9366",null,"Hit tpn 2 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9367",null,"Hit tpn 3 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9368",null,"Hit tpn over 3l diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9370",null,"Ht inj antiemetic diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9372",null,"Ht inj anticoag diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9373",null,"Hit hydra total diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9374",null,"Hit hydra 1 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9375",null,"Hit hydra 2 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9376",null,"Hit hydra 3 liter diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9377",null,"Hit hydra over 3l diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9379",null,"Hit noc per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9381",null,"Hit high risk/escort",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9401",null,"Anticoag clinic per session",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9430",null,"Pharmacy comp/disp serv",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9432",null,"Med food non inborn err meta",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9433",null,"Medical food oral 100% nutr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9434",null,"Mod solid food suppl",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9435",null,"Medical foods for inborn err",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9436",null,"Lamaze class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9437",null,"Childbirth refresher class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9438",null,"Cesarean birth class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9439",null,"Vbac class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9441",null,"Asthma education",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9442",null,"Birthing class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9443",null,"Lactation class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9444",null,"Parenting class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9445",null,"Pt education noc individ",null,44.652483532799998,null,44.652483532799998,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["S9446",null,"Pt education noc group",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9447",null,"Infant safety class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9449",null,"Weight mgmt class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9451",null,"Exercise class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9452",null,"Nutrition class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9453",null,"Smoking cessation class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9454",null,"Stress mgmt class",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9455",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9460",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9465",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9470",null,"Nutritional counseling, diet",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9472",null,"Cardiac rehabilitation progr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9473",null,"Pulmonary rehabilitation pro",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9474",null,"Enterostomal therapy by a re",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9475",null,"Ambulatory setting substance",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9476",null,"Vestibular rehab per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9480",null,"Intensive outpatient psychia",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["S9482",null,"Family stabilization 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9484",null,"Crisis intervention per hour",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9485",null,"Crisis intervention mental h",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9490",null,"Hit corticosteroid/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9494",null,"Hit antibiotic total diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9497",null,"Hit antibiotic q3h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9500",null,"Hit antibiotic q24h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9501",null,"Hit antibiotic q12h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9502",null,"Hit antibiotic q8h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9503",null,"Hit antibiotic q6h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9504",null,"Hit antibiotic q4h diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9529",null,"Venipuncture home/snf",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9537",null,"Ht hem horm inj diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9538",null,"Hit blood products diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9542",null,"Ht inj noc per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9558",null,"Ht inj growth horm diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9559",null,"Hit inj interferon diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9560",null,"Ht inj hormone diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9562",null,"Ht inj palivizumab diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9590",null,"Ht irrigation diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9810",null,"Ht pharm per hour",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9900",null,"Christian sci pract visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9901",null,"Christian sci nurse visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9960",null,"Air ambulanc nonemerg fixed",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9961",null,"Air ambulan nonemerg rotary",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9970",null,"Health club membership yr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9975",null,"Transplant related per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9976",null,"Lodging per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9977",null,"Meals per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9981",null,"Med record copy admin",null,28.913781124800003,null,28.913781124800003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["S9982",null,"Med record copy per page",null,0.57329981280000009,null,0.57329981280000009,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["S9986",null,"Not medically necessary svc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9988",null,"Serv part of phase i trial",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9989",null,"Services outside us",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9990",null,"Services provided as part of",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9991",null,"Services provided as part of",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9992",null,"Transportation costs to and",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9994",null,"Lodging costs (e.g. hotel ch",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9996",null,"Meals for clinical trial par",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["S9999",null,"Sales tax",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1000",null,"Private duty/independent nsg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1001",null,"Nursing assessment/evaluatn",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1002",null,"Rn services up to 15 minutes",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1003",null,"Lpn/lvn services up to 15min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1004",null,"Nsg aide service up to 15min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1005",null,"Respite care service 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1006",null,"Family/couple counseling",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1007",null,"Treatment plan development",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1009",null,"Child sitting services",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1010",null,"Meals when receive services",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1012",null,"Alcohol/substance abuse skil",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1013",null,"Sign lang/oral interpreter",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1014",null,"Telehealth transmit, per min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1015",null,"Clinic service",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["T1016",null,"Case management",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1017",null,"Targeted case management",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1018",null,"School-based iep ser bundled",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1019",null,"Personal care ser per 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1020",null,"Personal care ser per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1021",null,"Hh aide or cn aide per visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1022",null,"Contracted services per day",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1023",null,"Program intake assessment",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1024",null,"Team evaluation & management",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1025",null,"Ped compr care pkg, per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1026",null,"Ped compr care pkg, per hour",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1027",null,"Family training & counseling",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1028",null,"Home environment assessment",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1029",null,"Dwelling lead investigation",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1030",null,"Rn home care per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1031",null,"Lpn home care per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1040",null,"Comm bh clinic svc per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1041",null,"Comm bh clinic svc per month",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1502",null,"Medication admin visit",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1503",null,"Med admin, not oral/inject",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1505",null,"Elec med comp dev, noc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T1999",null,"Noc retail items andsupplies",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2001",null,"N-et; patient attend/escort",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2002",null,"N-et; per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2003",null,"N-et; encounter/trip",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2004",null,"N-et; commerc carrier pass",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2005",null,"N-et; stretcher van",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2007",null,"Non-emer transport wait time",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2010",null,"Pasrr level i",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2011",null,"Pasrr level ii",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2012",null,"Habil ed waiver, per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2013",null,"Habil ed waiver per hour",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2014",null,"Habil prevoc waiver, per d",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2015",null,"Habil prevoc waiver per hr",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2016",null,"Habil res waiver per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2017",null,"Habil res waiver 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2018",null,"Habil sup empl waiver/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2019",null,"Habil sup empl waiver 15min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2020",null,"Day habil waiver per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2021",null,"Day habil waiver per 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2022",null,"Case management, per month",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2023",null,"Targeted case mgmt per month",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2024",null,"Serv asmnt/care plan waiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2025",null,"Waiver service, nos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2026",null,"Special childcare waiver/d",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2027",null,"Spec childcare waiver 15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2028",null,"Special supply, nos waiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2029",null,"Special med equip, noswaiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2030",null,"Assist living waiver/month",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2031",null,"Assist living waiver/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2032",null,"Res care, nos waiver/month",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2033",null,"Res, nos waiver per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2034",null,"Crisis interven waiver/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2035",null,"Utility services waiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2036",null,"Camp overnite waiver/session",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2037",null,"Camp day waiver/session",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2038",null,"Comm trans waiver/service",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2039",null,"Vehicle mod waiver/service",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2040",null,"Financial mgt waiver/15min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2041",null,"Support broker waiver/15 min",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2042",null,"Hospice routine home care",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2043",null,"Hospice continuous home care",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2044",null,"Hospice respite care",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2045",null,"Hospice general care",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2046",null,"Hospice long term care, r&b",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2047",null,"Hab prevo waiver per 15",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2048",null,"Bh ltc res r&b, per diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2049",null,"N-et; stretcher van, mileage",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2050",null,"Financial mgt waiver/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2051",null,"Support broker waiver/diem",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T2101",null,"Breast milk proc/store/dist",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T4521",null,"Adult size brief/diaper sm",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4522",null,"Adult size brief/diaper med",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4523",null,"Adult size brief/diaper lg",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4524",null,"Adult size brief/diaper xl",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4525",null,"Adult size pull-on sm",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4526",null,"Adult size pull-on med",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4527",null,"Adult size pull-on lg",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4528",null,"Adult size pull-on xl",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4529",null,"Ped size brief/diaper sm/med",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T4530",null,"Ped size brief/diaper lg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T4531",null,"Ped size pull-on sm/med",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T4532",null,"Ped size pull-on lg",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T4533",null,"Youth size brief/diaper",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4534",null,"Youth size pull-on",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4535",null,"Disposable liner/shield/pad",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4536",null,"Reusable pull-on any size",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4537",null,"Reusable underpad bed size",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4538",null,"Diaper serv reusable diaper",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T4539",null,"Reuse diaper/brief any size",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4540",null,"Reusable underpad chair size",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4541",null,"Large disposable underpad",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4542",null,"Small disposable underpad",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4543",null,"Adult disp brief/diap abv xl",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T4544",null,"Adlt disp und/pull on abv xl",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T4545",null,"Incon disposable penile wrap",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["T5001",null,"Position seat spec orth need",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["T5999",null,"Supply, nos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["U0001",null,"2019-ncov diagnostic p",null,51.365600000000001,null,51.365600000000001,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
["U0002",null,"Covid-19 lab test non-cdc",null,73.3733,null,73.3733,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
["U0003",null,"SARS-COV-2 DNA/RNA HIGH THROUGHPUT",null,107.25,null,107.25,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
["U0004",null,"2019-NCOV ANY TECHNIQUE HIGH THROUGHPUT",null,107.25,null,107.25,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
["U0005",null,"Infec agen detec ampli probe",null,35.75,null,35.75,null,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM"]
["V0028",null,"Travel, vocational services, claimant",null,"State Rate",null,"State Rate",null,"000",0,0,0,9,9,9,9,9,9,"","S"]
["V2020",null,"Vision svcs frames purchases",null,76.755600000000001,null,76.755600000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2025",null,"Eyeglasses delux frames",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V2100",null,"Lens spher single plano 4.00",null,48.482100000000003,null,48.482100000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2101",null,"Single visn sphere 4.12-7.00",null,49.862299999999998,null,49.862299999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2102",null,"Singl visn sphere 7.12-20.00",null,62.850600000000007,null,62.850600000000007,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2103",null,"Spherocylindr 4.00d/12-2.00d",null,46.051300000000005,null,46.051300000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2104",null,"Spherocylindr 4.00d/2.12-4d",null,47.400600000000004,null,47.400600000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2105",null,"Spherocylinder 4.00d/4.25-6d",null,53.467299999999994,null,53.467299999999994,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2106",null,"Spherocylinder 4.00d/>6.00d",null,57.360700000000001,null,57.360700000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2107",null,"Spherocylinder 4.25d/12-2d",null,49.718100000000007,null,49.718100000000007,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2108",null,"Spherocylinder 4.25d/2.12-4d",null,48.513000000000005,null,48.513000000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2109",null,"Spherocylinder 4.25d/4.25-6d",null,59.554600000000001,null,59.554600000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2110",null,"Spherocylinder 4.25d/over 6d",null,52.962600000000002,null,52.962600000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2111",null,"Spherocylindr 7.25d/.25-2.25",null,55.208000000000006,null,55.208000000000006,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2112",null,"Spherocylindr 7.25d/2.25-4d",null,61.161400000000008,null,61.161400000000008,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2113",null,"Spherocylindr 7.25d/4.25-6d",null,72.244200000000006,null,72.244200000000006,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2114",null,"Spherocylinder over 12.00d",null,78.712600000000009,null,78.712600000000009,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2115",null,"Lens lenticular bifocal",null,95.058700000000016,null,95.058700000000016,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2118",null,"Lens aniseikonic single",null,89.712999999999994,null,89.712999999999994,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2121",null,"Lenticular lens, single",null,100.4147,null,100.4147,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2199",null,"Lens single vision not oth c",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V2200",null,"Lens spher bifoc plano 4.00d",null,68.989400000000003,null,68.989400000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2201",null,"Lens sphere bifocal 4.12-7.0",null,69.267499999999998,null,69.267499999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2202",null,"Lens sphere bifocal 7.12-20.",null,76.178799999999995,null,76.178799999999995,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2203",null,"Lens sphcyl bifocal 4.00d/.1",null,67.691599999999994,null,67.691599999999994,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2204",null,"Lens sphcy bifocal 4.00d/2.1",null,68.021200000000007,null,68.021200000000007,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2205",null,"Lens sphcy bifocal 4.00d/4.2",null,70.390200000000007,null,70.390200000000007,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2206",null,"Lens sphcy bifocal 4.00d/ove",null,70.946399999999997,null,70.946399999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2207",null,"Lens sphcy bifocal 4.25-7d/.",null,66.167199999999994,null,66.167199999999994,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2208",null,"Lens sphcy bifocal 4.25-7/2.",null,64.920900000000003,null,64.920900000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2209",null,"Lens sphcy bifocal 4.25-7/4.",null,74.932500000000005,null,74.932500000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2210",null,"Lens sphcy bifocal 4.25-7/ov",null,84.975000000000009,null,84.975000000000009,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2211",null,"Lens sphcy bifo 7.25-12/.25-",null,92.782399999999996,null,92.782399999999996,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2212",null,"Lens sphcyl bifo 7.25-12/2.2",null,93.482800000000012,null,93.482800000000012,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2213",null,"Lens sphcyl bifo 7.25-12/4.2",null,90.032299999999992,null,90.032299999999992,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2214",null,"Lens sphcyl bifocal over 12.",null,94.523099999999999,null,94.523099999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2215",null,"Lens lenticular bifocal",null,113.5472,null,113.5472,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2218",null,"Lens aniseikonic bifocal",null,118.86200000000001,null,118.86200000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2219",null,"Lens bifocal seg width over",null,48.1937,null,48.1937,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2220",null,"Lens bifocal add over 3.25d",null,39.088500000000003,null,39.088500000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2221",null,"Lenticular lens, bifocal",null,104.854,null,104.854,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2299",null,"Lens bifocal speciality",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V2300",null,"Lens sphere trifocal 4.00d",null,81.720200000000006,null,81.720200000000006,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2301",null,"Lens sphere trifocal 4.12-7.",null,85.871100000000013,null,85.871100000000013,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2302",null,"Lens sphere trifocal 7.12-20",null,88.775700000000001,null,88.775700000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2303",null,"Lens sphcy trifocal 4.0/.12-",null,81.205200000000005,null,81.205200000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2304",null,"Lens sphcy trifocal 4.0/2.25",null,75.0458,null,75.0458,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2305",null,"Lens sphcy trifocal 4.0/4.25",null,84.573300000000003,null,84.573300000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2306",null,"Lens sphcyl trifocal 4.00/>6",null,86.787800000000004,null,86.787800000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2307",null,"Lens sphcy trifocal 4.25-7/.",null,88.250400000000013,null,88.250400000000013,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2308",null,"Lens sphc trifocal 4.25-7/2.",null,97.860300000000009,null,97.860300000000009,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2309",null,"Lens sphc trifocal 4.25-7/4.",null,101.1769,null,101.1769,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2310",null,"Lens sphc trifocal 4.25-7/>6",null,96.614000000000004,null,96.614000000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2311",null,"Lens sphc trifo 7.25-12/.25-",null,96.449200000000005,null,96.449200000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2312",null,"Lens sphc trifo 7.25-12/2.25",null,99.322900000000004,null,99.322900000000004,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2313",null,"Lens sphc trifo 7.25-12/4.25",null,111.40479999999999,null,111.40479999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2314",null,"Lens sphcyl trifocal over 12",null,116.3488,null,116.3488,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2315",null,"Lens lenticular trifocal",null,131.69579999999999,null,131.69579999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2318",null,"Lens aniseikonic trifocal",null,158.78479999999999,null,158.78479999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2319",null,"Lens trifocal seg width > 28",null,53.755699999999997,null,53.755699999999997,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2320",null,"Lens trifocal add over 3.25d",null,64.179299999999998,null,64.179299999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2321",null,"Lenticular lens, trifocal",null,127.31830000000001,null,127.31830000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2399",null,"Lens trifocal speciality",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V2410",null,"Lens variab asphericity sing",null,114.845,null,114.845,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2430",null,"Lens variable asphericity bi",null,119.92290000000001,null,119.92290000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2499",null,"Variable asphericity lens",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V2500",null,"Contact lens pmma spherical",null,117.30670000000001,null,117.30670000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2501",null,"Cntct lens pmma-toric/prism",null,134.02360000000002,null,134.02360000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2502",null,"Contact lens pmma bifocal",null,165.10900000000001,null,165.10900000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2503",null,"Cntct lens pmma color vision",null,162.20439999999999,null,162.20439999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2510",null,"Cntct gas permeable sphericl",null,150.36970000000002,null,150.36970000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2511",null,"Cntct toric prism ballast",null,172.57650000000001,null,172.57650000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2512",null,"Cntct lens gas permbl bifocl",null,203.9194,null,203.9194,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2513",null,"Contact lens extended wear",null,186.93470000000002,null,186.93470000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2520",null,"Contact lens hydrophilic",null,126.60760000000001,null,126.60760000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2521",null,"Cntct lens hydrophilic toric",null,196.55490000000003,null,196.55490000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2522",null,"Cntct lens hydrophil bifocl",null,191.28130000000002,null,191.28130000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2523",null,"Cntct lens hydrophil extend",null,166.45830000000001,null,166.45830000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2524",null,"Cntct lens hydrophil photoch",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V2525",null,"Cl, hydrophilic, dual focus",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V2530",null,"Contact lens gas impermeable",null,241.43200000000002,null,241.43200000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2531",null,"Contact lens gas permeable",null,575.40949999999998,null,575.40949999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V2599",null,"Contact lens/es other type",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V2600",null,"Hand held low vision aids",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2610",null,"Single lens spectacle mount",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2615",null,"Telescop/othr compound lens",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2623",null,"Plastic eye prosth custom",null,1164.6313,null,1164.6313,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2624",null,"Polishing artifical eye",null,87.86930000000001,null,87.86930000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2625",null,"Enlargemnt of eye prosthesis",null,534.20949999999993,null,534.20949999999993,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2626",null,"Reduction of eye prosthesis",null,287.9674,null,287.9674,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2627",null,"Scleral cover shell",null,1859.7885999999999,null,1859.7885999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2628",null,"Fabrication & fitting",null,439.1302,null,439.1302,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2629",null,"Prosthetic eye other type",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2630",null,"Anter chamber intraocul lens",null,128.85300000000001,null,128.85300000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2631",null,"Iris support intraoclr lens",null,128.85300000000001,null,128.85300000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2632",null,"Post chmbr intraocular lens",null,128.85300000000001,null,128.85300000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2700",null,"Balance lens",null,47.421199999999999,null,47.421199999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2702",null,"Deluxe lens feature",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2710",null,"Glass/plastic slab off prism",null,69.411699999999996,null,69.411699999999996,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2715",null,"Prism lens/es",null,15.470599999999999,null,15.470599999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2718",null,"Fresnell prism press-on lens",null,30.910300000000003,null,30.910300000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2730",null,"Special base curve",null,22.8248,null,22.8248,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2744",null,"Tint photochromatic lens/es",null,19.662700000000001,null,19.662700000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2745",null,"Tint, any color/solid/grad",null,13.2973,null,13.2973,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2750",null,"Anti-reflective coating",null,20.661799999999999,null,20.661799999999999,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2755",null,"Uv lens/es",null,19.250700000000002,null,19.250700000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2756",null,"Eye glass case",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2760",null,"Scratch resistant coating",null,17.334899999999998,null,17.334899999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2761",null,"Mirror coating",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2762",null,"Polarization, any lens",null,63.334700000000005,null,63.334700000000005,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2770",null,"Occluder lens/es",null,21.321000000000002,null,21.321000000000002,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2780",null,"Oversize lens/es",null,13.565100000000001,null,13.565100000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2781",null,"Progressive lens per lens",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2782",null,"Lens, 1.54-1.65 p/1.60-1.79g",null,68.412599999999998,null,68.412599999999998,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2783",null,"Lens, >= 1.66 p/>=1.80 g",null,77.116100000000003,null,77.116100000000003,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2784",null,"Lens polycarb or equal",null,50.150700000000001,null,50.150700000000001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V2785",null,"Corneal tissue processing",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2786",null,"Occupational multifocal lens",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2787",null,"Astigmatism-correct function",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V2788",null,"Presbyopia-correct function",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V2790",null,"Amniotic membrane",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2797",null,"Vis item/svc in other code",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V2799",null,"Misc vision item or service",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5008",null,"Hearing screening",null,89.919316226694221,null,89.919316226694221,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V5010",null,"Assessment for hearing aid",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["V5011",null,"Hearing aid fitting/checking",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["V5014",null,"Hearing aid repair/modifying",null,59.949888950746086,null,59.949888950746086,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL"]
["V5020",null,"Conformity evaluation",null,"Bundled",null,"Bundled",null,"000",0,0,0,9,9,9,9,9,9,"","Bundled"]
["V5030",null,"Body-worn hearing aid air",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5040",null,"Body-worn hearing aid bone",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5050",null,"Hearing aid monaural in ear",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5060",null,"Behind ear hearing aid",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5070",null,"Glasses air conduction",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5080",null,"Glasses bone conduction",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5090",null,"Hearing aid dispensing fee",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5095",null,"Implant mid ear hearing pros",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5100",null,"Body-worn bilat hearing aid",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5110",null,"Hearing aid dispensing fee",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5120",null,"Body-worn binaur hearing aid",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5130",null,"In ear binaural hearing aid",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5140",null,"Behind ear binaur hearing ai",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5150",null,"Glasses binaural hearing aid",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5160",null,"Dispensing fee binaural",null,1702.5415361248697,null,1702.5415361248697,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V5171",null,"Hearing aid monaural ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5172",null,"Hearing aid monaural itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5181",null,"Hearing aid monaural bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5190",null,"Hearing aid monaural glasses",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5200",null,"Disp fee contralateral monau",null,1020.4612056258048,null,1020.4612056258048,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V5211",null,"Hearing aid binaural ite/ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5212",null,"Hearing aid binaural ite/itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5213",null,"Hearing aid binaural ite/bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5214",null,"Hearing aid binaural itc/itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5215",null,"Hearing aid binaural itc/bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5221",null,"Hearing aid binaural bte/bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5230",null,"Hearing aid binaural glasses",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5240",null,"Disp fee contralateral binau",null,1020.4612056258048,null,1020.4612056258048,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V5241",null,"Dispensing fee, monaural",null,851.27076806243485,null,851.27076806243485,null,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM"]
["V5242",null,"Hearing aid, monaural, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5243",null,"Hearing aid, monaural, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5244",null,"Hearing aid, prog, mon, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5245",null,"Hearing aid, prog, mon, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5246",null,"Hearing aid, prog, mon, ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5247",null,"Hearing aid, prog, mon, bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5248",null,"Hearing aid, binaural, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5249",null,"Hearing aid, binaural, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5250",null,"Hearing aid, prog, bin, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5251",null,"Hearing aid, prog, bin, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5252",null,"Hearing aid, prog, bin, ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5253",null,"Hearing aid, prog, bin, bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5254",null,"Hearing id, digit, mon, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5255",null,"Hearing aid, digit, mon, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5256",null,"Hearing aid, digit, mon, ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5257",null,"Hearing aid, digit, mon, bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5258",null,"Hearing aid, digit, bin, cic",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5259",null,"Hearing aid, digit, bin, itc",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5260",null,"Hearing aid, digit, bin, ite",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5261",null,"Hearing aid, digit, bin, bte",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM"]
["V5262",null,"Hearing aid, disp, monaural",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5263",null,"Hearing aid, disp, binaural",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5264",null,"Ear mold/insert",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-PHL"]
["V5265",null,"Ear mold/insert, disp",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5266",null,"Battery for hearing device",null,1.0482678907272001,null,1.0482678907272001,null,"000",0,0,0,9,9,9,9,9,9,"","F"]
["V5267",null,"Hearing aid sup/access/dev",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-PHL"]
["V5268",null,"Ald telephone amplifier",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5269",null,"Alerting device, any type",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5270",null,"Ald, tv amplifier, any type",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5271",null,"Ald, tv caption decoder",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5272",null,"Tdd",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5273",null,"Ald for cochlear implant",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5274",null,"Ald unspecified",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5275",null,"Ear impression",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5281",null,"Ald fm/dm system, monaural",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5282",null,"Ald fm/dm system binaural",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5283",null,"Ald neck, loop ind receiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5284",null,"Ald fm/dm ear level receiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5285",null,"Ald fm/dm aud input receiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5286",null,"Ald blu tooth fm/dm receiver",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5287",null,"Ald fm/dm receiver, nos",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5288",null,"Ald fm/dm transmitter ald",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5289",null,"Ald fm/dm adapt/boot couplin",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5290",null,"Ald transmitter microphone",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5298",null,"Hearing aid noc",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,9,9,9,9,9,9,"","X"]
["V5299",null,"Hearing service",null,"Not Covered",null,"Not Covered",null,"000",0,0,0,0,0,0,0,0,0,"","X"]
["V5336",null,"Repair communication device",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V5362",null,"Speech screening",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V5363",null,"Language screening",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]
["V5364",null,"Dysphagia screening",null,"By Report",null,"By Report",null,"000",0,0,0,9,9,9,9,9,9,"","N"]

{"sheet":"Updates and Corrections","index":4,"n_rows":32,"n_cols":4,"rows_kept":32,"cut":false,"hidden":false,"merged":[[0,0,0,2],[4,3,5,5]]}
["Updates and Corrections"]
["Posting date","Policy Area","Description"]
["2022-10-31","Chapter 5: Audiology and Hearing Services","Description: L&I will not be following the recent Food and Drug Administration (FDA) rule that allows the over the counter purchase, without a prescription, of hearing aids for people who have perceived mild to moderate hearing loss. To receive insurer purchased aids and services, a worker must have an allowed hearing loss workers' compensation claim and work through an appropriate state fund or self-insured provider.​"]
["2022-09-12","Chapter 25: Physical Medicine Services","Speech language pathologists are not subject to the PT/OT daily cap. Speech language pathologists may supervise speech language pathology students if they meet the other requirements outlined in Chapter 25. Effective July 1, 2022."]
["2022-09-06","Chapter 26: Radiology Services","Certain noninvasive cardiac imaging technologies for coronary artery disease are covered with conditions. See L&I’s coverage decision for details. Effective October 1, 2022.","*Background query may take up to 20 seconds to complete."]
["2022-08-30","Chapter 13: Independent Medical Exams","1124M has an updated description in Chapter 13: Independent Medical Exams​ for in-person exams. The temporary telehealth policy​ still allows the use of 1124M for record review.  The record review fee is to reimburse examiners for their time reviewing the medical file when an exam is canceled or the worker is a no-show, and the exam is not rescheduled with the firm. This isn’t the same as a forensic exam (billed using 1146M), where an IME report is required after the file review."]
["2022-07-01","Chapter 13: Independent Medical Exams","This is to clarify that compensation for downloading, printing, and sorting files is bundled into the reimbursement for the examination fees​."]
["2022-07-01","Chapter 25: Physical Medicine Services","Multiwave Locked System (MLS) laser therapy treatment is considered an investigational procedure and is not covered. 1044M may not be used to bill for this or any laser therapy treatment.​"]
[]
["Posting date","Description","Updated Version"]
["2022-11-02","Effective December 2, 2022, pricing for specific vision codes have new values. See file for details.","Vision Code Price Changes December 2022​"]
["2022-10-14","Effective October 1, 2022,  several injection codes have updated maximum fees.","October 2022 Injection Pricing Changes​​"]
["2022-10-10","New HCPCS and Deleted HCPCS codes. See file for effective dates.​","New and Deleted HCPCS October 2022​"]
["2022-09-30","90611 and 90622 are covered with conditions. These vaccines are for post-exposure prophylactic use only. Monkeypox exposure must be an accepted condition on the claim. Prior authorization is required. Both codes are paid \"By report\". Effective July 26, 2022.","N/A"]
["2022-05-31","New HCPCS and Deleted HCPCS codes. See file for effective dates.​","New and Deleted HCPCS July 2022"]
[]
["Posting date","Policy Area","Description"]
["2022-10-11","Chapter 35: Hospitals","Page 4 of Chapter 35: Hospitals has an incorrect statement about how hospitals are reimbursed for inpatient treatment of crime victims. The statement should read as follows:"]
[null,null,"\"Services for hospital inpatient care provided to crime victims covered by the Crime Victims Compensation Program are paid using L&I POAC rates, see WAC 296-30-090.\""]
["2022-08-30","Chapter 4: Anesthesia Services","Chapter 4: Anesthesia Services and Chapter 16: Medication Administration and Injections incorrectly list the CPT® billing codes for dry needling of trigger points as 20552 and 20553. The correct codes are CPT® 20560 and 20561. Providers may bill only one of these codes per date of service. See L&I’s coverage decision for additional details. Effective August 22, 2022."]
[]
[null,"Chapter 16: Medication Administration and Injections"]
["2022-07-19","Chapter 27: Reports and Forms","Page 5 of Chapter 27: Reports and Forms has incorrect prices listed for the Report of Accident (1040M) when submitted after 5 business days. The correct pricing is $34.44 (6-8 business days after first treatment date) and $24.44 (9 or more business days after first treatment date). Effective July 1, 2022."]
[]
["Posting date","Description","Updated Version"]
["2022-07-29","An error has been identified in the Professional Services Fee Schedule. Codes 62350 and 62351 were incorrectly listed as only requiring claim manager (CM) approval for prior authorization. They require utilization review (UR).","N/A"]
["2022-07-26","An error has been identified in the Professional Services Fee Schedule. 1104M should appear with a rate of $162.46, effective July 1, 2022. ​","N/A"]
["2022-07-14","An error has been identified in the Professional Services Fee Schedule. 27299 should have appeared in the fee schedule with prior authorization required through utilization review.​","N/A"]
["2022-07-14","An error has been identified in the Professional Services Fee Schedule. 95970 should have appeared in the fee schedule as requiring claim manager (CM) prior authorization, not utilization review​.","N/A"]
[]
["Posting date","Policy Area","Description"]
["2022-06-30","Temporary Telehealth IME and Record Review Policy​","To help support containment of the COVID-19 outbreak, the Temporary IME and Record Review policy allows temporary coverage for independent medical examiners to complete exams via telehealth. This policy is effective 3/9/2020 and expires 12/31/2022​. This is an emerging situation, and this policy may be updated as needed.​ ​"]

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[null,null,null,"DOLLAR VALUE",null,null,"MODIFIERS"]
["CODE","Modifiers","Modcheck","Short Description (HCPCS and Local Only)","NON-FACILITY SETTING","FACILITY SETTING","FOL UP","PRE OP\n(-56)","INTRA OP\n(-54)","POST OP\n(-55)","PCTC\n(26/TC)","MSI\n(-51)","BSI\n(-50)","ASI\n(-80)","CSI\n(-62)","TSI\n(-66)","ENDO\nBASE","FSI","LIC REQ","Prior Auth","MARFS Chapters","MARFS Chapters2","MARFS Chapters3"]
[10004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",90.973799999999997,75.514200000000002,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[10005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",252.11040000000003,130.2174,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[10006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",107.62260000000001,88.595399999999998,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[10007,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",559.51859999999999,159.94739999999999,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[10008,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",304.43520000000001,100.48739999999999,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[10009,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",844.33199999999999,195.02879999999999,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[10010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",494.11260000000004,139.73099999999999,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[10011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,2,0,0,0,0,"","N",null,"Y-CM",2,29]
[10012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,0,0,0,0,0,"","N",null,"Y-CM",2,29]
[10021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,29]
[10030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1240.9302,236.6508,"000",0,0,0,9,2,9,0,0,0,"","R",null,"Y-CM",2,29]
[10035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,1,0,0,0,"","X",null,null,2,29]
[10036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,29]
[10040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",213.4614,91.568399999999997,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[10060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",227.13720000000001,188.48820000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[10061,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",385.8954,328.2192,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[10080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",478.65300000000008,187.89360000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[10081,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",645.73559999999998,305.02980000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[10120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",275.2998,186.10980000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[10121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",483.40980000000008,327.03000000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[10140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",311.57040000000001,211.083,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[10160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",236.05620000000002,170.0556,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[10180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",482.22059999999999,317.51639999999998,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",106.43340000000001,48.757199999999997,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",48.162600000000005,24.973199999999999,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[11004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",997.14419999999996,997.14419999999996,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1356.8772000000001,1356.8772000000001,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[11006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1227.2544,1227.2544,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11008,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",478.05839999999995,478.05839999999995,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[11010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",831.84540000000004,488.76120000000003,"010",0.1,0.8,0.1,0,2,2,1,0,0,"","R",null,null,2,29]
[11011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",912.1164,522.05880000000002,"000",0,0,0,0,2,2,1,0,0,"","R",null,null,2,29]
[11012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1181.4702,731.95260000000007,"000",0,0,0,0,2,2,1,0,0,"","R",null,null,2,29]
[11042,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",239.02919999999997,106.43340000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11043,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",422.166,270.54300000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",557.73480000000006,394.81439999999998,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",73.730400000000003,45.784199999999998,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[11046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",131.4066,96.919799999999995,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[11047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",214.6506,169.46100000000001,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[11055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",134.37959999999998,27.946199999999997,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11056,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",153.4068,38.649000000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11057,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",167.6772,50.540999999999997,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",189.08280000000002,66.595200000000006,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",93.94680000000001,38.649000000000001,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[11104,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",234.86700000000002,82.6494,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",109.4064,45.189599999999999,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[11106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",290.75939999999997,99.892799999999994,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",132.00120000000001,54.703200000000002,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[11200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",164.1096,136.1634,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",32.703000000000003,28.540800000000001,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[11300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",189.67740000000001,60.054600000000001,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",226.54259999999999,89.784599999999998,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",255.678,105.83880000000001,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11303,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",281.84040000000005,124.2714,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",198.59639999999999,67.189799999999991,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",227.73180000000002,86.811599999999999,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",259.84019999999998,110.5956,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11308,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",274.70519999999999,124.2714,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",215.8398,80.271000000000001,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11311,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",253.89419999999998,110.001,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",287.1918,129.62280000000001,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",334.16520000000003,169.46100000000001,"000",0,0,0,0,2,9,0,0,0,"","R",null,null,2,29]
[11400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",236.05620000000002,149.83920000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11401,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",287.78640000000001,189.08280000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11402,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",316.3272,206.92080000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11403,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",361.51679999999999,265.19159999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11404,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",410.86860000000001,292.54320000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",579.1404,440.59860000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",235.4616,147.46080000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11421,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",293.73240000000004,195.02879999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11422,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",328.81380000000001,242.00220000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11423,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",374.0034,277.08359999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11424,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",427.51740000000001,315.73259999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",603.51900000000001,482.81519999999995,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",264.59700000000004,189.67740000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11441,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",319.89479999999998,237.84,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",353.78700000000003,261.62400000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11443,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",416.22,318.7056,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11444,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",516.11279999999999,401.94959999999998,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",699.24959999999999,567.84300000000007,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",805.68300000000011,469.73400000000004,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,null,2,29]
[11451,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.54939999999999,590.43780000000004,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,null,2,29]
[11462,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",783.08820000000003,447.13919999999996,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,null,2,29]
[11463,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",991.79279999999994,596.38379999999995,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,null,2,29]
[11470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",843.14279999999997,511.95059999999995,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[11471,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1006.6578,628.49220000000003,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[11600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",364.4898,217.62360000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11601,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",419.19299999999998,263.40780000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",446.5446,286.59720000000004,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11603,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",507.19379999999995,341.30040000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11604,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",564.87,375.78720000000004,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",809.25059999999996,560.11320000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",365.67900000000003,218.81280000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11621,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",420.38220000000001,264.59700000000004,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11622,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",461.40960000000001,299.67840000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11623,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",538.70760000000007,369.84120000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11624,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",612.4380000000001,420.38220000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11626,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",737.30400000000009,516.70740000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",374.0034,225.35339999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",433.46340000000004,275.2998,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11642,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",488.76120000000003,322.27319999999997,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11643,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",572.59980000000007,401.94959999999998,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11644,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",704.601,498.86940000000004,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11646,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",912.71100000000001,689.73599999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11719,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",24.973199999999999,13.081200000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",58.865400000000001,25.567799999999998,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[11721,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",79.676400000000001,42.2166,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[11730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",211.67760000000001,94.54140000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11732,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",61.2438,30.3246,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[11740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",105.24420000000001,56.486999999999995,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",293.13779999999997,180.75839999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",225.94799999999998,106.43340000000001,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[11760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",346.65180000000004,198.0018,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11762,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",531.57240000000002,335.94900000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11765,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",306.21900000000005,164.1096,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[11770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",671.30340000000001,331.78680000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11771,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1160.0646000000002,806.27760000000001,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11772,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1428.2292,1047.0906,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[11900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",103.46040000000001,51.730200000000004,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11901,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",127.839,80.865600000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[11920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",356.76,194.4342,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[11921,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",404.92259999999999,229.51560000000001,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[11922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",109.4064,51.730200000000004,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[11950,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",144.48780000000002,91.568399999999997,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[11951,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",193.83959999999999,129.0282,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[11952,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",258.0564,181.35299999999998,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[11954,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",284.21880000000004,198.0018,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[11960,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1827.8003999999999,1827.8003999999999,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[11970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1004.2794,1004.2794,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,null,2,29]
[11971,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",984.0630000000001,984.0630000000001,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,null,2,29]
[11976,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,29]
[11980,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,1,0,0,"","X",null,null,2,29]
[11981,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",183.13679999999999,111.1902,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[11982,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",204.54239999999999,130.2174,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[11983,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",256.27259999999995,181.94759999999999,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[12001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",171.2448,79.081800000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[12002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",205.73160000000001,103.46040000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[12004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",238.43459999999999,127.24440000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[12005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",321.084,165.89340000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[12006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",374.59800000000001,203.9478,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[12007,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",420.38220000000001,254.48880000000003,"000",0,0,0,0,2,0,1,1,0,"","R",null,null,2,29]
[12011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",204.54239999999999,96.325200000000009,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[12013,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",212.86680000000001,101.67659999999999,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[12014,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",260.4348,130.2174,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[12015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",311.57040000000001,164.70420000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[12016,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",397.78740000000005,224.75879999999998,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[12017,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",265.78620000000001,265.78620000000001,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[12018,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",301.4622,301.4622,"000",0,0,0,0,2,0,2,0,0,"","R",null,null,2,29]
[12020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",551.78879999999992,334.16520000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",322.27319999999997,251.51580000000004,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",487.57199999999995,268.75919999999996,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12032,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",557.14019999999994,336.54360000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12034,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",614.81640000000004,363.30060000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",714.1146,427.51740000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",793.19640000000004,501.8424,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12037,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",883.57560000000001,580.32960000000003,"010",0.1,0.8,0.1,0,2,0,0,1,0,"","R",null,null,2,29]
[12041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",489.35580000000004,255.08340000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12042,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",570.81600000000003,346.65180000000004,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",701.62800000000004,377.57099999999997,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",748.0068,482.22059999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",923.41379999999992,567.84300000000007,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[12047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1007.847,629.68140000000005,"010",0.1,0.8,0.1,0,2,0,2,1,0,"","R",null,null,2,29]
[12051,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",523.84260000000006,300.27299999999997,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12052,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",580.32960000000003,352.59780000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12053,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",671.30340000000001,379.35480000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12054,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",709.3578,385.30080000000004,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.98140000000001,528.00480000000005,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[12056,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1064.3339999999998,683.79,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[12057,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1121.4156,744.43920000000003,"010",0.1,0.8,0.1,0,2,0,2,1,0,"","R",null,null,2,29]
[13100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",628.49220000000003,354.38159999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[13101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",733.14179999999999,440.59860000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[13102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",213.4614,127.24440000000001,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[13120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",654.65459999999996,414.43619999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[13121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",782.49360000000001,454.27440000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[13122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",230.70480000000001,144.48780000000002,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[13131,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",712.33080000000007,427.51740000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[13132,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",863.9538,534.54539999999997,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[13133,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",303.84060000000005,220.00200000000001,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[13151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",774.76379999999995,491.73419999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[13152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",908.54880000000003,592.22160000000008,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[13153,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",333.57060000000001,240.2184,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[13160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1418.7156,1418.7156,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[14000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1150.5510000000002,895.46760000000006,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[14001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1461.5267999999999,1160.0646000000002,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[14020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1268.8764000000001,1005.4686,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[14021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1559.6358,1256.9844000000001,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[14040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1365.7962,1104.7667999999999,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[14041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1654.7718,1348.5527999999999,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[14060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1378.8774000000001,1178.4972,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[14061,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1783.8,1448.4456,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[14301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1956.2339999999999,1539.4194,"090",0.1,0.71,0.19,0,2,0,2,0,0,"","R",null,null,2,29]
[14302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",379.35480000000001,379.35480000000001,"000",0,0,0,0,0,0,2,0,0,"","R",null,null,2,29]
[14350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1211.2002,1211.2002,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",635.03279999999995,386.49,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[15003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",126.6498,79.676400000000001,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[15004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",720.65519999999992,460.22040000000004,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[15005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",211.083,159.3528,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[15040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",487.57199999999995,217.62360000000001,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1086.9288000000001,829.46699999999998,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1575.0953999999999,1276.0116,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",345.46260000000001,198.59639999999999,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1495.4189999999999,1259.3628000000001,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",199.78559999999999,178.38,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1445.4726000000001,1221.903,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",290.75939999999997,262.21860000000004,"000",0,0,0,0,0,0,1,1,0,"","R",null,null,2,29]
[15120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1526.3382000000001,1225.4705999999999,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",387.67919999999998,239.62380000000002,"000",0,0,0,0,0,0,1,1,0,"","R",null,null,2,29]
[15130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1314.6605999999999,1067.307,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15131,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",172.434,158.1636,"000",0,0,0,0,0,0,1,1,0,"","R",null,null,2,29]
[15135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1584.0144,1347.9582,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15136,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",170.65020000000001,158.1636,"000",0,0,0,0,0,0,1,1,0,"","R",null,null,2,29]
[15150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1277.2008000000001,1142.2266,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",209.8938,192.65040000000002,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",259.84019999999998,244.38060000000002,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1432.9860000000001,1298.6064000000001,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15156,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",281.84040000000005,264.59700000000004,"000",0,0,0,0,0,0,1,1,0,"","R",null,null,2,29]
[15157,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",313.35419999999999,287.78640000000001,"000",0,0,0,0,0,0,1,1,0,"","R",null,null,2,29]
[15200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1516.23,1195.7406000000001,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",257.46179999999998,133.785,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1390.1748,1083.3612000000001,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15221,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",240.2184,121.2984,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1674.3936000000001,1413.3642,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15241,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",316.3272,184.92060000000001,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1793.9082000000001,1498.9866000000002,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",375.19259999999997,240.2184,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15271,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",283.02960000000002,147.46080000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[15272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",45.189599999999999,30.9192,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15273,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",576.76199999999994,347.24639999999999,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[15274,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",153.4068,79.676400000000001,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",290.75939999999997,164.1096,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[15276,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",58.270800000000001,44.594999999999999,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15277,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",632.05980000000011,395.40900000000005,"000",0,0,0,0,2,0,1,1,0,"","R",null,null,2,29]
[15278,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",176.59620000000001,99.298199999999994,"000",0,0,0,0,0,0,1,1,0,"","R",null,null,2,29]
[15570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1647.6366,1304.5524,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15572,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1578.663,1303.9577999999999,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15574,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1588.7711999999999,1315.2552000000001,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15576,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1417.5264,1158.8753999999999,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",623.14080000000001,380.54400000000004,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",673.68180000000007,436.43639999999999,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",816.98040000000003,585.08640000000003,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",841.35900000000004,613.62720000000002,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",930.54899999999998,681.41160000000002,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2619.8076000000001,1626.231,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R",null,null,2,29]
[15731,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2019.8561999999999,1776.6648,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15733,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1833.7464,1833.7464,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R",null,null,2,29]
[15734,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2667.3755999999998,2667.3755999999998,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,null,2,29]
[15736,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2167.9115999999999,2167.9115999999999,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R",null,null,2,29]
[15738,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2267.2098000000001,2267.2098000000001,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,null,2,29]
[15740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1814.1246000000001,1490.6622,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1660.1232000000002,1660.1232000000002,"090",0.1,0.71,0.19,0,2,0,2,0,0,"","R",null,null,2,29]
[15756,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4061.7126000000003,4061.7126000000003,"090",0.1,0.71,0.19,0,2,0,2,2,0,"","R",null,null,2,29]
[15757,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4039.1178000000004,4039.1178000000004,"090",0.1,0.71,0.19,0,2,0,2,2,0,"","R",null,null,2,29]
[15758,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4036.1447999999996,4036.1447999999996,"090",0.1,0.71,0.19,0,2,0,2,2,0,"","R",null,null,2,29]
[15760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1522.7706000000001,1244.4978000000001,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15769,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",853.84559999999999,853.84559999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[15770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1200.4974000000002,1200.4974000000002,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,null,2,29]
[15771,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,1,0,0,"","X",null,null,2,29]
[15772,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,0,0,1,0,0,"","X",null,null,2,29]
[15773,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,1,0,0,"","X",null,null,2,29]
[15774,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,0,0,1,0,0,"","X",null,null,2,29]
[15775,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",686.76300000000003,451.3014,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[15776,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.38679999999999,616.60019999999997,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[15777,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",378.7602,378.7602,"000",0,0,0,0,0,1,1,0,0,"","R",null,null,2,29]
[15780,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1531.6896000000002,1174.9296000000002,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15781,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",985.25220000000002,768.81780000000003,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15782,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",881.79179999999997,656.4384,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15783,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",812.81820000000005,628.49220000000003,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15786,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",424.5444,236.6508,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[15787,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",56.486999999999995,30.3246,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[15788,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,0,1,0,0,"","X",null,null,2,29]
[15789,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,0,1,0,0,"","X",null,null,2,29]
[15792,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,0,0,0,0,"","X",null,null,2,29]
[15793,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,0,0,0,0,"","X",null,null,2,29]
[15819,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,0,0,0,0,"","X",null,null,2,29]
[15820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1044.1176,922.22460000000001,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[15821,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1120.8210000000001,987.03600000000006,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[15822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",838.98059999999998,718.87139999999999,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[15823,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1121.4156,986.44140000000004,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[15824,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1576.4879493792002,1576.4879493792002,"000",0,0,0,0,2,1,0,0,0,"","F",null,"Y-CM",2,29]
[15825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1355.5079139888001,1355.5079139888001,"000",0,0,0,0,2,1,0,0,0,"","F",null,"Y-CM",2,29]
[15826,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1281.8334795552003,1281.8334795552003,"000",0,0,0,0,2,1,0,0,0,"","F",null,"Y-CM",2,29]
[15828,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4390.6220248176014,4390.6220248176014,"000",0,0,0,0,2,1,0,0,0,"","F",null,"Y-CM",2,29]
[15829,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,2,1,0,0,0,"","N",null,"Y-CM",2,29]
[15830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2085.2622000000001,2085.2622000000001,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[15832,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1635.7446000000002,1635.7446000000002,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[15833,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1565.5817999999999,1565.5817999999999,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[15834,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1594.1225999999999,1594.1225999999999,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[15835,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1658.934,1658.934,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[15836,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1424.067,1424.067,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[15837,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1564.9872,1278.9846,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[15838,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1161.8483999999999,1161.8483999999999,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[15839,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1609.5822000000001,1318.8227999999999,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[15840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1813.53,1813.53,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15841,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3167.4342000000001,3167.4342000000001,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,null,2,29]
[15842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4792.4759999999997,4792.4759999999997,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,null,2,29]
[15845,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1894.3956000000001,1894.3956000000001,"090",0.1,0.71,0.19,0,2,0,2,0,0,"","R",null,null,2,29]
[15847,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,0,0,2,1,0,"","N",null,"Y-CM",2,29]
[15850,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,"000",0,0,0,9,9,9,9,9,9,"","Bundledundled",null,null,2,29]
[15851,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",197.40719999999999,79.081800000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[15852,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",82.0548,82.0548,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[15860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",187.29900000000001,187.29900000000001,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[15876,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,29]
[15877,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,29]
[15878,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,1,0,0,0,"","X",null,null,2,29]
[15879,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,1,0,0,0,"","X",null,null,2,29]
[15920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1149.9564,1149.9564,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1429.4184,1429.4184,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,null,2,29]
[15931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1251.0383999999999,1251.0383999999999,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15933,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1562.6088000000002,1562.6088000000002,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15934,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1694.6100000000001,1694.6100000000001,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2067.4242000000004,2067.4242000000004,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,null,2,29]
[15936,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1615.5282000000002,1615.5282000000002,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R",null,null,2,29]
[15937,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1869.4224000000002,1869.4224000000002,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R",null,null,2,29]
[15940,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1254.0114000000001,1254.0114000000001,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15941,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1670.826,1670.826,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15944,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1673.2044000000001,1673.2044000000001,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15945,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1824.8274000000001,1824.8274000000001,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,null,2,29]
[15946,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2887.3776000000003,2887.3776000000003,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R",null,null,2,29]
[15950,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1143.4158,1143.4158,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,null,2,29]
[15951,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1614.9336000000001,1614.9336000000001,"090",0.1,0.71,0.19,0,2,0,0,1,0,"","R",null,null,2,29]
[15952,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1639.3122000000001,1639.3122000000001,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,null,2,29]
[15953,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1807.5839999999998,1807.5839999999998,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R",null,null,2,29]
[15956,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2094.7757999999999,2094.7757999999999,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R",null,null,2,29]
[15958,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2132.2356,2132.2356,"090",0.1,0.71,0.19,0,2,0,1,1,0,"","R",null,null,2,29]
[15999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,2,0,0,1,1,"","N",null,null,2,29]
[16000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",137.3526,79.081800000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[16020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",154.596,96.919799999999995,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[16025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",286.00259999999997,196.8126,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[16030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",357.94919999999996,231.89400000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[16035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",337.13819999999998,337.13819999999998,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[16036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",137.3526,137.3526,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[17000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",122.4876,98.703599999999994,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",12.486599999999999,3.5676000000000001,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[17004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",309.19200000000001,173.02860000000001,"010",0.1,0.8,0.1,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[17106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",618.38400000000001,488.76120000000003,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",805.68300000000011,637.41120000000001,"090",0.1,0.71,0.19,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17108,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1133.3075999999999,928.76519999999994,"090",0.1,0.71,0.19,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[17110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",208.7046,119.51459999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",243.78599999999997,145.67700000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",165.89340000000001,66.595200000000006,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[17260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",181.94759999999999,125.4606,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",270.54300000000001,152.81219999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17262,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",326.43540000000002,194.4342,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",352.59780000000001,215.24520000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17264,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",376.97640000000001,230.11020000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17266,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",428.11200000000002,269.94839999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",271.13759999999996,166.488,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17271,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",302.65140000000002,184.32600000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",344.27339999999998,213.4614,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17273,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",380.54400000000004,241.40759999999997,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17274,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",443.57159999999999,294.92160000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17276,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",514.92359999999996,354.97620000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",255.678,152.2176,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17281,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",327.62459999999999,208.11,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",374.0034,240.2184,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17283,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",440.00400000000002,299.0838,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",500.05860000000001,350.21940000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",638.60040000000004,472.70699999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17311,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1223.6867999999999,624.33000000000004,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",748.0068,331.78680000000003,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[17313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1151.1456000000001,560.70780000000002,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[17314,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",716.49300000000005,307.40820000000002,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[17315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",139.13639999999998,88.000799999999998,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[17340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,1,0,0,"","X",null,null,2,29]
[17360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,1,0,0,"","X",null,null,2,29]
[17380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,29]
[17999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,2,0,0,1,1,"","N",null,null,2,29]
[19000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",189.67740000000001,74.919600000000003,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[19001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",47.568000000000005,36.865200000000002,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[19020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",868.11599999999999,562.49160000000006,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,null,2,29]
[19030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",304.43520000000001,132.5958,"000",0,0,0,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[19081,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",950.7654,288.38099999999997,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[19082,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",749.19600000000003,145.08240000000001,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[19083,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",963.84660000000008,272.32679999999999,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[19084,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",741.46620000000007,134.9742,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[19085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1487.0946000000001,316.3272,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[19086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1164.2267999999999,157.56899999999999,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[19100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",284.8134,121.89299999999999,"000",0,0,0,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[19101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",609.46500000000003,400.7604,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[19105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,1,1,0,0,"","X",null,null,2,29]
[19110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",898.44060000000002,632.65440000000001,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[19112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",855.03480000000002,582.11339999999996,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[19120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",941.2518,745.62839999999994,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[19125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1036.3878,825.89940000000001,"090",0.1,0.71,0.19,0,2,1,1,1,0,"","R",null,"Y-CM",2,29]
[19126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",281.84040000000005,281.84040000000005,"000",0,0,0,0,0,0,1,1,0,"","R",null,"Y-CM",2,29]
[19281,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",442.97700000000003,174.21780000000001,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[19282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",317.51639999999998,86.811599999999999,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[19283,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",483.40980000000008,175.40700000000001,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[19284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",363.89519999999999,88.000799999999998,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[19285,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",714.1146,148.65,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[19286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",592.22160000000008,74.919600000000003,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[19287,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1238.5518,221.19120000000001,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[19288,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",965.6303999999999,111.1902,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[19294,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",288.97560000000004,288.97560000000004,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[19296,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,1,0,0,0,"","X",null,null,2,29]
[19297,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,29]
[19298,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,1,0,0,0,"","X",null,null,2,29]
[19300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,1,1,0,0,"","X",null,null,2,29]
[19301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,1,0,0,0,"","X",null,null,2,29]
[19302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,1,2,1,0,"","X",null,null,2,29]
[19303,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,1,2,1,0,"","X",null,null,2,29]
[19305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,1,2,1,0,"","X",null,null,2,29]
[19306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,1,2,1,0,"","X",null,null,2,29]
[19307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,1,2,1,0,"","X",null,null,2,29]
[19316,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1412.175,1412.175,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[19318,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1946.7204000000002,1946.7204000000002,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[19325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1100.01,1100.01,"090",0.1,0.71,0.19,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[19328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",991.19820000000016,991.19820000000016,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[19330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1154.7132000000001,1154.7132000000001,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[19340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1353.9041999999999,1353.9041999999999,"090",0.1,0.71,0.19,0,2,1,1,1,0,"","R",null,"Y-CM",2,29]
[19342,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1359.8502000000001,1359.8502000000001,"090",0.1,0.71,0.19,0,2,1,0,1,0,"","R",null,"Y-CM",2,29]
[19350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1501.365,1202.8758,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[19355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.71,0.19,0,2,1,0,0,0,"","X",null,null,2,29]
[19357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2078.1270000000004,2078.1270000000004,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[19361,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2771.4306000000001,2771.4306000000001,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[19364,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4832.3141999999998,4832.3141999999998,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[19367,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3148.4070000000002,3148.4070000000002,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[19368,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3857.1702000000005,3857.1702000000005,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[19369,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3584.8434000000002,3584.8434000000002,"090",0.1,0.71,0.19,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[19370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1199.3082000000002,1199.3082000000002,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[19371,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1271.2547999999999,1271.2547999999999,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[19380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1441.3103999999998,1441.3103999999998,"090",0.1,0.71,0.19,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[19396,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",509.57220000000001,252.70500000000001,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[19499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,2,1,0,1,1,"","N",null,null,2,29]
[20100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1066.7124000000001,1066.7124000000001,"010",0.1,0.8,0.1,0,2,1,2,0,0,"","R",null,null,2,29]
[20101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1115.4696000000001,375.19259999999997,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[20102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1160.0646000000002,454.27440000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[20103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1037.577,613.0326,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[20150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1787.3676,1787.3676,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[20200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",408.49020000000002,166.488,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[20205,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",563.68080000000009,271.13759999999996,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[20206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",429.89580000000001,101.08199999999999,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[20220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",444.76080000000002,152.81219999999999,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[20225,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",735.52019999999993,228.32640000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[20240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",249.13740000000001,249.13740000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[20245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",611.24879999999996,611.24879999999996,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[20250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",688.54679999999996,688.54679999999996,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[20251,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",751.57440000000008,751.57440000000008,"010",0.1,0.8,0.1,0,2,0,2,0,0,"","R",null,null,2,29]
[20500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",220.5966,155.7852,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[20501,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",274.70519999999999,65.406000000000006,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[20520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",399.57119999999998,264.59700000000004,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[20525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",862.17,440.59860000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[20526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",148.05540000000002,101.08199999999999,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[20527,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",156.9744,115.947,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[20550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",103.46040000000001,68.97359999999999,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[20551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",104.64960000000001,68.97359999999999,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[20552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",96.919799999999995,66.595200000000006,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[20553,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",111.78479999999999,75.514200000000002,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[20555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,29]
[20560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",48.162600000000005,26.757000000000001,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[20561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",68.378999999999991,39.243600000000001,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[20600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",95.73060000000001,63.027600000000007,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[20604,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",148.65,80.865600000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[20605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",98.703599999999994,65.406000000000006,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[20606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",161.7312,90.973799999999997,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[20610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",117.1362,79.676400000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[20611,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",180.75839999999999,104.64960000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[20612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",115.947,72.541200000000003,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[20615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",461.40960000000001,286.00259999999997,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[20650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",406.11180000000002,288.38099999999997,"010",0.1,0.8,0.1,0,2,0,1,1,0,"","R",null,null,2,29]
[20660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",419.7876,419.7876,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[20661,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",916.8732,916.8732,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[20662,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",937.08960000000002,937.08960000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[20663,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",863.9538,863.9538,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[20664,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1573.3116,1573.3116,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[20665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",209.8938,171.83940000000001,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[20670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",671.30340000000001,258.65100000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[20680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1100.01,748.0068,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[20690,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1063.7394000000002,1063.7394000000002,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[20692,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1998.4505999999999,1998.4505999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20693,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",794.98019999999997,794.98019999999997,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[20694,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",781.899,610.65419999999995,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[20696,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2107.2624000000001,2107.2624000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20697,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3553.9242000000004,3553.9242000000004,"000",0,0,0,3,0,0,2,1,0,"","R",null,null,2,29]
[20700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",149.83920000000001,149.83920000000001,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[20701,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",113.5686,113.5686,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[20702,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",252.11040000000003,252.11040000000003,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[20703,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",183.73140000000001,183.73140000000001,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[20704,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",266.38080000000002,266.38080000000002,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[20705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",218.2182,218.2182,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[20802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4858.4766,4858.4766,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[20805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5768.8091999999997,5768.8091999999997,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[20808,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6957.4146000000001,6957.4146000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[20816,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3637.7628,3637.7628,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3146.6232,3146.6232,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20824,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3644.3033999999998,3644.3033999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[20827,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3229.2726000000002,3229.2726000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[20838,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4938.7476000000006,4938.7476000000006,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[20900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",726.00660000000005,321.084,"000",0,0,0,0,2,0,2,1,0,"","R",null,null,2,29]
[20902,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",488.76120000000003,488.76120000000003,"000",0,0,0,0,2,0,2,1,0,"","R",null,null,2,29]
[20910,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",855.03480000000002,855.03480000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[20912,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",864.54840000000002,864.54840000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[20920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",714.70920000000001,714.70920000000001,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,null,2,29]
[20922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1087.5234,869.89980000000003,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20924,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",906.76499999999999,906.76499999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,29]
[20931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",192.0558,192.0558,"000",0,0,0,0,0,0,1,1,0,"","R",null,null,2,29]
[20932,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1328.3363999999999,1328.3363999999999,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR",2,29]
[20933,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1219.5246000000002,1219.5246000000002,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR",2,29]
[20934,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1327.1472000000001,1327.1472000000001,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR",2,29]
[20936,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,29]
[20937,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",291.35400000000004,291.35400000000004,"000",0,0,0,0,0,0,2,1,0,"","R",null,null,2,29]
[20938,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",320.48939999999999,320.48939999999999,"000",0,0,0,0,0,0,2,1,0,"","R",null,null,2,29]
[20939,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",121.2984,121.2984,"000",0,0,0,0,0,1,0,0,0,"","R",null,"Y-UR",2,29]
[20950,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",498.27480000000003,155.7852,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[20955,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4376.2559999999994,4376.2559999999994,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20956,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4674.7452000000003,4674.7452000000003,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20957,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4868.5847999999996,4868.5847999999996,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20962,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4727.07,4727.07,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20969,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4813.2870000000003,4813.2870000000003,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5038.6403999999993,5038.6403999999993,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[20972,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5023.1808000000001,5023.1808000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[20973,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5306.8050000000003,5306.8050000000003,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[20974,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",147.46080000000001,88.000799999999998,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[20975,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",305.02980000000002,305.02980000000002,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM",2,29]
[20979,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",99.892799999999994,55.297800000000002,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[20982,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,1,1,0,0,"","X",null,null,2,29]
[20983,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,1,1,0,0,"","X",null,null,2,29]
[20985,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",255.08340000000001,255.08340000000001,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,29]
[20999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,2,0,0,1,1,"","N",null,null,2,29]
[21010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1329.5255999999999,1329.5255999999999,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[21011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",687.35760000000005,466.16640000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",608.2758,608.2758,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21013,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",979.30619999999999,719.46600000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21014,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",934.11660000000006,934.11660000000006,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1250.4438,1250.4438,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[21016,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,2,0,0,"","X",null,null,2,29]
[21025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1425.8507999999999,1179.0917999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21026,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",972.17100000000005,767.62860000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21029,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1387.7963999999999,1106.5506,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[21030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",843.14279999999997,650.49239999999998,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[21031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",706.38480000000004,489.9504,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[21032,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",682.00620000000004,467.9502,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[21034,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2342.7240000000002,2014.5048000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",855.62940000000003,655.84379999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[21044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1548.3383999999999,1548.3383999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2141.7492000000002,2141.7492000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1802.8271999999999,1802.8271999999999,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R",null,"Y-CM",2,29]
[21047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2233.3176000000003,2233.3176000000003,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21048,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1815.9084,1815.9084,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R",null,"Y-CM",2,29]
[21049,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2176.2360000000003,2176.2360000000003,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1557.8520000000001,1557.8520000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[21060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1412.175,1412.175,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[21070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1093.4694,1093.4694,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[21073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",687.95220000000006,441.19319999999999,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[21076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1532.8788000000002,1247.4708000000001,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[21077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3764.4126000000001,3071.1089999999999,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[21079,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2584.1316000000002,2067.4242000000004,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2993.2164000000002,2358.7782000000002,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21081,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2747.6466,2153.0466000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21082,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2522.8878,1959.8016,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21083,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2411.1030000000001,1820.0706,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21084,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2750.6196,2106.0732000000003,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1210.0110000000002,853.84559999999999,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[21086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2804.1335999999997,2264.8314,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[21087,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2804.1335999999997,2264.8314,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21088,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","090",0.1,0.69,0.21,0,0,0,0,0,0,"","N",null,null,2,29]
[21089,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,0,0,1,1,1,"","N",null,null,2,29]
[21100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1149.9564,635.03279999999995,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1617.9066,1337.85,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",415.03080000000006,80.271000000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[21120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1222.4975999999999,925.79219999999998,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-CM",2,29]
[21121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1149.3617999999999,951.95460000000014,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1356.2826,1356.2826,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21123,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1537.6356000000001,1537.6356000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5030.3159999999998,1189.7946000000002,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21127,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7727.4216000000006,1364.0124000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21137,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1342.6068,1342.6068,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21138,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1632.7716,1632.7716,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21139,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1956.2339999999999,1956.2339999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21141,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2391.4812000000002,2391.4812000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21142,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2454.5088000000001,2454.5088000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21143,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2528.2392000000004,2528.2392000000004,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2777.9712,2777.9712,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2899.8642000000004,2899.8642000000004,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3051.4872,3051.4872,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2934.9456,2934.9456,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3226.8942000000002,3226.8942000000002,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21154,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3471.8694,3471.8694,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3847.6565999999998,3847.6565999999998,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21159,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4605.7716,4605.7716,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4992.8562000000002,4992.8562000000002,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21172,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3742.4123999999997,3742.4123999999997,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3939.2249999999999,3939.2249999999999,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21179,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2711.3760000000002,2711.3760000000002,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3026.5140000000001,3026.5140000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21181,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1324.7688000000001,1324.7688000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[21182,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3760.8450000000003,3760.8450000000003,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21183,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4089.6588000000002,4089.6588000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21184,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4397.6615999999995,4397.6615999999995,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21188,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2844.5664000000002,2844.5664000000002,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21193,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2204.1822000000002,2204.1822000000002,"090",0.1,0.69,0.21,0,2,2,2,1,0,"","R",null,"Y-CM",2,29]
[21194,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2553.2123999999999,2553.2123999999999,"090",0.1,0.69,0.21,0,2,2,2,0,0,"","R",null,"Y-CM",2,29]
[21195,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2417.6435999999999,2417.6435999999999,"090",0.1,0.69,0.21,0,2,2,2,0,0,"","R",null,"Y-CM",2,29]
[21196,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2581.7532000000001,2581.7532000000001,"090",0.1,0.69,0.21,0,2,2,2,1,0,"","R",null,"Y-CM",2,29]
[21198,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1855.152,1855.152,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21199,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1814.7192,1814.7192,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1735.0427999999999,1735.0427999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21208,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3093.1092000000003,1315.2552000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21209,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1498.9866000000002,1116.6588000000002,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[21210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3316.0842000000002,1350.3366000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7882.0176000000001,1401.4721999999999,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,null,2,29]
[21230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1340.8230000000001,1340.8230000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1331.904,1018.5498,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1871.2061999999999,1871.2061999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[21242,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1814.1246000000001,1814.1246000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[21243,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2869.5396000000001,2869.5396000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[21244,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1811.1516000000001,1811.1516000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2139.3707999999997,1647.0419999999999,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21246,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1522.1760000000002,1522.1760000000002,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21247,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2827.9176000000002,2827.9176000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21248,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1774.8810000000001,1409.202,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21249,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2409.3192000000004,1977.6396,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21255,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2412.2921999999999,2412.2921999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21256,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2209.5335999999998,2209.5335999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,2,1,0,"","X",null,null,2,29]
[21261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,2,1,0,"","X",null,null,2,29]
[21263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,2,1,0,"","X",null,null,2,29]
[21267,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[21268,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[21270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1830.1788000000001,1333.6877999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1512.6624000000002,1512.6624000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1048.8744000000002,1048.8744000000002,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[21282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",715.30380000000002,715.30380000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[21295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,0,0,0,"","X",null,null,2,29]
[21296,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,0,0,0,"","X",null,null,2,29]
[21299,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,0,1,1,"","N",null,null,2,29]
[21315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",278.86740000000003,104.64960000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[21320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",404.32799999999997,168.8664,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[21325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",816.38580000000002,816.38580000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",975.73860000000002,975.73860000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1295.6333999999999,1295.6333999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21336,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1176.1188000000002,1176.1188000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",771.79079999999999,541.68060000000003,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21338,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1230.8219999999999,1230.8219999999999,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21339,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1386.6072000000001,1386.6072000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1344.9852000000001,1344.9852000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21343,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1966.3422,1966.3422,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2502.6714000000002,2502.6714000000002,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,null,2,29]
[21345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1453.2024000000001,1144.605,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21346,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1877.7467999999999,1877.7467999999999,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,null,2,29]
[21347,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1887.2603999999999,1887.2603999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21348,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1951.4772,1951.4772,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,null,2,29]
[21355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",814.00739999999996,588.654,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[21356,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",994.76580000000001,727.79039999999998,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[21360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",938.87339999999995,938.87339999999995,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[21365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1932.45,1932.45,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21366,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2276.7233999999999,2276.7233999999999,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[21385,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1318.8227999999999,1318.8227999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21386,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1236.768,1236.768,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[21387,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1375.3098,1375.3098,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[21390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1438.3374000000001,1438.3374000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21395,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1802.8271999999999,1802.8271999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",386.49,299.0838,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[21401,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",937.68420000000003,589.84320000000002,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[21406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1049.4689999999998,1049.4689999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21407,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1150.5510000000002,1150.5510000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21408,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1614.3389999999999,1614.3389999999999,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[21421,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1186.2269999999999,994.76580000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21422,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1123.7939999999999,1123.7939999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21423,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1434.1752000000001,1434.1752000000001,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,null,2,29]
[21431,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1273.6332000000002,1273.6332000000002,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[21432,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1299.7955999999999,1299.7955999999999,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[21433,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3086.5686000000001,3086.5686000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2509.212,2509.212,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[21436,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3623.4924000000001,3623.4924000000001,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,null,2,29]
[21440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1291.4712,1032.8202000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1493.0406,1196.3352,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[21450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1110.1182000000001,896.65679999999998,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21451,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1436.5536,1193.3622,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21452,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1423.4724000000001,874.06200000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21453,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2048.3970000000004,1737.4212,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21454,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",869.89980000000003,869.89980000000003,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R",null,null,2,29]
[21461,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3448.68,1950.2879999999998,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,null,2,29]
[21462,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3769.1694000000002,2170.8845999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1417.5264,1417.5264,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2075.154,2075.154,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",262.21860000000004,54.108600000000003,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[21485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1834.3410000000001,1492.4460000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[21490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1396.1208000000001,1396.1208000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[21497,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1327.1472000000001,1098.8208,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,0,1,1,"","N",null,null,2,29]
[21501,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",894.87300000000005,600.54599999999994,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",907.95420000000001,907.95420000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[21510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",812.22360000000003,812.22360000000003,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[21550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",494.7072,279.46199999999999,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[21552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",799.73699999999997,799.73699999999997,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21554,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1303.9577999999999,1303.9577999999999,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",800.92619999999999,551.78879999999992,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[21556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",951.95460000000014,951.95460000000014,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[21557,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1698.7722000000001,1698.7722000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,2,1,0,"","X",null,null,2,29]
[21600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1004.8739999999999,1004.8739999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[21601,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2042.451,2042.451,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,null,2,29]
[21602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2762.5116000000003,2762.5116000000003,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,null,2,29]
[21603,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2995.5948000000003,2995.5948000000003,"090",0.1,0.71,0.19,0,2,0,2,1,0,"","R",null,null,2,29]
[21610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2126.2896000000001,2126.2896000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1082.172,1082.172,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[21616,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1249.8491999999999,1249.8491999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[21620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",903.19740000000002,903.19740000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21627,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",972.17100000000005,972.17100000000005,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[21630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2342.1294000000003,2342.1294000000003,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2139.9654,2139.9654,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","X",null,null,2,29]
[21700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",624.33000000000004,624.33000000000004,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[21705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",931.73820000000001,931.73820000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[21720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",947.19780000000003,947.19780000000003,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",975.14399999999989,975.14399999999989,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1801.6380000000001,1801.6380000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[21742,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","090",0.1,0.69,0.21,0,2,0,2,1,0,"","N",null,"Y-CM",2,29]
[21743,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","090",0.1,0.69,0.21,0,2,0,2,1,0,"","N",null,"Y-CM",2,29]
[21750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1192.7675999999999,1192.7675999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21811,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1039.3607999999999,1039.3607999999999,"000",0,0,0,0,2,1,2,0,0,"","R",null,null,2,29]
[21812,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1261.1466,1261.1466,"000",0,0,0,0,2,1,2,0,0,"","R",null,null,2,29]
[21813,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1724.34,1724.34,"000",0,0,0,0,2,1,2,0,0,"","R",null,null,2,29]
[21820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",272.32679999999999,266.97540000000004,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",982.27919999999995,982.27919999999995,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[21899,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,0,1,1,"","N",null,"Y-UR",2,29]
[21920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",478.05839999999995,278.86740000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[21925,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",906.17039999999997,678.43860000000006,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",922.81920000000002,652.27620000000002,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[21931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",840.16980000000001,840.16980000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[21932,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1185.0378000000001,1185.0378000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[21933,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1318.2282,1318.2282,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[21935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1824.2328,1824.2328,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-CM",2,29]
[21936,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,2,1,0,"","X",null,null,2,29]
[22010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1723.1508000000001,1723.1508000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[22015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1694.0154,1694.0154,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[22100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1542.9870000000001,1542.9870000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1534.068,1534.068,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1392.5532000000001,1392.5532000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",236.6508,236.6508,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM",2,29]
[22110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1873.5846000000001,1873.5846000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2009.7479999999998,2009.7479999999998,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22114,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2009.7479999999998,2009.7479999999998,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",246.16439999999997,246.16439999999997,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM",2,29]
[22206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4309.0662000000002,4309.0662000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22207,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4224.0384000000004,4224.0384000000004,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22208,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1025.6849999999999,1025.6849999999999,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR",2,29]
[22210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3162.0828000000001,3162.0828000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22212,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2678.6729999999998,2678.6729999999998,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22214,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2679.8622,2679.8622,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22216,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",632.65440000000001,632.65440000000001,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM",2,29]
[22220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2868.9450000000002,2868.9450000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22222,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3100.8389999999999,3100.8389999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22224,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2820.7824000000001,2820.7824000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22226,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",629.08680000000004,629.08680000000004,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM",2,29]
[22310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",562.49160000000006,535.7346,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[22315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1587.5819999999999,1378.8774000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[22318,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2896.2966000000001,2896.2966000000001,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-CM",2,29]
[22319,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3220.9482000000003,3220.9482000000003,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-CM",2,29]
[22325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2603.1588000000002,2603.1588000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22326,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2664.9972000000002,2664.9972000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22327,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2709.5922,2709.5922,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",488.16660000000007,488.16660000000007,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM",2,29]
[22505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",230.11020000000002,230.11020000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[22510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,1,0,0,"","X",null,null,2,29]
[22511,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,1,0,0,"","X",null,null,2,29]
[22512,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,0,0,1,0,0,"","X",null,null,2,29]
[22513,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,1,0,0,"","X",null,null,2,29]
[22514,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,1,0,0,"","X",null,null,2,29]
[22515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,0,0,1,0,0,"","X",null,null,2,29]
[22526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,9,9,9,9,9,9,"","X",null,null,2,29]
[22527,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,29]
[22532,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3181.11,3181.11,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22533,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2931.9726000000001,2931.9726000000001,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22534,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",626.70839999999998,626.70839999999998,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22548,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3451.6529999999998,3451.6529999999998,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2998.5677999999998,2998.5677999999998,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",689.73599999999999,689.73599999999999,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22554,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2226.777,2226.777,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2940.297,2940.297,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2700.0785999999998,2700.0785999999998,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",567.24839999999995,567.24839999999995,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22586,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3570.5729999999999,3570.5729999999999,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2799.3768,2799.3768,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22595,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2677.4838,2677.4838,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2301.1020000000003,2301.1020000000003,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2263.6422000000002,2263.6422000000002,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2804.7282,2804.7282,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22614,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",680.81700000000001,680.81700000000001,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2791.0524,2791.0524,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",557.14019999999994,557.14019999999994,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22633,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3261.3810000000003,3261.3810000000003,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22634,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",863.9538,863.9538,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2408.7246,2408.7246,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3735.2772,3735.2772,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22804,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4284.6876000000002,4284.6876000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22808,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3226.2995999999998,3226.2995999999998,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3560.4648000000002,3560.4648000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22812,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3901.7652000000003,3901.7652000000003,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22818,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3807.2238000000002,3807.2238000000002,"090",0.11,0.76,0.13,0,2,0,2,2,2,"","R",null,"Y-UR",2,29]
[22819,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4382.7965999999997,4382.7965999999997,"090",0.11,0.76,0.13,0,2,0,2,2,2,"","R",null,"Y-UR",2,29]
[22830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1460.9322,1460.9322,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1321.7958000000001,1321.7958000000001,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR",2,29]
[22841,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,"Y-UR",2,29]
[22842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1328.3363999999999,1328.3363999999999,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22843,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1420.4994000000002,1420.4994000000002,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22844,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1717.7994000000001,1717.7994000000001,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22845,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1265.9033999999999,1265.9033999999999,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22846,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1315.8498,1315.8498,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22847,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1406.8235999999999,1406.8235999999999,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22848,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",627.303,627.303,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22849,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2310.6156000000001,2310.6156000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22850,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1311.6876,1311.6876,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22852,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1260.5519999999999,1260.5519999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22853,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",448.923,448.923,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22854,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",582.70800000000008,582.70800000000008,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22855,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1961.5854000000002,1961.5854000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[22856,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2874.8910000000001,2874.8910000000001,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22857,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3134.1366000000003,3134.1366000000003,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22858,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",882.38639999999998,882.38639999999998,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22859,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",579.73500000000001,579.73500000000001,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22861,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4058.145,4058.145,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22862,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4061.7126000000003,4061.7126000000003,"090",0.1,0.71,0.19,0,2,0,2,2,2,"","R",null,"Y-UR",2,29]
[22864,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3626.4654,3626.4654,"090",0.1,0.69,0.21,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[22865,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3965.9820000000004,3965.9820000000004,"090",0.1,0.71,0.19,0,2,0,2,2,2,"","R",null,"Y-UR",2,29]
[22867,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1902.1253999999999,1902.1253999999999,"090",0.1,0.8,0.1,0,2,0,2,0,0,"","R",null,"Y-UR",2,29]
[22868,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",423.35520000000002,423.35520000000002,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22869,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",776.54759999999999,776.54759999999999,"090",0.1,0.8,0.1,0,2,0,2,0,0,"","R",null,"Y-UR",2,29]
[22870,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",209.8938,209.8938,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[22899,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,2,1,1,"","N",null,"Y-UR",2,29]
[22900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1010.82,1010.82,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22901,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1192.7675999999999,1192.7675999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22902,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",871.08900000000006,599.35680000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22903,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",788.43960000000004,788.43960000000004,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[22904,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,1,"","X",null,null,2,29]
[22905,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,1,"","X",null,null,2,29]
[22999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,0,1,1,"","N",null,"Y-CM",2,29]
[23000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1063.7394000000002,667.14120000000003,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1240.3355999999999,1240.3355999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[23030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",818.16959999999995,457.84200000000004,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[23031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",789.62879999999996,393.62520000000001,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[23035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1228.4436000000001,1228.4436000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[23040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1293.2550000000001,1293.2550000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1020.3336,1020.3336,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-CM",2,29]
[23065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,1,1,0,0,"","X",null,null,2,29]
[23066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1041.1446000000001,658.22220000000004,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[23071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",753.35820000000001,753.35820000000001,"090",0.1,0.8,0.1,0,2,1,2,0,0,"","R",null,null,2,29]
[23073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1245.6869999999999,1245.6869999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[23075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",962.65740000000005,592.81620000000009,"090",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[23076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",975.73860000000002,975.73860000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[23078,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[23100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",915.68400000000008,915.68400000000008,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",827.08860000000004,827.08860000000004,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[23105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1152.9294,1152.9294,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",909.14339999999993,909.14339999999993,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[23107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1189.2,1189.2,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1060.1717999999998,1060.1717999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1276.6061999999999,1276.6061999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1118.4425999999999,1118.4425999999999,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[23140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1002.4956,1002.4956,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[23145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1252.8222000000001,1252.8222000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1124.3886,1124.3886,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[23150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1191.5783999999999,1191.5783999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1432.9860000000001,1432.9860000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23156,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1221.903,1221.903,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[23170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1019.1444,1019.1444,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[23172,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1029.2526,1029.2526,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[23174,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1374.7152000000001,1374.7152000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1196.3352,1196.3352,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-CM",2,29]
[23182,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1211.7947999999999,1211.7947999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[23184,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1328.931,1328.931,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23190,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1037.577,1037.577,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23195,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1333.0932,1333.0932,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[23210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[23220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[23330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",559.51859999999999,300.86759999999998,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[23333,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",852.06180000000006,852.06180000000006,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[23334,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1893.8010000000002,1893.8010000000002,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[23335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2255.3177999999998,2255.3177999999998,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[23350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",314.54340000000002,88.000799999999998,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[23395,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2281.4802,2281.4802,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[23397,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2028.1805999999999,2028.1805999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[23400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1739.7996000000001,1739.7996000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1114.2803999999999,1114.2803999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[23406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1335.4716000000001,1335.4716000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[23410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1469.8512000000001,1469.8512000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23412,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1526.3382000000001,1526.3382000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1257.579,1257.579,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[23420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1744.5563999999999,1744.5563999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1337.2554,1337.2554,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1356.2826,1356.2826,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1691.6369999999999,1691.6369999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1773.0971999999999,1773.0971999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23460,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1947.3150000000001,1947.3150000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23462,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1904.5038000000002,1904.5038000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1997.2614000000003,1997.2614000000003,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23466,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2002.6128000000001,2002.6128000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2136.3978000000002,2136.3978000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23472,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2571.0504000000001,2571.0504000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23473,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2862.4043999999999,2862.4043999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23474,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3087.1632,3087.1632,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1469.8512000000001,1469.8512000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[23485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1698.7722000000001,1698.7722000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1541.2032000000002,1541.2032000000002,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[23491,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1816.5030000000002,1816.5030000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[23500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",408.49020000000002,417.4092,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",660.00599999999997,611.24879999999996,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1293.8496,1293.8496,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[23520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",443.57159999999999,437.03100000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[23525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",727.79039999999998,664.16819999999996,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[23530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1039.3607999999999,1039.3607999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[23532,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1129.1453999999999,1129.1453999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[23540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",439.40940000000001,432.27420000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",645.73559999999998,577.95120000000009,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[23550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1032.2256,1032.2256,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1177.9025999999999,1177.9025999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[23570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",431.67959999999999,444.76080000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",753.35820000000001,693.89819999999997,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[23585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1748.7185999999999,1748.7185999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[23600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",614.81640000000004,581.51879999999994,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",859.79160000000002,778.33140000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1582.8252,1582.8252,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[23616,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2199.4254000000001,2199.4254000000001,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[23620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",498.86940000000004,478.65300000000008,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23625,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",704.601,642.76260000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1397.9046000000001,1397.9046000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[23650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",598.76220000000001,539.30219999999997,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23655,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",745.03379999999993,745.03379999999993,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1053.6312,1053.6312,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[23665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",793.79099999999994,728.9796,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1556.6628000000001,1556.6628000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[23675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1006.0632000000002,908.54880000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[23680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1658.934,1658.934,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[23700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",352.59780000000001,352.59780000000001,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[23800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1834.9356,1834.9356,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2286.8316,2286.8316,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2463.4277999999999,2463.4277999999999,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[23920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2002.6128000000001,2002.6128000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[23921,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",851.46720000000005,851.46720000000005,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[23929,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled","000",0,0,0,0,2,0,2,1,1,"","Bundled",null,"Y-UR",2,29]
[23930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",669.51959999999997,385.30080000000004,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[23931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",566.05920000000003,289.5702,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[23935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",921.63,921.63,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[24000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",855.03480000000002,855.03480000000002,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,"Y-UR",2,29]
[24006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1280.7683999999999,1280.7683999999999,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,"Y-UR",2,29]
[24065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",482.81519999999995,294.327,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[24066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1141.6320000000001,754.54739999999993,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",727.79039999999998,727.79039999999998,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[24073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1238.5518,1238.5518,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[24075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","994.1+E7712",594.00540000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",979.9008,979.9008,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,1,1,0,"","X",null,null,2,29]
[24079,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[24100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",760.49339999999995,760.49339999999995,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",912.1164,912.1164,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[24102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1115.4696000000001,1115.4696000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",655.24919999999997,655.24919999999997,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1065.5232000000001,1065.5232000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[24115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1324.7688000000001,1324.7688000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1540.6086,1540.6086,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[24120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",963.25199999999995,963.25199999999995,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[24125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1123.7939999999999,1123.7939999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1172.5511999999999,1172.5511999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[24130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",922.22460000000001,922.22460000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[24134,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1342.6068,1342.6068,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[24136,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1139.8482000000001,1139.8482000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24138,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1242.1194,1242.1194,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[24140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1265.3088,1265.3088,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[24145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1072.6584,1072.6584,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[24147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1136.8752000000002,1136.8752000000002,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[24149,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2108.4515999999999,2108.4515999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[24152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[24155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1526.3382000000001,1526.3382000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2229.75,2229.75,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[24164,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1300.3902,1300.3902,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[24200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",404.92259999999999,254.48880000000003,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[24201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1009.6308,659.41139999999996,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",361.51679999999999,116.5416,"000",0,0,0,0,2,1,0,0,0,"","R",null,null,2,29]
[24300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",796.76400000000001,796.76400000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1346.769,1346.769,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[24305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1045.3067999999998,1045.3067999999998,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,"Y-UR",2,29]
[24310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",860.98080000000004,860.98080000000004,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,"Y-UR",2,29]
[24320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1399.6884,1399.6884,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[24330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1290.8766000000001,1290.8766000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[24331,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1409.202,1409.202,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[24332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1110.7128,1110.7128,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[24340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1114.875,1114.875,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24341,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1340.8230000000001,1340.8230000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24342,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1390.7694000000001,1390.7694000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24343,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1287.309,1287.309,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1959.8016,1959.8016,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1280.7683999999999,1280.7683999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24346,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1976.4504000000002,1976.4504000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",760.49339999999995,760.49339999999995,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[24358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",956.71140000000003,956.71140000000003,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[24359,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1192.173,1192.173,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[24360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1618.5011999999999,1618.5011999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24361,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1802.8271999999999,1802.8271999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24362,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1895.5847999999999,1895.5847999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[24363,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2572.2395999999999,2572.2395999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[24365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1155.3078,1155.3078,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24366,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1225.4705999999999,1225.4705999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2732.1870000000004,2732.1870000000004,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[24371,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3136.5149999999999,3136.5149999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[24400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1481.1486,1481.1486,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[24420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1924.7202,1924.7202,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1883.6928,1883.6928,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1932.45,1932.45,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1211.2002,1211.2002,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[24495,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1475.2025999999998,1475.2025999999998,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[24498,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1551.9060000000002,1551.9060000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",665.952,613.0326,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",922.22460000000001,824.71019999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1580.4467999999999,1580.4467999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24516,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1538.2302,1538.2302,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[24530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",702.81720000000007,643.95180000000005,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1126.1724000000002,1031.6310000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24538,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1431.7967999999998,1431.7967999999998,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1660.7177999999999,1660.7177999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1852.1789999999999,1852.1789999999999,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[24560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",614.22180000000003,541.68060000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",989.4144,900.22440000000006,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24566,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1299.7955999999999,1299.7955999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1317.039,1317.039,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24576,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",648.70860000000005,576.16739999999993,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24577,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1016.7660000000001,924.60300000000007,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24579,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1495.4189999999999,1495.4189999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24582,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1472.2296000000001,1472.2296000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24586,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1940.7744,1940.7744,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24587,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1943.7474,1943.7474,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",684.38459999999998,616.60019999999997,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",869.89980000000003,869.89980000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1281.9576,1281.9576,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1020.3336,1020.3336,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[24635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1215.3624000000002,1215.3624000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,1,0,0,0,"","X",null,null,2,29]
[24650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",486.38279999999997,451.3014,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24655,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",819.95339999999999,737.30400000000009,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1187.4161999999999,1187.4161999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24666,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1315.8498,1315.8498,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",539.89679999999998,492.32879999999994,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",850.87260000000003,768.22320000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[24685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1178.4972,1178.4972,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1496.0136,1496.0136,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[24802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1793.9082000000001,1793.9082000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[24900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1324.7688000000001,1324.7688000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1315.8498,1315.8498,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[24925,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1027.4688000000001,1027.4688000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[24930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1387.7963999999999,1387.7963999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[24931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1664.2854,1664.2854,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[24935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2201.8038000000001,2201.8038000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[24940,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2003.7910155120003,2003.7910155120003,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","F",null,"Y-UR",2,29]
[24999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,1,0,1,1,"","N",null,"Y-UR",2,29]
[25000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",628.49220000000003,628.49220000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[25001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",630.27599999999995,630.27599999999995,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[25020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1384.8234,1384.8234,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[25023,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2417.049,2417.049,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[25024,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1403.8506,1403.8506,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[25025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2101.3164000000002,2101.3164000000002,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[25028,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1300.3902,1300.3902,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",669.51959999999997,669.51959999999997,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1057.1988000000001,1057.1988000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1007.847,1007.847,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",475.68,284.8134,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[25066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",662.97900000000004,662.97900000000004,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",761.08800000000008,761.08800000000008,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",962.06280000000004,962.06280000000004,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",969.19800000000009,569.03219999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",931.73820000000001,931.73820000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,1,0,0,"","X",null,null,2,29]
[25078,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,0,0,"","X",null,null,2,29]
[25085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",811.03440000000001,811.03440000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",636.81660000000011,636.81660000000011,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",734.92560000000003,734.92560000000003,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",880.60260000000005,880.60260000000005,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,null,2,29]
[25107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1113.6858,1113.6858,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[25109,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",966.81960000000015,966.81960000000015,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[25110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",630.27599999999995,630.27599999999995,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[25111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",589.84320000000002,589.84320000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",707.57400000000007,707.57400000000007,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1357.4718,1357.4718,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1088.1180000000002,1088.1180000000002,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,null,2,29]
[25118,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",694.49279999999999,694.49279999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25119,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",909.73800000000006,909.73800000000006,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",907.3596,907.3596,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,null,2,29]
[25125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1075.0367999999999,1075.0367999999999,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1082.7666000000002,1082.7666000000002,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",818.16959999999995,818.16959999999995,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1013.793,1013.793,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25136,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",902.6028,902.6028,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",943.03559999999993,943.03559999999993,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1025.0903999999998,1025.0903999999998,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[25151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1054.2257999999999,1054.2257999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[25210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",890.71080000000006,890.71080000000006,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R",null,null,2,29]
[25215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1115.4696000000001,1115.4696000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",783.68280000000004,783.68280000000004,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[25240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",777.73680000000002,777.73680000000002,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,null,2,29]
[25246,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",372.21960000000001,128.43360000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[25248,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",759.30420000000004,759.30420000000004,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",966.22500000000002,966.22500000000002,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25251,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1293.2550000000001,1293.2550000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25259,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",787.84500000000003,787.84500000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1145.7942,1145.7942,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[25263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1145.7942,1145.7942,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[25265,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1350.3366000000001,1350.3366000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[25270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",893.68380000000002,893.68380000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[25272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1011.4146000000001,1011.4146000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[25274,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1196.9297999999999,1196.9297999999999,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R",null,null,2,29]
[25275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1210.0110000000002,1210.0110000000002,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,null,2,29]
[25280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1022.712,1022.712,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R",null,null,2,29]
[25290,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",789.62879999999996,789.62879999999996,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[25295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",952.54920000000004,952.54920000000004,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[25300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1244.4978000000001,1244.4978000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1157.6861999999999,1157.6861999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1118.4425999999999,1118.4425999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[25312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1286.1197999999999,1286.1197999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[25315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1381.8504,1381.8504,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25316,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1642.2852,1642.2852,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1768.3404,1768.3404,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[25332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1515.0408,1515.0408,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,0,0,"","X",null,null,2,29]
[25337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1590.5550000000001,1590.5550000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1214.1732000000002,1214.1732000000002,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1374.7152000000001,1374.7152000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1180.2810000000002,1180.2810000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1644.069,1644.069,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1814.1246000000001,1814.1246000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25375,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1708.8804,1708.8804,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1380.0666000000001,1380.0666000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25391,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1782.6108000000002,1782.6108000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25392,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1813.53,1813.53,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25393,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2015.694,2015.694,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25394,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1408.0128,1408.0128,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1438.932,1438.932,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1855.7466000000002,1855.7466000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1733.8536000000001,1733.8536000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2081.6945999999998,2081.6945999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1726.7184,1726.7184,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2004.3966,2004.3966,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1315.8498,1315.8498,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25431,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1413.3642,1413.3642,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1378.2828,1378.2828,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25441,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1680.3396,1680.3396,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1454.3916000000002,1454.3916000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25443,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1410.9858000000002,1410.9858000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25444,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1487.6892,1487.6892,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1292.0658000000001,1292.0658000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[25446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2087.6406000000002,2087.6406000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25447,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1492.4460000000001,1492.4460000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25449,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1848.0167999999999,1848.0167999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1114.875,1114.875,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[25455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1315.8498,1315.8498,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[25490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1292.6604,1292.6604,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25491,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1328.3363999999999,1328.3363999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25492,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1625.6364000000001,1625.6364000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",525.03179999999998,472.70699999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",924.60300000000007,836.00760000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1206.4433999999999,1206.4433999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1053.6312,990.60360000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1416.9317999999998,1416.9317999999998,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[25526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1714.2318,1714.2318,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[25530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",486.97739999999999,445.95,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",907.95420000000001,834.22379999999998,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1127.3616000000002,1127.3616000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",535.14,475.68,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",949.57620000000009,846.71040000000005,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25574,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1215.3624000000002,1215.3624000000002,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[25575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1622.0688,1622.0688,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",625.51919999999996,597.57300000000009,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",985.84679999999992,929.95440000000008,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1205.8488,1205.8488,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1330.1202000000001,1330.1202000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25608,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1485.9053999999999,1485.9053999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25609,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1884.8820000000001,1884.8820000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25622,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",567.24839999999995,522.65339999999992,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25624,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",902.00819999999999,814.60199999999998,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25628,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1295.6333999999999,1295.6333999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",562.49160000000006,521.46420000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",855.62940000000003,774.16919999999993,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1032.2256,1032.2256,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",608.2758,561.30240000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25651,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",886.54859999999996,886.54859999999996,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25652,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1123.7939999999999,1123.7939999999999,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[25660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",818.76419999999996,818.76419999999996,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1097.6316000000002,1097.6316000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25671,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",959.6844000000001,959.6844000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",822.92640000000006,740.27699999999993,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25676,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1137.4697999999999,1137.4697999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",963.84660000000008,963.84660000000008,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1321.2012,1321.2012,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25690,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",894.87300000000005,894.87300000000005,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25695,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1144.0103999999999,1144.0103999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[25800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1314.6605999999999,1314.6605999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[25805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1521.5814,1521.5814,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[25810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1550.1222,1550.1222,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[25820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1180.8756000000001,1180.8756000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[25825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1438.3374000000001,1438.3374000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[25830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1894.3956000000001,1894.3956000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[25900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1287.9036000000001,1287.9036000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25905,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1262.9304,1262.9304,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25907,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1108.3344,1108.3344,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25909,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1233.7950000000001,1233.7950000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25915,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2078.1270000000004,2078.1270000000004,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1325.9580000000001,1325.9580000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1177.9025999999999,1177.9025999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25924,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1296.2280000000001,1296.2280000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25927,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1590.5550000000001,1590.5550000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[25929,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1081.5774000000001,1081.5774000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[25931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1476.9864,1476.9864,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[25999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,1,0,1,1,"","N",null,null,2,29]
[26010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",655.24919999999997,254.48880000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[26011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",914.49480000000005,334.75979999999998,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[26020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1006.0632000000002,1006.0632000000002,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",762.27719999999999,762.27719999999999,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[26030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",886.54859999999996,886.54859999999996,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[26034,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",999.5225999999999,999.5225999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1546.5546000000002,1546.5546000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26037,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1009.0361999999999,1009.0361999999999,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[26040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",574.97820000000002,574.97820000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[26045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",855.62940000000003,855.62940000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[26055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1111.902,529.78859999999997,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",467.35560000000004,467.35560000000004,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",582.70800000000008,582.70800000000008,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[26075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",613.62720000000002,613.62720000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[26080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",724.81740000000002,724.81740000000002,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",617.7894,617.7894,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[26105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",621.9516000000001,621.9516000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[26110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",592.22160000000008,592.22160000000008,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",747.41219999999998,747.41219999999998,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26113,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",982.87380000000007,982.87380000000007,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1020.9282000000001,598.16759999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",945.41399999999999,945.41399999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26117,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,1,0,0,"","X",null,null,2,29]
[26118,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,2,0,0,"","X",null,null,2,29]
[26121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1080.9828,1080.9828,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[26123,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1504.9325999999999,1504.9325999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[26125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",473.89619999999996,473.89619999999996,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[26130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",851.46720000000005,851.46720000000005,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[26135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1001.9010000000001,1001.9010000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",919.25160000000005,919.25160000000005,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",932.33280000000002,932.33280000000002,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1155.3078,572.59980000000007,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",740.27699999999993,740.27699999999993,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",814.60199999999998,814.60199999999998,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26185,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1007.847,1007.847,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[26200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",812.81820000000005,812.81820000000005,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26205,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1093.4694,1093.4694,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",811.03440000000001,811.03440000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1025.0903999999998,1025.0903999999998,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",903.19740000000002,903.19740000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",888.92700000000002,888.92700000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26236,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",799.73699999999997,799.73699999999997,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1900.3416,1900.3416,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1427.04,1427.04,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26262,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1133.3075999999999,1133.3075999999999,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",635.62739999999997,635.62739999999997,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",647.51940000000002,647.51940000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[26341,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",215.24520000000001,141.51480000000001,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[26350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1392.5532000000001,1392.5532000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26352,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1545.96,1545.96,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26356,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1438.3374000000001,1438.3374000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1610.1768,1610.1768,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1775.4756,1775.4756,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1460.3375999999998,1460.3375999999998,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26372,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1696.9884,1696.9884,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26373,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1635.7446000000002,1635.7446000000002,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1618.5011999999999,1618.5011999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26392,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1850.3952000000002,1850.3952000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1124.9832000000001,1124.9832000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26412,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1334.2824000000001,1334.2824000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1577.4738,1577.4738,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26416,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1701.7452000000001,1701.7452000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26418,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1168.9836,1168.9836,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1384.2288000000001,1384.2288000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",910.33260000000007,910.33260000000007,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26428,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1480.5539999999999,1480.5539999999999,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26432,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1019.1444,1019.1444,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26433,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1069.6853999999998,1069.6853999999998,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26434,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1295.6333999999999,1295.6333999999999,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26437,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1240.3355999999999,1240.3355999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1218.93,1218.93,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1824.8274000000001,1824.8274000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1141.6320000000001,1141.6320000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26449,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1257.579,1257.579,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",865.73760000000004,865.73760000000004,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",856.22400000000005,856.22400000000005,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26460,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",843.14279999999997,843.14279999999997,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26471,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1228.4436000000001,1228.4436000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26474,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1215.9569999999999,1215.9569999999999,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26476,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1202.2811999999999,1202.2811999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26477,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1166.0106000000001,1166.0106000000001,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,null,2,29]
[26478,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1234.3896000000002,1234.3896000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26479,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1259.3628000000001,1259.3628000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1461.5267999999999,1461.5267999999999,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26483,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1612.5552,1612.5552,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1548.3383999999999,1548.3383999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26489,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1784.9892,1784.9892,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1550.7167999999999,1550.7167999999999,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26492,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1709.4750000000001,1709.4750000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26494,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1556.0682000000002,1556.0682000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26496,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1670.826,1670.826,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26497,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1669.0422000000001,1669.0422000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26498,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2156.6142000000004,2156.6142000000004,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1607.7983999999999,1607.7983999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1243.3086000000001,1243.3086000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1402.0667999999998,1402.0667999999998,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26508,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1257.579,1257.579,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[26510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1195.7406000000001,1195.7406000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26516,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1378.2828,1378.2828,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[26517,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1599.4739999999999,1599.4739999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[26518,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1619.6904,1619.6904,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[26520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1277.2008000000001,1277.2008000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1281.3630000000001,1281.3630000000001,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,null,2,29]
[26530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",978.11699999999996,978.11699999999996,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26531,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1138.6589999999999,1138.6589999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",790.8180000000001,790.8180000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26536,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1394.337,1394.337,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1299.201,1299.201,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R",null,null,2,29]
[26541,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1538.2302,1538.2302,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26542,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1340.2284,1340.2284,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1356.2826,1356.2826,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1902.1253999999999,1902.1253999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[26548,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1475.2025999999998,1475.2025999999998,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3002.73,3002.73,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[26551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5901.9996000000001,5901.9996000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[26553,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5862.1614,5862.1614,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[26554,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6814.116,6814.116,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[26555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2533.5906,2533.5906,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6097.0284000000001,6097.0284000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1186.2269999999999,1186.2269999999999,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1805.8002000000001,1805.8002000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26562,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2505.6444000000001,2505.6444000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1331.3094000000001,1331.3094000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26567,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1334.877,1334.877,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26568,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1725.5291999999999,1725.5291999999999,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26580,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,0,0,"","X",null,null,2,29]
[26587,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,2,0,0,"","X",null,null,2,29]
[26590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,2,0,0,"","X",null,null,2,29]
[26591,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",913.30560000000003,913.30560000000003,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26593,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1201.6866,1201.6866,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26596,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1500.1758,1500.1758,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",555.95100000000002,528.00480000000005,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",610.65419999999995,548.22120000000007,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",934.71120000000008,934.71120000000008,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26608,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",877.03499999999997,877.03499999999997,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1040.55,1040.55,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",771.19620000000009,700.43880000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[26645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",795.5748000000001,721.84440000000006,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[26650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",877.62959999999998,877.62959999999998,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[26665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1128.5508,1128.5508,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[26670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",640.97879999999998,570.22140000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",847.30500000000006,770.60160000000008,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26676,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.98140000000001,926.98140000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1042.3338000000001,1042.3338000000001,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,null,2,29]
[26686,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1124.9832000000001,1124.9832000000001,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[26700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",619.57320000000004,567.84300000000007,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",778.92600000000004,704.00639999999999,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26706,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",812.22360000000003,812.22360000000003,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1036.9824000000001,1036.9824000000001,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",369.2466,346.65180000000004,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",629.08680000000004,557.14019999999994,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26727,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",863.35919999999999,863.35919999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26735,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1074.4422,1074.4422,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",429.30119999999999,405.5172,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26742,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",687.35760000000005,614.22180000000003,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26746,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1336.6608000000001,1336.6608000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",344.27339999999998,346.65180000000004,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",588.654,502.43699999999995,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26756,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",775.95300000000009,775.95300000000009,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26765,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",910.92720000000008,910.92720000000008,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",523.84260000000006,474.49080000000004,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26775,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",722.43900000000008,645.73559999999998,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26776,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",821.14260000000002,821.14260000000002,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26785,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",988.81979999999999,988.81979999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1534.6625999999999,1534.6625999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[26841,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1432.3914,1432.3914,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,null,2,29]
[26842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1538.8247999999999,1538.8247999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[26843,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1450.8239999999998,1450.8239999999998,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26844,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1589.3658,1589.3658,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26850,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1361.634,1361.634,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26852,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1535.8517999999999,1535.8517999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1142.8211999999999,1142.8211999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26861,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",179.5692,179.5692,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[26862,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1418.1210000000001,1418.1210000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[26863,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",400.16580000000005,400.16580000000005,"000",0,0,0,0,0,0,2,0,0,"","R",null,null,2,29]
[26910,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1408.0128,1408.0128,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26951,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1298.6064000000001,1298.6064000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26952,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1268.2818,1268.2818,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26989,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,1,1,1,"","N",null,null,2,29]
[26990,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1240.3355999999999,1240.3355999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[26991,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1294.4441999999999,941.84640000000002,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[26992,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1814.7192,1814.7192,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[27000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",727.19580000000008,727.19580000000008,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",973.36020000000008,973.36020000000008,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1080.3882000000001,1080.3882000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1297.4172000000001,1297.4172000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1288.4982000000002,1288.4982000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1651.7988,1651.7988,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,null,2,29]
[27027,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1581.0414000000001,1581.0414000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1673.2044000000001,1673.2044000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27033,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1735.6374000000001,1735.6374000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2069.8026,2069.8026,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[27036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1820.6652000000001,1820.6652000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",626.70839999999998,353.19240000000002,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[27041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1268.8764000000001,1268.8764000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27043,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",838.38599999999997,838.38599999999997,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1309.9038,1309.9038,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",910.92720000000008,647.51940000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27048,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1089.9017999999999,1089.9017999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27049,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[27050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",734.92560000000003,734.92560000000003,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,null,2,29]
[27052,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1041.7392,1041.7392,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27054,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1236.768,1236.768,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27057,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1801.0434,1801.0434,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27059,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[27060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",841.35900000000004,841.35900000000004,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27062,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",822.33180000000004,822.33180000000004,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",950.17079999999999,950.17079999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1462.1214,1462.1214,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27067,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1850.9898000000001,1850.9898000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1606.0146000000002,1606.0146000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1760.0160000000001,1760.0160000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3687.7092000000002,3687.7092000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[27076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4452.3647999999994,4452.3647999999994,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[27077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4963.7208000000001,4963.7208000000001,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[27078,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3635.9789999999998,3635.9789999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",918.06240000000003,918.06240000000003,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[27086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",579.1404,303.84060000000005,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[27087,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1099.4153999999999,1099.4153999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27090,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1487.6892,1487.6892,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27091,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2827.9176000000002,2827.9176000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27093,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",449.51759999999996,118.92,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[27095,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",605.89739999999995,145.67700000000002,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[27096,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",299.0838,145.67700000000002,"000",0,0,0,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[27097,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1229.6328000000001,1229.6328000000001,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27098,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1251.633,1251.633,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1490.0675999999999,1490.0675999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1561.4196000000002,1561.4196000000002,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1738.0158000000001,1738.0158000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1619.0958000000001,1619.0958000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2312.3994000000002,2312.3994000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1969.3151999999998,1969.3151999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2015.694,2015.694,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2280.8856000000001,2280.8856000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27132,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2963.4864000000002,2963.4864000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27134,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3371.3820000000001,3371.3820000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27137,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2598.9965999999999,2598.9965999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27138,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2700.6732000000002,2700.6732000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1598.2847999999999,1598.2847999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2279.1017999999999,2279.1017999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2598.9965999999999,2598.9965999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2807.1066000000001,2807.1066000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27156,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3022.9464000000003,3022.9464000000003,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27158,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2488.9956000000002,2488.9956000000002,"090",0.1,0.69,0.21,0,2,2,2,0,0,"","R",null,null,2,29]
[27161,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2175.6414000000004,2175.6414000000004,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27165,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2455.1034,2455.1034,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2074.5594000000001,2074.5594000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1193.9567999999999,1193.9567999999999,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27176,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1651.2041999999999,1651.2041999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27177,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1991.3154000000002,1991.3154000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27178,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1651.2041999999999,1651.2041999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27179,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1751.097,1751.097,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27181,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1997.2614000000003,1997.2614000000003,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27185,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1290.8766000000001,1290.8766000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27187,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1782.6108000000002,1782.6108000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27197,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",242.5968,242.5968,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[27198,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",569.6268,569.6268,"000",0,0,0,0,2,0,0,2,0,"","R",null,null,2,29]
[27200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",344.27339999999998,345.46260000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[27202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",946.60320000000002,946.60320000000002,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[27215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1076.2260000000001,1076.2260000000001,"090",0.1,0.69,0.21,9,9,9,9,9,9,"","R",null,null,2,29]
[27216,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1589.9603999999999,1589.9603999999999,"090",0.1,0.69,0.21,9,9,9,9,9,9,"","R",null,null,2,29]
[27217,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1494.8244,1494.8244,"090",0.1,0.69,0.21,9,9,9,9,9,9,"","R",null,null,2,29]
[27218,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2048.3970000000004,2048.3970000000004,"090",0.1,0.69,0.21,9,9,9,9,9,9,"","R",null,null,2,29]
[27220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",756.33120000000008,743.84460000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27222,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1760.0160000000001,1760.0160000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27226,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1881.3144,1881.3144,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27227,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2927.8104000000003,2927.8104000000003,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27228,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3325.0032000000001,3325.0032000000001,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",883.57560000000001,865.73760000000004,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27232,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1314.066,1314.066,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1622.6633999999999,1622.6633999999999,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27236,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2125.1004000000003,2125.1004000000003,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27238,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",846.71040000000005,846.71040000000005,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1714.8263999999999,1714.8263999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27244,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2185.7496000000001,2185.7496000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2183.9657999999999,2183.9657999999999,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27246,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",709.3578,699.8442,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27248,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1335.4716000000001,1335.4716000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",313.94880000000001,313.94880000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[27252,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1352.1204,1352.1204,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27253,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1681.5288,1681.5288,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27254,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2264.8314,2264.8314,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27256,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",551.19420000000002,420.38220000000001,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[27257,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",642.16800000000001,642.16800000000001,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[27258,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1984.1801999999998,1984.1801999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27259,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2741.1060000000002,2741.1060000000002,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27265,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",742.65539999999999,742.65539999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27266,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1054.2257999999999,1054.2257999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27267,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",798.54779999999994,798.54779999999994,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27268,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",981.68460000000016,981.68460000000016,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27269,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2204.1822000000002,2204.1822000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",329.40840000000003,329.40840000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[27279,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1490.6622,1490.6622,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2408.13,2408.13,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1542.3924000000002,1542.3924000000002,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[27284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2843.3771999999999,2843.3771999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2914.1345999999999,2914.1345999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27290,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2887.3776000000003,2887.3776000000003,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[27295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2242.2366000000002,2242.2366000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27299,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,1,2,1,1,"","N",null,null,2,29]
[27301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1231.4166,910.92720000000008,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27303,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1147.578,1147.578,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",872.87279999999998,872.87279999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",613.0326,613.0326,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",755.14199999999994,755.14199999999994,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,null,2,29]
[27310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1315.2552000000001,1315.2552000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27323,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",503.62620000000004,311.57040000000001,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[27324,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",733.7364,733.7364,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1020.3336,1020.3336,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[27326,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",946.0086,946.0086,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[27327,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",934.71120000000008,566.65379999999993,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1114.2803999999999,1114.2803999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27329,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1851.5844,1851.5844,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",764.65559999999994,764.65559999999994,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[27331,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",860.98080000000004,860.98080000000004,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1163.0375999999999,1163.0375999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27333,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1063.1448,1063.1448,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27334,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1233.7950000000001,1233.7950000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1375.3098,1375.3098,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",752.16899999999998,752.16899999999998,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27339,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1347.9582,1347.9582,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",680.81700000000001,680.81700000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[27345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",878.2242,878.2242,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27347,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",949.57620000000009,949.57620000000009,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1179.0917999999999,1179.0917999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1097.037,1097.037,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27356,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1329.5255999999999,1329.5255999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1472.2296000000001,1472.2296000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",483.40980000000008,483.40980000000008,"000",0,0,0,0,0,0,2,0,0,"","R",null,"Y-UR",2,29]
[27360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1636.9338,1636.9338,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27364,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[27365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3633.6006000000002,3633.6006000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27369,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",330.5976,70.162800000000004,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[27372,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1093.4694,724.22280000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1133.9022,1133.9022,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27381,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1485.3108,1485.3108,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27385,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1106.5506,1106.5506,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27386,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1551.9060000000002,1551.9060000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",812.81820000000005,812.81820000000005,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[27391,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1003.6848,1003.6848,"090",0.1,0.69,0.21,0,2,0,0,1,0,"","R",null,"Y-UR",2,29]
[27392,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1281.9576,1281.9576,"090",0.1,0.69,0.21,0,2,2,2,1,0,"","R",null,"Y-UR",2,29]
[27393,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",906.17039999999997,906.17039999999997,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27394,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1178.4972,1178.4972,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-UR",2,29]
[27395,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1580.4467999999999,1580.4467999999999,"090",0.1,0.69,0.21,0,2,2,2,1,0,"","R",null,"Y-UR",2,29]
[27396,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1114.2803999999999,1114.2803999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27397,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1638.123,1638.123,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[27400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1252.2275999999999,1252.2275999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27403,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1161.2538000000002,1161.2538000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1218.3353999999999,1218.3353999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27407,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1431.7967999999998,1431.7967999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27409,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1731.4752000000001,1731.4752000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27412,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[27415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2444.4005999999999,2444.4005999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27416,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1751.097,1751.097,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[27418,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1491.2567999999999,1491.2567999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1333.6877999999999,1333.6877999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27422,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1334.2824000000001,1334.2824000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27424,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1344.9852000000001,1344.9852000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",822.33180000000004,822.33180000000004,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[27427,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1277.2008000000001,1277.2008000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27428,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1997.8560000000002,1997.8560000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27429,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2248.7772,2248.7772,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1334.2824000000001,1334.2824000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1446.0672,1446.0672,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27437,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1187.4161999999999,1187.4161999999999,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[27438,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1504.9325999999999,1504.9325999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1430.6076,1430.6076,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27441,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1476.3917999999999,1476.3917999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1558.4466,1558.4466,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27443,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1462.7160000000001,1462.7160000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2233.3176000000003,2233.3176000000003,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2051.37,2051.37,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27447,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2278.5072,2278.5072,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27448,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1449.6348,1449.6348,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1808.7732000000001,1808.7732000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27454,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2301.6966000000002,2301.6966000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1724.9346,1724.9346,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27457,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1716.0155999999999,1716.0155999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2221.4256,2221.4256,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27466,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2112.6138000000001,2112.6138000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27468,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2387.319,2387.319,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2103.1001999999999,2103.1001999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27472,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2250.5610000000001,2250.5610000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27475,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,1,1,0,"","X",null,null,2,29]
[27477,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,1,1,0,"","X",null,null,2,29]
[27479,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,0,0,"","X",null,null,2,29]
[27485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,1,0,0,"","X",null,null,2,29]
[27486,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2494.9416000000001,2494.9416000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27487,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3107.9742000000001,3107.9742000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27488,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2136.9924000000001,2136.9924000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27495,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2015.694,2015.694,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27496,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",991.19820000000016,991.19820000000016,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27497,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1045.3067999999998,1045.3067999999998,"090",0.1,0.69,0.21,0,2,1,0,2,0,"","R",null,null,2,29]
[27498,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1183.2539999999999,1183.2539999999999,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1261.1466,1261.1466,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",946.60320000000002,867.52139999999997,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27501,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",918.06240000000003,899.62980000000005,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1357.4718,1357.4718,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27503,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1432.3914,1432.3914,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27506,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2381.373,2381.373,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27507,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1724.9346,1724.9346,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27508,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",956.1167999999999,904.38660000000004,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27509,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1229.6328000000001,1229.6328000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1216.5516,1216.5516,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27511,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1773.0971999999999,1773.0971999999999,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27513,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2196.4523999999997,2196.4523999999997,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27514,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1721.9616000000001,1721.9616000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27516,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",946.0086,881.79179999999997,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27517,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1240.3355999999999,1240.3355999999999,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27519,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1589.3658,1589.3658,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",599.35680000000002,552.97800000000007,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27524,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1352.7149999999999,1352.7149999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",569.03219999999999,533.35620000000006,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27532,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1124.9832000000001,1046.4960000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1599.4739999999999,1599.4739999999999,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27536,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2114.3976000000002,2114.3976000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27538,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",890.71080000000006,825.30480000000011,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1459.1484,1459.1484,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",938.27879999999993,859.197,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1144.605,1144.605,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1564.3925999999999,1564.3925999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27557,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1861.6925999999999,1861.6925999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2114.3976000000002,2114.3976000000002,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",676.06020000000001,614.22180000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27562,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",888.92700000000002,888.92700000000002,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27566,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1597.0955999999999,1597.0955999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",275.2998,275.2998,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[27580,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2639.4294,2639.4294,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1387.7963999999999,1387.7963999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27591,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1723.1508000000001,1723.1508000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27592,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1185.0378000000001,1185.0378000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27594,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",906.76499999999999,906.76499999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[27596,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1267.0925999999999,1267.0925999999999,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[27598,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1242.1194,1242.1194,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27599,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,1,2,1,1,"","N",null,"Y-UR",2,29]
[27600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",721.84440000000006,721.84440000000006,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27601,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",803.89919999999995,803.89919999999995,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",849.68340000000001,849.68340000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27603,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",973.95479999999998,705.79019999999991,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27604,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",819.95339999999999,576.16739999999993,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",610.05960000000005,326.43540000000002,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[27606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",487.57199999999995,487.57199999999995,"010",0.1,0.8,0.1,0,2,1,1,1,0,"","R",null,null,2,29]
[27607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1069.6853999999998,1069.6853999999998,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1162.443,1162.443,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[27612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1003.0902000000001,1003.0902000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27613,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",464.38259999999997,287.1918,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[27614,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1064.9286,739.68240000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,0,1,0,"","X",null,null,2,29]
[27616,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,0,1,0,"","X",null,null,2,29]
[27618,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",906.76499999999999,550.59960000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27619,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",825.89940000000001,825.89940000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",810.4398000000001,810.4398000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27625,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1029.2526,1029.2526,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27626,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1079.1989999999998,1079.1989999999998,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[27630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",993.5766000000001,645.14099999999996,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",737.89859999999999,737.89859999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27634,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1205.8488,1205.8488,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1041.1446000000001,1041.1446000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27637,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1318.2282,1318.2282,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27638,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1344.3905999999999,1344.3905999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1488.2838000000002,1488.2838000000002,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1167.1997999999999,1167.1997999999999,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3132.3528000000001,3132.3528000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27646,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2725.0517999999997,2725.0517999999997,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27647,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1760.6106,1760.6106,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27648,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",412.65240000000006,89.784599999999998,"000",0,0,0,0,2,1,0,0,0,"","R",null,null,2,29]
[27650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1183.8486,1183.8486,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27652,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1178.4972,1178.4972,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[27654,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1277.2008000000001,1277.2008000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27656,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1008.4416000000001,634.43820000000005,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27658,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",662.97900000000004,662.97900000000004,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[27659,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",842.54819999999995,842.54819999999995,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[27664,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",657.62760000000003,657.62760000000003,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,"Y-UR",2,29]
[27665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",759.89879999999994,759.89879999999994,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[27675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",882.38639999999998,882.38639999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27676,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1090.4964,1090.4964,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[27680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",750.97980000000007,750.97980000000007,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-UR",2,29]
[27681,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",913.30560000000003,913.30560000000003,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[27685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1195.7406000000001,833.03459999999995,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27686,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",954.33300000000008,954.33300000000008,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[27687,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",814.60199999999998,814.60199999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27690,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1149.9564,1149.9564,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27691,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1334.2824000000001,1334.2824000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27692,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",177.1908,177.1908,"000",0,0,0,0,0,0,2,1,0,"","R",null,null,2,29]
[27695,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",862.17,862.17,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[27696,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",982.27919999999995,982.27919999999995,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[27698,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1140.4428,1140.4428,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1097.037,1097.037,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27702,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1718.394,1718.394,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27703,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1975.2611999999999,1975.2611999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[27704,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1025.0903999999998,1025.0903999999998,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[27705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1359.2556,1359.2556,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27707,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",730.76339999999993,730.76339999999993,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[27709,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2035.9104000000002,2035.9104000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27712,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1966.3422,1966.3422,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1915.8011999999999,1915.8011999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1566.1764000000001,1566.1764000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27722,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1603.0416,1603.0416,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27724,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2228.5607999999997,2228.5607999999997,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2166.7224000000001,2166.7224000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27726,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1711.2588000000001,1711.2588000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27727,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[27730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1061.3610000000001,1061.3610000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-CM",2,29]
[27732,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",821.14260000000002,821.14260000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[27734,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1184.4432000000002,1184.4432000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[27740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1272.444,1272.444,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[27742,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1394.337,1394.337,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[27745,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1358.0663999999999,1358.0663999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",638.60040000000004,591.62699999999995,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27752,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.54939999999999,889.52160000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27756,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1045.9014,1045.9014,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27758,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1605.42,1605.42,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27759,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1780.827,1780.827,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",611.84339999999997,564.27539999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27762,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",881.19720000000007,794.98019999999997,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27766,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1089.9017999999999,1089.9017999999999,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27767,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",538.70760000000007,533.35620000000006,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27768,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",814.00739999999996,814.00739999999996,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27769,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1307.5254,1307.5254,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27780,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",571.41059999999993,524.43720000000008,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27781,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",797.95320000000004,732.54719999999998,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27784,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1271.2547999999999,1271.2547999999999,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27786,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",578.54579999999999,529.78859999999997,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27788,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",777.73680000000002,701.62800000000004,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27792,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1161.2538000000002,1161.2538000000002,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27808,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",618.97860000000003,563.08620000000008,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",861.57540000000006,773.57460000000003,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27814,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1372.3367999999998,1372.3367999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27816,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",609.46500000000003,539.89679999999998,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27818,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",891.9,793.19640000000004,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1584.6089999999999,1584.6089999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27823,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1776.6648,1776.6648,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27824,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",582.70800000000008,557.73480000000006,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",985.25220000000002,885.95400000000006,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27826,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1546.5546000000002,1546.5546000000002,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27827,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2019.2616,2019.2616,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27828,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2388.5082000000002,2388.5082000000002,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27829,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1283.1468,1283.1468,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[27830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",717.08760000000007,659.41139999999996,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27831,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",745.03379999999993,745.03379999999993,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27832,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1360.4448,1360.4448,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",694.49279999999999,694.49279999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",897.846,897.846,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27846,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1297.4172000000001,1297.4172000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27848,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1415.1480000000001,1415.1480000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",297.3,297.3,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[27870,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1804.6110000000001,1804.6110000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27871,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1238.5518,1238.5518,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[27880,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1586.9874000000002,1586.9874000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27881,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1515.0408,1515.0408,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27882,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1045.9014,1045.9014,"090",0.1,0.69,0.21,0,2,1,0,1,0,"","R",null,null,2,29]
[27884,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1027.4688000000001,1027.4688000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[27886,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1154.7132000000001,1154.7132000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27888,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1155.3078,1155.3078,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[27889,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1124.3886,1124.3886,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[27892,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",958.49520000000007,958.49520000000007,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27893,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1105.9560000000001,1105.9560000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[27894,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1457.9592,1457.9592,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[27899,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,1,0,1,1,"","N",null,null,2,29]
[28001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",316.92180000000002,170.65020000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[28002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",455.46360000000004,249.73200000000003,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[28003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",692.11440000000005,461.40960000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[28005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1021.5228,1021.5228,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28008,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",778.33140000000003,525.03179999999998,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",419.19299999999998,370.43580000000003,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",564.27539999999999,498.86940000000004,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1003.6848,662.97900000000004,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-UR",2,29]
[28022,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",885.35940000000005,583.30259999999998,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-UR",2,29]
[28024,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",828.27779999999996,542.86980000000005,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-UR",2,29]
[28035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",952.54920000000004,635.03279999999995,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[28039,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",888.33240000000001,617.7894,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[28041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",801.52080000000001,801.52080000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28043,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",696.87120000000004,463.1934,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",865.14300000000003,614.81640000000004,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,1,1,0,"","X",null,null,2,29]
[28047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[28050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",754.54739999999993,495.30180000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[28052,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",708.16859999999997,454.86900000000003,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[28054,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",667.14120000000003,416.81459999999998,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",680.22239999999999,680.22239999999999,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",944.81940000000009,645.14099999999996,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28062,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1029.8471999999999,712.92539999999997,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[28070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",935.90039999999999,620.16779999999994,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28072,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",893.08920000000001,580.32960000000003,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",968.00880000000006,674.87099999999998,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[28086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",978.11699999999996,638.00580000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28088,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",831.25080000000003,515.51819999999998,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28090,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",844.33199999999999,548.22120000000007,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28092,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",761.68260000000009,481.62599999999998,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1119.0372,752.16899999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1101.1992,1101.1992,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[28103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",689.73599999999999,689.73599999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[28104,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",951.95460000000014,629.68140000000005,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[28106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",757.5204,757.5204,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[28107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",913.30560000000003,615.41099999999994,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,null,2,29]
[28108,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",789.03419999999994,513.73440000000005,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",837.19680000000005,519.08580000000006,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[28111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",872.87279999999998,572.59980000000007,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[28112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",879.41339999999991,558.32940000000008,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[28113,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1058.9826,759.30420000000004,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[28114,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1926.5039999999999,1494.8244,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1395.5262,1041.1446000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[28118,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1094.6586,752.16899999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28119,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",954.33300000000008,649.30320000000006,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[28120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1220.7138,888.33240000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[28122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1068.4962,780.11519999999996,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28124,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",863.35919999999999,594.00540000000001,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[28126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",708.16859999999997,441.7878,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1094.6586,1094.6586,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1039.3607999999999,764.06100000000004,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,null,2,29]
[28150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",757.5204,495.30180000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28153,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",741.46620000000007,472.70699999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",748.60140000000001,478.05839999999995,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28171,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,2,0,0,"","X",null,null,2,29]
[28173,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,1,1,0,"","X",null,null,2,29]
[28175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,1,1,0,"","X",null,null,2,29]
[28190,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",446.5446,236.05620000000002,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[28192,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",836.60220000000004,554.16719999999998,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28193,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",946.0086,652.27620000000002,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",903.19740000000002,585.68100000000004,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-UR",2,29]
[28202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1076.2260000000001,761.08800000000008,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[28208,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",878.81880000000001,571.41059999999993,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,"Y-UR",2,29]
[28210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1060.7664,746.22300000000007,"090",0.1,0.69,0.21,0,2,0,2,0,0,"","R",null,"Y-UR",2,29]
[28220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",817.57500000000005,542.86980000000005,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[28222,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",943.03559999999993,641.57339999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[28225,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",755.14199999999994,472.11240000000004,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[28226,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1133.3075999999999,718.87139999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[28230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",785.46660000000008,506.00459999999998,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[28232,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",689.14139999999998,429.89580000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-UR",2,29]
[28234,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",743.84460000000001,478.05839999999995,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,"Y-UR",2,29]
[28238,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1212.9839999999999,871.08900000000006,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",808.65599999999995,523.84260000000006,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1051.8474000000001,723.62819999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1283.1468,939.46800000000007,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2173.2629999999999,1676.1774,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28262,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2515.1579999999999,2005.5857999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28264,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1632.7716,1236.768,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,null,2,29]
[28270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",883.57560000000001,595.19460000000004,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",696.87120000000004,446.5446,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",927.57600000000002,620.16779999999994,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28285,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",973.36020000000008,684.97919999999999,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[28286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",802.11540000000002,528.59940000000006,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28288,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1097.6316000000002,776.54759999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28289,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1248.6600000000001,818.16959999999995,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28291,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1282.5522000000001,872.27819999999997,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28292,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1258.7682000000002,857.41319999999996,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2002.0182000000002,1102.9829999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28296,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1625.0418,911.52179999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28297,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1896.1794,1077.4152000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28298,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1518.0138000000002,894.87300000000005,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28299,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1839.0978,1047.6852000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1160.6592000000001,1160.6592000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1286.1197999999999,1286.1197999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28304,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1494.8244,1090.4964,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1210.0110000000002,1210.0110000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1099.4153999999999,719.46600000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1437.1482000000001,930.54899999999998,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28308,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1035.7932000000001,688.54679999999996,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28309,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1586.9874000000002,1586.9874000000002,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",988.81979999999999,643.95180000000005,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[28312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",943.03559999999993,586.87019999999995,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,null,2,29]
[28313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",957.90059999999994,641.57339999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",872.27819999999997,583.30259999999998,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,null,2,29]
[28320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1089.3072,1089.3072,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28322,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1420.4994000000002,1029.8471999999999,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[28340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,1,0,0,"","X",null,null,2,29]
[28341,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,1,0,0,"","X",null,null,2,29]
[28344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,1,1,0,"","X",null,null,2,29]
[28345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,0,0,0,0,"","X",null,null,2,29]
[28360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,0,0,"","X",null,null,2,29]
[28400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",453.08519999999999,419.19299999999998,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",708.16859999999997,635.62739999999997,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1024.4958000000001,1024.4958000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2020.4507999999998,2020.4507999999998,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2332.0212000000001,2332.0212000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",441.19319999999999,385.30080000000004,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",676.65480000000002,597.57300000000009,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28436,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",909.14339999999993,909.14339999999993,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1825.422,1825.422,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,2,1,0,"","X",null,null,2,29]
[28450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",387.08459999999997,349.03020000000004,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",530.38319999999999,470.32859999999999,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[28456,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",684.97919999999999,684.97919999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1145.7942,1145.7942,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",399.57119999999998,375.19259999999997,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28475,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",464.97720000000004,407.30099999999999,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28476,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",712.92539999999997,712.92539999999997,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[28485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1012.6038000000001,1012.6038000000001,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,null,2,29]
[28490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",258.65100000000001,226.54259999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28495,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",326.43540000000002,269.94839999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28496,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",830.65620000000001,443.57159999999999,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1195.7406000000001,891.9,"090",0.1,0.69,0.21,0,2,1,1,0,0,"","R",null,null,2,29]
[28510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",218.81280000000001,216.43440000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",297.89459999999997,258.65100000000001,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1034.604,726.60120000000006,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[28530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",206.92080000000001,178.38,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28531,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",603.51900000000001,322.86779999999999,"090",0.1,0.69,0.21,0,2,1,1,2,0,"","R",null,null,2,29]
[28540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",354.38159999999999,316.92180000000002,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",567.84300000000007,494.7072,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1086.3342,638.60040000000004,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1556.6628000000001,1176.7133999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",431.08499999999998,358.54380000000003,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",692.70900000000006,618.38400000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28576,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",694.49279999999999,694.49279999999999,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,null,2,29]
[28585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1597.0955999999999,1243.9032000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,null,2,29]
[28600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",395.40900000000005,335.3544,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[28605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",627.303,556.54559999999992,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[28606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",683.79,683.79,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1489.473,1489.473,"090",0.1,0.69,0.21,0,2,0,2,1,0,"","R",null,null,2,29]
[28630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",277.6782,196.8126,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[28635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",315.13799999999998,237.24540000000002,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[28636,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",572.59980000000007,356.76,"010",0.1,0.8,0.1,0,2,0,1,2,0,"","R",null,null,2,29]
[28645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1176.7133999999999,865.73760000000004,"090",0.1,0.69,0.21,0,2,0,1,1,0,"","R",null,null,2,29]
[28660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",222.97499999999999,165.89340000000001,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[28665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",271.73220000000003,225.35339999999999,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[28666,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",320.48939999999999,320.48939999999999,"010",0.1,0.8,0.1,0,2,0,1,2,0,"","R",null,null,2,29]
[28675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1048.8744000000002,737.30400000000009,"090",0.1,0.69,0.21,0,2,0,1,0,0,"","R",null,null,2,29]
[28705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2172.6684,2172.6684,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1681.5288,1681.5288,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1390.1748,1390.1748,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1309.3091999999999,1309.3091999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28735,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1395.5262,1395.5262,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28737,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1224.8760000000002,1224.8760000000002,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1498.9866000000002,1102.9829999999999,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1422.2832000000001,1035.1985999999999,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[28755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",922.81920000000002,598.16759999999999,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[28760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1378.2828,1011.4146000000001,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",942.44100000000003,942.44100000000003,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[28805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1258.1736000000001,1258.1736000000001,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[28810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",755.14199999999994,755.14199999999994,"090",0.1,0.69,0.21,0,2,0,0,0,0,"","R",null,null,2,29]
[28820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",545.2482,314.54340000000002,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[28825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",535.14,305.62439999999998,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[28890,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.69,0.21,0,2,1,1,1,0,"","X",null,null,2,29]
[28899,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,0,1,1,"","N",null,null,2,29]
[29000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",630.87059999999997,346.05720000000002,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",488.76120000000003,283.02960000000002,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",525.03179999999998,318.7056,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",459.62580000000003,253.2996,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",523.84260000000006,304.43520000000001,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",513.73440000000005,294.327,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",563.08620000000008,331.78680000000003,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29049,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",177.78540000000001,123.6768,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",398.97660000000002,242.5968,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29058,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",220.00200000000001,165.2988,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",173.02860000000001,121.2984,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",155.7852,110.001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",171.2448,119.51459999999999,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",137.3526,88.000799999999998,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",146.27160000000001,72.541200000000003,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",118.3254,70.757400000000004,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",139.13639999999998,87.406199999999998,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",73.730400000000003,51.730200000000004,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29131,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",94.54140000000001,60.6492,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",60.054600000000001,33.297600000000003,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[29240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",54.703200000000002,32.703000000000003,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",53.514000000000003,33.892199999999995,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",52.919400000000003,35.081400000000002,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",442.38240000000002,279.46199999999999,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",488.16660000000007,312.75959999999998,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[29345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",242.00220000000002,176.0016,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",253.2996,187.89360000000002,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",286.59720000000004,181.94759999999999,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",220.00200000000001,154.596,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",142.70400000000001,102.86580000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",134.9742,95.73060000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",200.97479999999999,140.92020000000002,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",75.514200000000002,49.351799999999997,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",229.51560000000001,175.40700000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,1,1,0,0,"","X",null,null,2,29]
[29505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",156.9744,90.973799999999997,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",127.24440000000001,86.811599999999999,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",64.216800000000006,32.703000000000003,"000",0,0,0,0,2,1,0,0,0,"","R",null,null,2,29]
[29530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",54.703200000000002,32.108400000000003,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49.946399999999997,30.9192,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",34.486799999999995,19.6218,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29580,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",117.1362,46.973400000000005,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29581,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",165.2988,48.162600000000005,"000",0,0,0,0,2,1,0,0,0,"","R",null,null,2,29]
[29584,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",153.4068,27.946199999999997,"000",0,0,0,0,2,1,0,0,0,"","R",null,null,2,29]
[29700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",110.5956,58.270800000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[29705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",112.97399999999999,78.487200000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[29710,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",217.029,145.08240000000001,"000",0,0,0,0,2,1,0,0,0,"","R",null,null,2,29]
[29720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",151.62299999999999,75.514200000000002,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[29730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",113.5686,77.892600000000002,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[29740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",176.0016,121.89299999999999,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[29750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,1,0,0,0,"","X",null,null,2,29]
[29799,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,0,1,1,"","N",null,null,2,29]
[29800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",954.33300000000008,954.33300000000008,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[29804,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1079.7936,1079.7936,"090",0.1,0.69,0.21,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[29805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",844.92660000000001,844.92660000000001,"090",0.1,0.69,0.21,0,2,1,1,1,0,"","R",null,"Y-UR",2,29]
[29806,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1893.2064,1893.2064,"090",0.1,0.69,0.21,0,3,1,1,1,0,29805,"R",null,"Y-UR",2,29]
[29807,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1847.4222,1847.4222,"090",0.1,0.69,0.21,0,3,1,1,1,0,29805,"R",null,"Y-UR",2,29]
[29819,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1056.0096000000001,1056.0096000000001,"090",0.1,0.69,0.21,0,3,1,1,1,0,29805,"R",null,"Y-UR",2,29]
[29821,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1070.28,1070.28,"090",0.1,0.69,0.21,0,3,1,2,1,0,29805,"R",null,"Y-UR",2,29]
[29836,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1053.6312,1053.6312,"090",0.1,0.69,0.21,0,3,1,2,1,0,29830,"R",null,"Y-UR",2,29]
[29855,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1400.2830000000001,1400.2830000000001,"090",0.1,0.69,0.21,0,2,1,2,2,0,"","R",null,null,2,29]
[29866,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1881.3144,1881.3144,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[29881,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.54939999999999,974.54939999999999,"090",0.1,0.69,0.21,0,3,1,0,0,0,29870,"R",null,"Y-UR",2,29]
[29884,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1110.7128,1110.7128,"090",0.1,0.69,0.21,0,3,1,2,1,0,29870,"R",null,"Y-UR",2,29]
[29892,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1137.4697999999999,1137.4697999999999,"090",0.1,0.69,0.21,0,2,1,2,0,0,"","R",null,"Y-UR",2,29]
[29902,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1033.4148,1033.4148,"090",0.1,0.69,0.21,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[30000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",504.22080000000005,217.029,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[30150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1473.4188000000001,1473.4188000000001,"090",0.1,0.76,0.14000000000000001,0,2,0,1,1,0,"","R",null,null,2,29]
[30435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2480.6711999999998,2480.6711999999998,"090",0.1,0.76,0.14000000000000001,0,2,0,2,0,0,"","R",null,null,2,29]
[30520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1243.9032000000002,1243.9032000000002,"090",0.1,0.76,0.14000000000000001,0,2,0,1,0,0,"","R",null,null,2,29]
[30905,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",660.00599999999997,185.51520000000002,"000",0,0,0,0,2,2,1,0,0,"","R",null,null,2,29]
[30920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1596.5010000000002,1596.5010000000002,"090",0.1,0.76,0.14000000000000001,0,2,0,1,0,0,"","R",null,null,2,29]
[31032,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1088.1180000000002,1088.1180000000002,"090",0.1,0.76,0.14000000000000001,0,2,1,1,0,0,"","R",null,null,2,29]
[31085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2280.8856000000001,2280.8856000000001,"090",0.1,0.76,0.14000000000000001,0,2,1,2,1,0,"","R",null,null,2,29]
[31231,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",350.81400000000002,112.37939999999999,"000",0,0,0,0,2,2,1,0,0,"","R",null,null,2,29]
[31257,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",785.46660000000008,785.46660000000008,"000",0,0,0,0,3,1,1,0,0,31231,"R",null,"Y-CM",2,29]
[31296,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3292.8948,315.73259999999999,"000",0,0,0,0,3,1,2,0,0,31231,"R",null,null,2,29]
[31365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","X",null,null,2,29]
[31502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",61.8384,61.8384,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[31520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,29]
[31527,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",342.4896,342.4896,"000",0,0,0,0,3,0,0,0,0,31525,"R",null,null,2,29]
[31545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",635.62739999999997,635.62739999999997,"000",0,0,0,0,3,1,1,0,0,31526,"R",null,null,2,29]
[31571,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",437.62560000000002,437.62560000000002,"000",0,0,0,0,3,0,1,0,0,31526,"R",null,null,2,29]
[31590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1703.529,1703.529,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","R",null,null,2,29]
[31614,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1297.4172000000001,1297.4172000000001,"090",0.1,0.76,0.14000000000000001,0,2,0,1,0,0,"","R",null,null,2,29]
[31626,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1525.1489999999999,344.27339999999998,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[31638,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",432.86880000000002,432.86880000000002,"000",0,0,0,0,3,0,1,0,0,31622,"R",null,null,2,29]
[31648,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",346.65180000000004,346.65180000000004,"000",0,0,0,0,3,0,1,0,0,31622,"R",null,null,2,29]
[31725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",139.13639999999998,139.13639999999998,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[31760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2402.1839999999997,2402.1839999999997,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","R",null,null,2,29]
[31786,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","X",null,null,2,29]
[32100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1416.3371999999999,1416.3371999999999,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","R",null,null,2,29]
[32160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1396.7153999999998,1396.7153999999998,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","R",null,null,2,29]
[32442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5290.1562000000004,5290.1562000000004,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[32506,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",270.54300000000001,270.54300000000001,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM",2,29]
[32554,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",445.35540000000003,156.9744,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[32607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",533.95080000000007,533.95080000000007,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[32651,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1911.6389999999999,1911.6389999999999,"090",0.1,0.76,0.14000000000000001,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[32659,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1282.5522000000001,1282.5522000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[32672,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2641.8078,2641.8078,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[32850,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,29]
[32940,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2149.4789999999998,2149.4789999999998,"090",0.1,0.76,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3476.6262000000002,3476.6262000000002,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1346.1744000000001,1346.1744000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,"","R",null,null,2,29]
[33215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",547.62660000000005,547.62660000000005,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[33220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",667.73580000000004,667.73580000000004,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[33227,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",601.73519999999996,601.73519999999996,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[33241,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",383.517,383.517,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[33256,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3349.3818000000001,3349.3818000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33267,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1824.8274000000001,1824.8274000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,null,2]
[33305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7070.3886000000002,7070.3886000000002,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3246.5160000000001,3246.5160000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33369,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,0,0,0,0,1,"","X",null,null,2,29]
[33411,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5809.8365999999996,5809.8365999999996,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[33414,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3719.8176000000003,3719.8176000000003,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33427,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4229.3897999999999,4229.3897999999999,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33471,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2307.6426000000001,2307.6426000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3564.0324000000001,3564.0324000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33518,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",708.76319999999998,708.76319999999998,"000",0,0,0,0,0,0,2,0,0,"","R",null,"Y-CM",2,29]
[33534,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3814.3590000000004,3814.3590000000004,"090",0.09,0.82,0.09,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[33536,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4571.2847999999994,4571.2847999999994,"090",0.09,0.82,0.09,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[33621,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1618.5011999999999,1618.5011999999999,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3003.3245999999999,3003.3245999999999,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33688,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3259.5972000000002,3259.5972000000002,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33724,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2668.5648000000001,2668.5648000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33762,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","X",null,null,2,29]
[33779,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","X",null,null,2,29]
[33800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,"","X",null,null,2,29]
[33803,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","X",null,null,2,29]
[33871,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5636.2134000000005,5636.2134000000005,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[33880,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3088.3523999999998,3088.3523999999998,"090",0.09,0.84,7.0000000000000007E-2,0,2,2,2,2,0,"","R",null,null,2,29]
[33910,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4560.5820000000003,4560.5820000000003,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33926,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","X",null,null,2,29]
[33948,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",415.03080000000006,415.03080000000006,"000",0,0,0,0,0,0,1,0,0,"","R",null,"Y-CM",2,29]
[33956,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1440.7157999999999,1440.7157999999999,"000",0,0,0,0,2,0,0,1,1,"","R",null,"Y-CM",2,29]
[33970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",612.4380000000001,612.4380000000001,"000",0,0,0,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33973,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",866.33220000000006,866.33220000000006,"000",0,0,0,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[33989,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",850.87260000000003,850.87260000000003,"000",0,0,0,0,2,0,0,1,1,"","R",null,"Y-CM",2,29]
[33992,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",327.03000000000003,327.03000000000003,"000",0,0,0,0,2,0,2,0,0,"","R",null,null,2,29]
[34201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1765.3674000000001,1765.3674000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[34502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2680.4567999999999,2680.4567999999999,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[34709,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",553.57260000000008,553.57260000000008,"000",0,0,0,0,0,0,2,2,0,"","R",null,"Y-UR",2,29]
[34718,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2129.8571999999999,2129.8571999999999,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[34834,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",221.19120000000001,221.19120000000001,"000",0,0,0,0,0,1,2,2,0,"","R",null,"Y-CM",2,29]
[34842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,2,2,0,"","N",null,null,2,29]
[35082,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3735.8717999999999,3735.8717999999999,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[35102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3230.4618,3230.4618,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[35152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2401.5893999999998,2401.5893999999998,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[35201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1638.123,1638.123,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,null,2,29]
[35256,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1760.6106,1760.6106,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,null,2,29]
[35303,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2128.0733999999998,2128.0733999999998,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[35355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1774.2864,1774.2864,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[35371,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1409.202,1409.202,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[35522,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2010.3426000000002,2010.3426000000002,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[35526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3006.2976000000003,3006.2976000000003,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[35570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2532.4014000000002,2532.4014000000002,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[35583,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2480.6711999999998,2480.6711999999998,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[35632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3101.4335999999998,3101.4335999999998,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[35647,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2671.5378000000001,2671.5378000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[35681,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",136.75799999999998,136.75799999999998,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM",2,29]
[35685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",338.92200000000003,338.92200000000003,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM",2,29]
[35875,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1030.4417999999998,1030.4417999999998,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,1,1,0,"","R",null,"Y-CM",2,29]
[35881,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1764.1782000000001,1764.1782000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[36015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1648.2311999999999,296.7054,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[36160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1071.4692,215.8398,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[36227,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",429.89580000000001,205.73160000000001,"000",0,0,0,0,0,1,1,0,0,"","R",null,null,2,29]
[36254,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3832.7915999999996,711.14160000000004,"000",0,0,0,0,2,2,1,0,0,"","R",null,null,2,29]
[36415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4.29,4.29,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,29,23]
[36455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,1,0,0,"","X",null,null,2,29]
[36468,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,29]
[36481,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3348.7872000000002,561.89699999999993,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[36561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1898.5578,587.46480000000008,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[36566,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8374.9409999999989,630.87059999999997,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[36581,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1512.6624000000002,322.27319999999997,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[36591,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49.351799999999997,49.351799999999997,"000",0,0,0,3,0,0,0,0,0,"","R",null,null,2,29]
[36680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,29]
[36821,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1150.5510000000002,1150.5510000000002,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[36832,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1313.4713999999999,1313.4713999999999,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,null,2,29]
[36904,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3478.41,636.81660000000011,"000",0,0,0,0,2,0,1,1,0,"","R",null,"Y-CM",2,29]
[37187,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3320.2464000000004,680.22239999999999,"000",0,0,0,0,2,1,1,2,0,"","R",null,null,2,29]
[37192,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2441.4276,590.43780000000004,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[37217,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1866.4494,1866.4494,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,0,0,0,"","R",null,null,2,29]
[37225,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17296.3194,1033.4148,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[37237,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2502.6714000000002,362.70599999999996,"000",0,0,0,0,0,1,0,0,0,"","R",null,null,2,29]
[37246,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3539.0592000000001,599.95140000000004,"000",0,0,0,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[37253,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",311.57040000000001,121.2984,"000",0,0,0,0,0,0,0,1,0,"","R",null,null,2,29]
[37615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",953.14380000000006,953.14380000000006,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,null,2,29]
[37785,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",645.73559999999998,451.89599999999996,"090",0.09,0.84,7.0000000000000007E-2,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[37799,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,0,1,1,"","N",null,null,2,29]
[38207,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,29]
[38214,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,29]
[38305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",887.14319999999998,887.14319999999998,"090",0.11,0.73,0.16,0,2,0,1,0,0,"","R",null,null,2,29]
[38510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",959.08979999999997,744.43920000000003,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[38542,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",934.11660000000006,934.11660000000006,"090",0.11,0.73,0.16,0,2,1,2,1,0,"","R",null,null,2,29]
[38589,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,1,2,1,1,"","N",null,null,2,29]
[38999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,0,1,1,"","N",null,null,2,29]
[39220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1984.7748000000001,1984.7748000000001,"090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[39503,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,"","X",null,null,2,29]
[40527,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1123.1994,1123.1994,"090",0.09,0.81,0.1,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[40801,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",532.16699999999992,353.19240000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[40819,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",494.7072,357.3546,"090",0.09,0.81,0.1,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[40845,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2691.7542000000003,2159.5871999999999,"090",0.09,0.81,0.1,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[41009,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",775.35839999999996,506.5992,"090",0.09,0.81,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[41113,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,1,0,0,"","X",null,null,2,29]
[41120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[41150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[41805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",588.0594000000001,365.67900000000003,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[41870,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",633.55037803200003,633.55037803200003,"000",0,0,0,0,2,0,0,0,0,"","F",null,"Y-CM",2,29]
[42140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",582.70800000000008,290.75939999999997,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[42215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,0,0,"","X",null,null,2,29]
[42280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",327.62459999999999,195.6234,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[42408,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1009.0361999999999,626.11379999999997,"090",0.09,0.81,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[42420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,1,2,1,0,"","X",null,null,2,29]
[42500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",825.30480000000011,624.33000000000004,"090",0.09,0.81,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[42720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",809.84519999999998,687.95220000000006,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,null,2,29]
[42826,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",459.03120000000001,459.03120000000001,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[42890,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[42961,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",753.95280000000002,753.95280000000002,"090",0.09,0.81,0.1,0,2,0,2,0,0,"","R",null,null,2,29]
[43020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1012.6038000000001,1012.6038000000001,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,null,2,29]
[43121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4967.2884000000004,4967.2884000000004,"090",0.09,0.81,0.1,0,2,0,2,2,0,"","R",null,"Y-CM",2,29]
[43130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[43193,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",299.0838,299.0838,"000",0,0,0,0,3,0,1,0,0,43191,"R",null,"Y-CM",2,29]
[43210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",757.5204,757.5204,"000",0,0,0,0,3,0,1,0,0,43235,"R",null,"Y-CM",2,29]
[43217,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,3,0,1,0,0,43200,"X",null,null,2,29]
[43242,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",463.1934,463.1934,"000",0,0,0,0,3,0,1,0,0,43235,"R",null,null,2,29]
[43250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",864.54840000000002,299.0838,"000",0,0,0,0,3,0,1,0,0,43235,"R",null,null,2,29]
[43259,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",397.19279999999998,397.19279999999998,"000",0,0,0,0,3,0,1,0,0,43235,"R",null,null,2,29]
[43265,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",763.46640000000002,763.46640000000002,"000",0,0,0,0,3,0,1,0,0,43260,"R",null,"Y-CM",2,29]
[43278,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,3,0,1,0,0,43260,"X",null,null,2,29]
[43285,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1196.3352,1196.3352,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[43325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2410.5084000000002,2410.5084000000002,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[43340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2447.3735999999999,2447.3735999999999,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[43400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2698.2948000000001,2698.2948000000001,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[43500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1398.4992,1398.4992,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,null,2,29]
[43611,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[43633,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3393.9767999999999,3393.9767999999999,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[43648,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,2,1,0,"","X",null,null,2,29]
[43754,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",434.65260000000001,64.216800000000006,"000",0,0,0,0,0,0,2,0,0,"","R",null,null,2,29]
[43775,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[43846,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[43880,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","090",0.09,0.81,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[44025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1740.9888000000001,1740.9888000000001,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,null,2,29]
[44121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",420.97680000000003,420.97680000000003,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-CM",2,29]
[44132,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,0,0,0,0,0,"","N",null,null,2,29]
[44147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3404.085,3404.085,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[44155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3660.3576000000003,3660.3576000000003,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[44205,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2356.9944,2356.9944,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[44312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1064.9286,1064.9286,"090",0.09,0.81,0.1,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[44345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1861.6925999999999,1861.6925999999999,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[44376,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",500.05860000000001,500.05860000000001,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[44384,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,3,0,1,0,0,44380,"X",null,null,2,29]
[44391,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1224.8760000000002,406.11180000000002,"000",0,0,0,0,3,0,1,0,0,44388,"R",null,"Y-CM",2,29]
[44602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2482.4549999999999,2482.4549999999999,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,null,2,29]
[44605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2298.1289999999999,2298.1289999999999,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,null,2,29]
[44720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",479.84220000000005,479.84220000000005,"000",0,0,0,0,2,0,2,1,0,"","R",null,null,2,29]
[44820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[45100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",542.27519999999993,542.27519999999993,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[45116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2720.8896,2720.8896,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[45136,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3155.5421999999999,3155.5421999999999,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[45321,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",181.94759999999999,181.94759999999999,"000",0,0,0,0,3,0,1,0,0,45300,"R",null,"Y-CM",2,29]
[45335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",561.30240000000003,116.5416,"000",0,0,0,0,3,0,1,0,0,45330,"R",null,"Y-CM",2,29]
[45340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",894.27839999999992,137.94719999999998,"000",0,0,0,0,3,0,1,0,0,45330,"R",null,"Y-CM",2,29]
[45385,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",849.68340000000001,448.32839999999999,"000",0,0,0,0,3,0,1,0,0,45378,"R",null,"Y-CM",2,29]
[45390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,3,0,1,0,0,45378,"X",null,null,2,29]
[45505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1085.145,1085.145,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[45563,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2956.3512000000001,2956.3512000000001,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[45915,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",654.65459999999996,413.84160000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[46230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",579.1404,308.00279999999998,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[46262,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1060.1717999999998,1060.1717999999998,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[46280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",869.30520000000001,869.30520000000001,"090",0.09,0.81,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[46612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",647.51940000000002,168.27180000000001,"000",0,0,0,0,3,0,1,0,0,46600,"R",null,"Y-CM",2,29]
[46705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[46746,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[46761,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1630.3932000000002,1630.3932000000002,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[46940,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",491.73419999999999,256.86720000000003,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[47130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5819.3502000000008,5819.3502000000008,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[47144,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","090",0.09,0.81,0.1,0,2,0,2,1,0,"","N",null,"Y-CM",2,29]
[47147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",667.14120000000003,667.14120000000003,"000",0,0,0,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[47400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3811.3859999999995,3811.3859999999995,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[47480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1564.3925999999999,1564.3925999999999,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[47541,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2220.8310000000001,579.1404,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[47552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",475.68,475.68,"000",0,0,0,0,2,0,1,1,0,"","R",null,null,2,29]
[47612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2263.0476000000003,2263.0476000000003,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,null,2,29]
[47765,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5358.5352000000003,5358.5352000000003,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[47999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,0,1,1,1,"","N",null,null,2,29]
[48120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1957.4232000000002,1957.4232000000002,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[48400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",187.89360000000002,187.89360000000002,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[48520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1957.4232000000002,1957.4232000000002,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[49002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1846.8275999999998,1846.8275999999998,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,null,2,29]
[49040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1788.5567999999998,1788.5567999999998,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,null,2,29]
[49255,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1407.4182000000001,1407.4182000000001,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,null,2,29]
[49405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1707.6912,339.51659999999998,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[49421,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",397.19279999999998,397.19279999999998,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[49428,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",766.43940000000009,766.43940000000009,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[49460,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1303.9577999999999,85.027799999999999,"000",0,0,0,0,2,0,0,0,0,"","R",null,null,2,29]
[49492,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.81,0.1,0,2,1,2,1,0,"","X",null,null,2,29]
[49553,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1130.3346000000001,1130.3346000000001,"090",0.09,0.81,0.1,0,2,1,2,1,0,"","R",null,null,2,29]
[49565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1367.58,1367.58,"090",0.09,0.81,0.1,0,2,1,2,1,0,"","R",null,null,2,29]
[49610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1240.3355999999999,1240.3355999999999,"090",0.09,0.81,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[49655,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1839.6924000000001,1839.6924000000001,"090",0.09,0.81,0.1,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[50045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1638.123,1638.123,"090",0.08,0.83,0.09,0,2,1,2,1,0,"","R",null,null,2,29]
[50100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.08,0.83,0.09,0,2,1,2,1,0,"","X",null,null,2,29]
[50236,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2568.672,2568.672,"090",0.08,0.83,0.09,0,2,1,2,1,0,"","R",null,null,2,29]
[50280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.08,0.83,0.09,0,2,1,2,1,0,"","X",null,null,2,29]
[50370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2158.9926,2158.9926,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[50386,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1438.932,281.84040000000005,"000",0,0,0,0,2,1,0,0,0,"","R",null,null,2,29]
[50435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1167.7944,174.21780000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[50540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.08,0.83,0.09,0,2,2,2,1,0,"","X",null,null,2,29]
[50549,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,1,2,1,1,"","N",null,null,2,29]
[50561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",842.54819999999995,684.97919999999999,"000",0,0,0,0,3,1,0,0,0,50551,"R",null,null,2,29]
[50630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1566.7710000000002,1566.7710000000002,"090",0.08,0.83,0.09,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[50684,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",238.43459999999999,88.595399999999998,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[50740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2175.6414000000004,2175.6414000000004,"090",0.08,0.83,0.09,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[50770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2019.8561999999999,2019.8561999999999,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[50845,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2203.5876000000003,2203.5876000000003,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[50947,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2424.7788,2424.7788,"090",0.08,0.83,0.09,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[50972,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",622.5462,622.5462,"000",0,0,0,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[51030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",838.98059999999998,838.98059999999998,"090",0.08,0.83,0.09,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[51555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2213.1012000000001,2213.1012000000001,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,null,2,29]
[51575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.08,0.83,0.09,0,2,2,2,1,0,"","X",null,null,2,29]
[51710,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",249.13740000000001,139.73099999999999,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2,29]
[51725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",426.9228,426.9228,"000",0,0,0,1,2,0,0,0,0,"","R",null,null,2,29]
[51729,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",726.00660000000005,726.00660000000005,"000",0,0,0,1,2,0,0,0,0,"","R",null,null,2,29]
[51741,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",14.865,14.865,"000",0,0,0,1,2,0,1,0,0,"","R",null,null,2,29]
[51792,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",417.4092,417.4092,"000",0,0,0,1,2,0,0,0,0,"","R",null,null,2,29]
[51798,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.6218,19.6218,"000",0,0,0,3,0,0,0,0,0,"","R",null,null,2,29]
[51992,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1477.5810000000001,1477.5810000000001,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[52001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",803.89919999999995,498.86940000000004,"000",0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,29]
[52276,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",459.03120000000001,459.03120000000001,"000",0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,29]
[52282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",583.30259999999998,583.30259999999998,"000",0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,29]
[52320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",428.11200000000002,428.11200000000002,"000",0,0,0,0,3,1,1,0,0,52000,"R",null,null,2,29]
[52342,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",536.32920000000001,536.32920000000001,"000",0,0,0,0,3,1,1,0,0,52000,"R",null,null,2,29]
[52355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,3,1,1,0,0,52351,"X",null,null,2,29]
[52630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",716.49300000000005,716.49300000000005,"090",0.08,0.83,0.09,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[53080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",745.03379999999993,745.03379999999993,"090",0.08,0.83,0.09,0,2,0,1,0,0,"","R",null,null,2,29]
[53240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",752.16899999999998,752.16899999999998,"090",0.08,0.83,0.09,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[53420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1478.7702000000002,1478.7702000000002,"090",0.08,0.83,0.09,0,2,0,1,1,0,"","R",null,"Y-CM",2,29]
[53431,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2021.0454000000002,2021.0454000000002,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[53453,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,0,0,0,0,0,"","N",null,null,2]
[53510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1116.0642,1116.0642,"090",0.08,0.83,0.09,0,2,0,2,1,0,"","R",null,null,2,29]
[53852,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.08,0.83,0.09,0,2,0,1,0,0,"","X",null,null,2,29]
[54050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",258.0564,187.89360000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[54120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1115.4696000000001,1115.4696000000001,"090",0.1,0.8,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[54163,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,1,0,0,"","X",null,null,2,29]
[54240,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",74.919600000000003,74.919600000000003,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,29]
[54250,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",26.162400000000002,26.162400000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,29]
[54322,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.8,0.1,0,2,0,2,0,0,"","X",null,null,2,29]
[54380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.8,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[54417,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1581.6360000000002,1581.6360000000002,"090",0.1,0.8,0.1,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[54450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,1,0,0,"","X",null,null,2,29]
[54640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",761.68260000000009,761.68260000000009,"090",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[54700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",376.97640000000001,376.97640000000001,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[55040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",601.14059999999995,601.14059999999995,"090",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[55100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",420.38220000000001,297.89459999999997,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,null,2,29]
[55250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.8,0.1,0,2,2,1,0,0,"","X",null,null,2,29]
[55605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.98140000000001,926.98140000000001,"090",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[55821,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.8,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[55865,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.8,0.1,0,2,2,2,1,0,"","X",null,null,2,29]
[56405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",273.51599999999996,231.29940000000002,"010",0.1,0.8,0.1,0,2,0,1,2,0,"","R",null,"Y-CM",2,29]
[56606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",68.97359999999999,51.135599999999997,"000",0,0,0,0,0,0,1,2,0,"","R",null,"Y-CM",2,29]
[56700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,2,1,0,"","X",null,null,2,29]
[56805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","X",null,null,2,29]
[57022,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",327.03000000000003,327.03000000000003,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[57120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",954.92759999999998,954.92759999999998,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[57230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",756.33120000000008,756.33120000000008,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[57270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1454.9862000000001,1454.9862000000001,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[57292,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","X",null,null,2,29]
[57311,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",993.5766000000001,993.5766000000001,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[57452,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",230.70480000000001,160.542,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[57456,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",276.48900000000003,178.38,"000",0,0,0,0,3,0,1,0,0,57452,"R",null,"Y-CM",2,29]
[57513,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,1,0,0,"","X",null,null,2,29]
[57558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",290.75939999999997,233.67780000000002,"010",0.1,0.8,0.1,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[58180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1708.8804,1708.8804,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[58267,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1912.2335999999998,1912.2335999999998,"090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[58301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,29]
[58353,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,1,2,0,"","X",null,null,2,29]
[58548,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.12,0.74,0.14000000000000001,0,2,2,2,2,0,"","X",null,null,2,29]
[58553,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1991.91,1991.91,"090",0.12,0.74,0.14000000000000001,0,2,0,2,2,0,"","R",null,"Y-CM",2,29]
[58563,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,3,0,0,2,0,58555,"X",null,null,2,29]
[58605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.12,0.74,0.14000000000000001,0,2,2,2,0,0,"","X",null,null,2,29]
[58700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.12,0.74,0.14000000000000001,0,2,2,2,1,0,"","X",null,null,2,29]
[58800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.12,0.74,0.14000000000000001,0,2,2,1,0,0,"","X",null,null,2,29]
[58950,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.12,0.74,0.14000000000000001,0,2,2,2,1,0,"","X",null,null,2,29]
[58960,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.12,0.74,0.14000000000000001,0,2,0,2,1,0,"","X",null,null,2,29]
[59025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",86.216999999999999,86.216999999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,29]
[59030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,29]
[59120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1444.8780000000002,1444.8780000000002,"090",0.17,0.6,0.23,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[59320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",264.59700000000004,264.59700000000004,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[59414,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",156.9744,156.9744,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[59620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1632.1769999999999,1632.1769999999999,"000",0,0,0,0,2,0,2,0,0,"","R",null,"Y-CM",2,29]
[59852,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1053.0366000000001,1053.0366000000001,"090",0.17,0.6,0.23,0,2,0,0,0,0,"","R",null,"Y-CM",2,29]
[59898,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,0,2,1,2,1,1,"","N",null,null,2,29]
[60260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.82,0.09,0,2,1,2,1,0,"","X",null,null,2,29]
[60270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.09,0.82,0.09,0,2,0,2,1,0,"","X",null,null,2,29]
[60512,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,0,0,2,1,0,"","X",null,null,2,29]
[61001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,0,2,2,1,0,0,"","X",null,null,2,29]
[61107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",540.4914,540.4914,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[61304,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2884.4045999999998,2884.4045999999998,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,null,2,29]
[61330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3151.9746,3151.9746,"090",0.11,0.76,0.13,0,2,1,2,1,0,"","R",null,null,2,29]
[61460,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3694.8444,3694.8444,"090",0.11,0.76,0.13,0,2,0,2,2,0,"","R",null,null,2,29]
[61522,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3836.3591999999999,3836.3591999999999,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[61524,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3656.1954000000001,3656.1954000000001,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[61537,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4294.7957999999999,4294.7957999999999,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[61556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.11,0.76,0.13,0,2,0,2,1,0,"","X",null,null,2,29]
[61567,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4470.7974000000004,4470.7974000000004,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[61590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5434.6440000000002,5434.6440000000002,"090",0.11,0.76,0.13,0,2,1,2,1,2,"","R",null,"Y-CM",2,29]
[61607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4738.3674000000001,4738.3674000000001,"090",0.11,0.76,0.13,0,2,0,2,1,2,"","R",null,"Y-CM",2,29]
[61619,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2511.5904,2511.5904,"090",0.11,0.76,0.13,0,2,0,2,1,2,"","R",null,null,2,29]
[61680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3964.7928000000006,3964.7928000000006,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[61682,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7238.0658000000003,7238.0658000000003,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[61702,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7004.9826000000003,7004.9826000000003,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[61760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2791.0524,2791.0524,"090",0.11,0.76,0.13,0,2,0,1,2,0,"","R",null,"Y-CM",2,29]
[61796,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1794.5028,1794.5028,"090",0.11,0.76,0.13,0,0,0,2,0,0,"","R",null,"Y-CM",2,29]
[61885,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",939.46800000000007,939.46800000000007,"090",0.11,0.76,0.13,0,2,1,0,0,0,"","R",null,"Y-UR",2,29]
[62140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1802.2326,1802.2326,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,null,2,29]
[62148,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",218.2182,218.2182,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[62220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1721.9616000000001,1721.9616000000001,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[62223,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1843.26,1843.26,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[62263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,1,0,0,"","X",null,null,2,29]
[62287,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1028.0634,1028.0634,"090",0.11,0.76,0.13,0,2,0,1,0,0,"","R",null,"Y-UR",2,29]
[62320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",300.27299999999997,176.0016,"000",0,0,0,0,2,9,1,0,0,"","R",null,"Y-UR",2,29]
[62329,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",567.84300000000007,194.4342,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[62365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",527.41019999999992,527.41019999999992,"010",0.1,0.8,0.1,0,2,0,0,0,0,"","R",null,"Y-UR",2,29]
[63016,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2686.4027999999998,2686.4027999999998,"090",0.11,0.76,0.13,0,2,0,2,2,0,"","R",null,"Y-UR",2,29]
[63047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1958.6124,1958.6124,"090",0.11,0.76,0.13,0,2,2,2,2,0,"","R",null,"Y-UR",2,29]
[63056,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2632.2942000000003,2632.2942000000003,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[63066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",354.97620000000001,354.97620000000001,"000",0,0,0,0,0,0,2,1,0,"","R",null,"Y-UR",2,29]
[63091,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",309.78660000000002,309.78660000000002,"000",0,0,0,0,0,0,2,2,2,"","R",null,"Y-UR",2,29]
[63191,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2436.0762,2436.0762,"090",0.11,0.76,0.13,0,2,1,2,1,0,"","R",null,"Y-UR",2,29]
[63268,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2506.8335999999999,2506.8335999999999,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[63277,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2751.8088000000002,2751.8088000000002,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[63301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3870.8459999999995,3870.8459999999995,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-UR",2,29]
[63621,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",435.84180000000003,435.84180000000003,"000",0,0,0,0,0,0,2,0,0,"","R",null,"Y-CM",2,29]
[63685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","010",0.1,0.8,0.1,0,2,0,2,1,0,"","X",null,"Y-UR",2,29]
[63702,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2532.9960000000001,2532.9960000000001,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[64418,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",159.94739999999999,98.703599999999994,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[64435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",148.65,76.108800000000002,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[64455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",89.19,58.865400000000001,"000",0,0,0,0,2,1,0,0,0,"","R",null,null,2,29]
[64484,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",207.51540000000003,90.973799999999997,"000",0,0,0,0,0,1,1,0,0,"","R",null,"Y-UR",2,29]
[64510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",271.73220000000003,136.75799999999998,"000",0,0,0,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[64575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.11,0.76,0.13,0,2,0,1,0,0,"","X",null,null,2,29]
[64590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",485.1936,286.00259999999997,"010",0.1,0.8,0.1,0,2,0,1,1,0,"","R",null,"Y-UR",2,29]
[64605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1179.6864,617.7894,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[64635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",827.68320000000006,339.51659999999998,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[64644,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",323.4624,206.92080000000001,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[64704,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",581.51879999999994,581.51879999999994,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[64719,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",734.92560000000003,734.92560000000003,"090",0.11,0.76,0.13,0,2,1,1,0,0,"","R",null,"Y-UR",2,29]
[64755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1638.7175999999999,1638.7175999999999,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,"Y-CM",2,29]
[64783,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",378.7602,378.7602,"000",0,0,0,0,0,0,1,0,0,"","R",null,null,2,29]
[64795,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",335.3544,335.3544,"000",0,0,0,0,2,0,1,0,0,"","R",null,"Y-CM",2,29]
[64809,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1923.5310000000002,1923.5310000000002,"090",0.11,0.76,0.13,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[64837,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",638.00580000000002,638.00580000000002,"000",0,0,0,0,0,0,2,0,0,"","R",null,null,2,29]
[64862,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2436.0762,2436.0762,"090",0.11,0.76,0.13,0,2,1,2,0,0,"","R",null,null,2,29]
[64892,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1867.6386,1867.6386,"090",0.11,0.76,0.13,0,2,0,2,1,0,"","R",null,null,2,29]
[64902,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1205.8488,1205.8488,"000",0,0,0,0,0,0,2,1,0,"","R",null,null,2,29]
[65110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2385.5351999999998,2385.5351999999998,"090",0.1,0.7,0.2,0,2,1,2,1,0,"","R",null,null,2,29]
[65135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1579.2575999999999,1579.2575999999999,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,null,2,29]
[65270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",526.81560000000002,248.5428,"010",0.1,0.8,0.1,0,2,1,0,0,0,"","R",null,null,2,29]
[65275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1061.9556,817.57500000000005,"090",0.1,0.7,0.2,0,2,1,0,0,0,"","R",null,null,2,29]
[65436,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",688.54679999999996,652.87080000000003,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,null,2,29]
[65756,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2076.3432000000003,2076.3432000000003,"090",0.1,0.7,0.2,0,2,1,2,1,0,"","R",null,null,2,29]
[65781,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2342.7240000000002,2342.7240000000002,"090",0.1,0.7,0.2,0,2,1,2,1,0,"","R",null,null,2,29]
[65850,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1496.0136,1496.0136,"090",0.1,0.7,0.2,0,2,1,1,1,0,"","R",null,null,2,29]
[66150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1558.4466,1558.4466,"090",0.1,0.7,0.2,0,2,1,1,1,0,"","R",null,null,2,29]
[66174,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1353.3096,1353.3096,"090",0.1,0.7,0.2,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[66605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1942.5582000000002,1942.5582000000002,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,null,2,29]
[66635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1012.6038000000001,1012.6038000000001,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,null,2,29]
[66820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",861.57540000000006,861.57540000000006,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,null,2,29]
[66920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1322.3904,1322.3904,"090",0.1,0.7,0.2,0,2,1,0,1,0,"","R",null,null,2,29]
[66991,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","090",0.1,0.7,0.2,0,2,1,1,0,0,"","X",null,null,2]
[67028,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",202.16399999999999,161.13659999999999,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[67110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1592.9333999999999,1438.932,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,null,2,29]
[67141,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",485.78820000000002,384.11160000000001,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[67255,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1221.903,1221.903,"090",0.1,0.7,0.2,0,2,1,2,1,0,"","R",null,null,2,29]
[67314,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",983.46839999999997,983.46839999999997,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[67405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1647.6366,1647.6366,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,null,2,29]
[67414,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2646.5645999999997,2646.5645999999997,"090",0.1,0.7,0.2,0,2,1,2,1,0,"","R",null,null,2,29]
[67715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",494.11260000000004,191.46120000000002,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[67820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",33.892199999999995,39.243600000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[67882,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1031.6310000000001,831.84540000000004,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,null,2,29]
[67908,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",984.0630000000001,766.43940000000009,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,null,2,29]
[67930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",674.27639999999997,415.03080000000006,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[67961,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1064.9286,802.11540000000002,"090",0.1,0.7,0.2,0,2,1,0,0,0,"","R",null,null,2,29]
[68200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",74.919600000000003,60.054600000000001,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[68326,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1136.8752000000002,1136.8752000000002,"090",0.1,0.7,0.2,0,2,1,1,0,0,"","R",null,null,2,29]
[68525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",453.08519999999999,453.08519999999999,"000",0,0,0,0,2,1,1,1,0,"","R",null,"Y-CM",2,29]
[68720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1453.2024000000001,1453.2024000000001,"090",0.1,0.7,0.2,0,2,1,2,1,0,"","R",null,null,2,29]
[68811,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",237.24540000000002,237.24540000000002,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[69000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",344.86799999999999,223.56959999999998,"010",0.1,0.8,0.1,0,2,1,1,0,0,"","R",null,null,2,29]
[69200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",146.27160000000001,83.8386,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[69220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",140.32560000000001,89.784599999999998,"000",0,0,0,0,2,1,1,0,0,"","R",null,null,2,29]
[69502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1714.2318,1714.2318,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,"","R",null,"Y-CM",2,29]
[69530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3068.136,3068.136,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[69636,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2593.6451999999999,2593.6451999999999,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,"","R",null,null,2,29]
[69645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2723.8626000000004,2723.8626000000004,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[69670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1728.5022000000001,1728.5022000000001,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[69714,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1167.7944,1167.7944,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,"","R",null,"Y-CM",2,29]
[69805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1858.125,1858.125,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,0,0,"","R",null,"Y-CM",2,29]
[69915,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2705.43,2705.43,"090",7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,1,0,"","R",null,"Y-CM",2,29]
[70030,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",44.594999999999999,44.594999999999999,"000",0,0,0,1,0,3,0,0,0,"","R",null,null,2,26]
[70100,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",55.892399999999995,55.892399999999995,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[70140,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",17.838000000000001,17.838000000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[70160,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",14.865,14.865,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[70200,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",66.000600000000006,66.000600000000006,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[70220,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",18.432600000000001,18.432600000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[70250,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",15.4596,15.4596,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[70320,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",19.6218,19.6218,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[70336,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",125.4606,125.4606,"000",0,0,0,1,4,3,0,0,0,"","R",null,null,2,26]
[70350,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",14.2704,14.2704,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[70371,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",71.946600000000004,71.946600000000004,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[70390,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",32.703000000000003,32.703000000000003,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[70470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",335.3544,335.3544,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-UR",2,26]
[70486,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",246.16439999999997,246.16439999999997,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[70488,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",357.94919999999996,357.94919999999996,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[70496,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",532.76160000000004,532.76160000000004,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[70543,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",664.76279999999997,664.76279999999997,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[70544,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",419.7876,419.7876,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[70548,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",479.24760000000003,479.24760000000003,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[70551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",379.94939999999997,379.94939999999997,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-UR",2,26]
[70553,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",426.32819999999998,426.32819999999998,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-UR",2,26]
[70558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[71045,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",32.108400000000003,32.108400000000003,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[71100,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",48.757199999999997,48.757199999999997,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[71120,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",45.784199999999998,45.784199999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[71130,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",58.270800000000001,58.270800000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[71271,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,4,0,0,0,0,"","X",null,null,2,26]
[71550,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",548.22120000000007,548.22120000000007,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[71552,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",191.46120000000002,191.46120000000002,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[72050,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",23.784000000000002,23.784000000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[72070,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",17.243399999999998,17.243399999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[72081,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",22.594799999999999,22.594799999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[72100,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",19.6218,19.6218,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[72114,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",89.19,89.19,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[72127,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",108.21720000000001,108.21720000000001,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[72128,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",85.027799999999999,85.027799999999999,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[72131,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",248.5428,248.5428,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[72146,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",244.38060000000002,244.38060000000002,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-UR",2,26]
[72148,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",126.6498,126.6498,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-UR",2,26]
[72157,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",625.51919999999996,625.51919999999996,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-UR",2,26]
[72190,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",78.487200000000001,78.487200000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[72191,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",152.2176,152.2176,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[72196,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",528.00480000000005,528.00480000000005,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[72197,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",663.57360000000006,663.57360000000006,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[72200,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",46.378800000000005,46.378800000000005,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[72265,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",70.757400000000004,70.757400000000004,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[72270,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",190.86660000000001,190.86660000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[73010,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",27.946199999999997,27.946199999999997,"000",0,0,0,1,0,3,0,0,0,"","R",null,null,2,26]
[73050,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",36.270600000000002,36.270600000000002,"000",0,0,0,1,0,2,0,0,0,"","R",null,null,2,26]
[73070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",54.108600000000003,54.108600000000003,"000",0,0,0,1,0,3,0,0,0,"","R",null,null,2,26]
[73092,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,3,0,0,0,"","X",null,null,2,26]
[73100,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",48.162600000000005,48.162600000000005,"000",0,0,0,1,0,3,0,0,0,"","R",null,null,2,26]
[73115,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",48.757199999999997,48.757199999999997,"000",0,0,0,1,0,3,0,0,0,"","R",null,null,2,26]
[73202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",491.73419999999999,491.73419999999999,"000",0,0,0,1,4,3,0,0,0,"","R",null,null,2,26]
[73202,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",103.46040000000001,103.46040000000001,"000",0,0,0,1,4,3,0,0,0,"","R",null,null,2,26]
[73220,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",183.13679999999999,183.13679999999999,"000",0,0,0,1,4,3,0,0,0,"","R",null,"Y-UR",2,26]
[73225,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",148.05540000000002,148.05540000000002,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[73502,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",67.784399999999991,67.784399999999991,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[73523,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",26.757000000000001,26.757000000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[73525,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",50.540999999999997,50.540999999999997,"000",0,0,0,1,0,3,0,0,0,"","R",null,null,2,26]
[73564,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",85.622399999999999,85.622399999999999,"000",0,0,0,1,0,3,0,0,0,"","R",null,null,2,26]
[73565,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",14.865,14.865,"000",0,0,0,1,0,2,0,0,0,"","R",null,null,2,26]
[73592,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,3,0,0,0,"","X",null,null,2,26]
[73620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",52.324800000000003,52.324800000000003,"000",0,0,0,1,0,3,0,0,0,"","R",null,null,2,26]
[73650,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",39.243600000000001,39.243600000000001,"000",0,0,0,1,0,3,0,0,0,"","R",null,null,2,26]
[73702,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",377.57099999999997,377.57099999999997,"000",0,0,0,1,4,3,0,0,0,"","R",null,null,2,26]
[73720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",663.57360000000006,663.57360000000006,"000",0,0,0,1,4,3,0,0,0,"","R",null,"Y-UR",2,26]
[73722,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",482.81519999999995,482.81519999999995,"000",0,0,0,1,4,3,0,0,0,"","R",null,"Y-UR",2,26]
[74018,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",39.838200000000001,39.838200000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",80.271000000000001,80.271000000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74150,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",161.13659999999999,161.13659999999999,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[74175,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",442.38240000000002,442.38240000000002,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[74177,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",155.19059999999999,155.19059999999999,"000",0,0,0,1,4,0,9,0,0,"","R",null,null,2,26]
[74183,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",478.65300000000008,478.65300000000008,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[74220,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",135.56879999999998,135.56879999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74230,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",45.784199999999998,45.784199999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74246,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",76.108800000000002,76.108800000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74250,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",164.70420000000001,164.70420000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74261,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",203.35319999999999,203.35319999999999,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-CM",2,26]
[74280,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",107.62260000000001,107.62260000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,1,0,0,0,0,0,"","N",null,null,2,26]
[74329,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",41.0274,41.0274,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74360,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",48.162600000000005,48.162600000000005,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",266.97540000000004,266.97540000000004,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",259.84019999999998,259.84019999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74430,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",26.757000000000001,26.757000000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,1,0,0,0,0,0,"","N",null,null,2,26]
[74485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",222.38040000000001,222.38040000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[74713,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[75557,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",547.03199999999993,547.03199999999993,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-CM",2,26]
[75565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",90.973799999999997,90.973799999999997,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[75572,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",436.43639999999999,436.43639999999999,"000",0,0,0,1,4,0,0,0,0,"","R",null,"Y-CM",2,26]
[75573,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,4,0,0,0,0,"","X",null,null,2,26]
[75630,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",166.488,166.488,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[75705,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",201.5694,201.5694,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[75726,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",145.67700000000002,145.67700000000002,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[75736,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",92.163000000000011,92.163000000000011,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[75756,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",96.325200000000009,96.325200000000009,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[75805,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",68.97359999999999,68.97359999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[75809,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",41.0274,41.0274,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[75810,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",84.433199999999999,84.433199999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[75833,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",270.54300000000001,270.54300000000001,"000",0,0,0,1,6,2,0,0,0,"","R",null,null,2,26]
[75840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",237.24540000000002,237.24540000000002,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[75870,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",296.7054,296.7054,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[75885,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",248.5428,248.5428,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[75893,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",191.46120000000002,191.46120000000002,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[75902,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",174.8124,174.8124,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[75957,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,1,0,0,0,0,0,"","N",null,null,2,26]
[75958,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT"," By Report "," By Report ","000",0,0,0,1,0,0,0,0,0,"","N",null,null,2,26]
[76000,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",52.324800000000003,52.324800000000003,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[76010,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[76100,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",117.1362,117.1362,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[76145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1506.7164,1506.7164,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,26]
[76390,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",121.2984,121.2984,"000",0,0,0,1,9,9,9,9,9,"","R",null,"Y-CM",2,26]
[76497,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT"," By Report "," By Report ","000",0,0,0,1,0,0,0,0,0,"","N",null,null,2,26]
[76506,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",54.703200000000002,54.703200000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[76510,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",57.081600000000002,57.081600000000002,"000",0,0,0,1,7,3,0,0,0,"","R",null,null,2,26]
[76519,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",122.4876,122.4876,"000",0,0,0,1,7,2,0,0,0,"","R",null,null,2,26]
[76519,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",53.514000000000003,53.514000000000003,"000",0,0,0,1,7,3,0,0,0,"","R",null,null,2,26]
[76641,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",61.8384,61.8384,"000",0,0,0,1,0,1,0,0,0,"","R",null,"Y-CM",2,26]
[76705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",163.51500000000001,163.51500000000001,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[76776,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",279.46199999999999,279.46199999999999,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[76801,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",83.8386,83.8386,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[76811,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",319.30020000000002,319.30020000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[76812,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",357.3546,357.3546,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[76817,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",108.21720000000001,108.21720000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[76818,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",211.083,211.083,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[76825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",492.32879999999994,492.32879999999994,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[76827,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",81.460200000000015,81.460200000000015,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[76856,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",139.13639999999998,139.13639999999998,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[76872,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",381.73320000000001,381.73320000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[76882,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",62.433000000000007,62.433000000000007,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[76885,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[76940,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[76941,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT"," By Report "," By Report ","000",0,0,0,1,0,0,0,0,0,"","N",null,null,2,26]
[76965,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[76975,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",71.946600000000004,71.946600000000004,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[76981,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",51.135599999999997,51.135599999999997,"000",0,0,0,1,4,0,0,0,0,"","R",null,null,2,26]
[76998,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT"," By Report "," By Report ","000",0,0,0,1,0,0,0,0,0,"","N",null,null,2,26]
[77002,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",48.162600000000005,48.162600000000005,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[77003,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",51.135599999999997,51.135599999999997,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[77022,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,9,0,0,"","X",null,null,2,26]
[77022,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[77054,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,9,0,0,"","X",null,null,2,26]
[77061,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,9,0,0,"","X",null,null,2,26]
[77065,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",164.70420000000001,164.70420000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",101.67659999999999,101.67659999999999,"000",0,0,0,2,0,2,0,0,0,"","R",null,null,2,26]
[77075,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",47.568000000000005,47.568000000000005,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[77076,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[77085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",93.94680000000001,93.94680000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[77085,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",26.162400000000002,26.162400000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[77285,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",101.08199999999999,101.08199999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77290,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",146.27160000000001,146.27160000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",117.7308,117.7308,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77306,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",129.62280000000001,129.62280000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77318,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",269.35380000000004,269.35380000000004,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",69.56819999999999,69.56819999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77338,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",398.97660000000002,398.97660000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77371,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,3,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[77425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,26]
[77432,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",750.97980000000007,750.97980000000007,"000",0,0,0,2,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77522,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,3,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[77605,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",177.78540000000001,177.78540000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77750,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",236.05620000000002,236.05620000000002,"090",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77763,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1378.8774000000001,1378.8774000000001,"090",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[77771,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[77771,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[78012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",149.24459999999999,149.24459999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78013,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",344.27339999999998,344.27339999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78016,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",441.7878,441.7878,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",517.89660000000003,517.89660000000003,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78099,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[78104,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",442.38240000000002,442.38240000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",132.00120000000001,132.00120000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",144.48780000000002,144.48780000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78191,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",186.70440000000002,186.70440000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78195,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",526.221,526.221,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78201,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",302.05680000000001,302.05680000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78226,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",513.73440000000005,513.73440000000005,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78232,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",157.56899999999999,157.56899999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78262,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",376.3818,376.3818,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78266,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",690.92520000000002,690.92520000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[78268,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,26]
[78300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",404.32799999999997,404.32799999999997,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[78305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",486.97739999999999,486.97739999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[78315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",611.84339999999997,611.84339999999997,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[78414,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",38.054400000000001,38.054400000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78431,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",156.9744,156.9744,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-UR",2,26]
[78434,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",51.730200000000004,51.730200000000004,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-UR",2,26]
[78452,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",136.1634,136.1634,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-UR",2,26]
[78456,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",555.35640000000001,555.35640000000001,"000",0,0,0,1,6,9,9,9,9,"","R",null,"Y-CM",2,26]
[78466,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",344.86799999999999,344.86799999999999,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM",2,26]
[78468,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",348.43560000000002,348.43560000000002,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM",2,26]
[78472,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",403.73340000000002,403.73340000000002,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM",2,26]
[78491,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3221.5014518544003,3221.5014518544003,"000",0,0,0,1,0,0,0,0,0,"","F",null,"Y-UR",2,26]
[78499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[78582,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",587.46480000000008,587.46480000000008,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78599,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[78601,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",339.51659999999998,339.51659999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[78606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",580.92419999999993,580.92419999999993,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[78610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",310.38119999999998,310.38119999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[78635,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",545.2482,545.2482,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[78699,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[78708,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",321.084,321.084,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[78725,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",176.0016,176.0016,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[78799,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[78801,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",60.054600000000001,60.054600000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[78803,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",589.84320000000002,589.84320000000002,"000",0,0,0,1,2,0,0,0,0,"","R",null,"Y-CM",2,26]
[78812,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[78814,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[78831,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",1101.1992,1101.1992,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[79005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",244.9752,244.9752,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[79200,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",142.10940000000002,142.10940000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[79445,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[80050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",35.135100000000001,35.135100000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[80069,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",12.4124,12.4124,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[80156,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.835100000000001,20.835100000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[80164,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.362199999999998,19.362199999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[80179,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.655200000000001,26.655200000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[80192,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",23.952500000000001,23.952500000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[80200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",23.065899999999999,23.065899999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[80305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.017999999999997,18.017999999999997,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[80324,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[80329,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[80342,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[80345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[80358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[80363,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[80375,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[80417,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",62.905700000000003,62.905700000000003,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[80420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",231.48839999999998,231.48839999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[81000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5.7485999999999988,5.7485999999999988,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[81020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6.7210000000000001,6.7210000000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[81099,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,23]
[81163,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81168,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81181,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81193,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81219,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81226,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81229,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81242,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81247,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81259,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81266,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81273,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81292,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81299,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81371,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",578.46359999999993,578.46359999999993,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[81378,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",494.1651,494.1651,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[81400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81408,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81416,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81434,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81513,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81523,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
[81538,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[81599,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[82013,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.574699999999996,17.574699999999996,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",13.885300000000001,13.885300000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[82154,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[82247,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7.1785999999999994,7.1785999999999994,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82274,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",22.765599999999999,22.765599999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.5624,19.5624,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82379,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",24.124100000000002,24.124100000000002,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82383,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",41.584399999999995,41.584399999999995,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82482,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",14.0283,14.0283,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.1477,19.1477,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.220199999999998,20.220199999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82626,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",36.136099999999999,36.136099999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82668,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.869699999999998,26.869699999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82681,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",39.9542,39.9542,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
[82747,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.239499999999996,25.239499999999996,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[82941,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.210899999999999,25.210899999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82947,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5.6199000000000003,5.6199000000000003,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[82979,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[83010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.9894,17.9894,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[83021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.825799999999997,25.825799999999997,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[83045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.2806999999999995,9.2806999999999995,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[83505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[83519,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.311999999999998,26.311999999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[83615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8.6372,8.6372,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[83632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",28.914599999999997,28.914599999999997,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[83701,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[83735,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.5809999999999995,9.5809999999999995,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[83864,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[83883,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.448,19.448,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[83993,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",28.070899999999998,28.070899999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[84060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",10.925199999999998,10.925199999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[84120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",21.035299999999999,21.035299999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[84134,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.863699999999998,20.863699999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[84155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5.2481,5.2481,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[84166,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",32.108400000000003,32.108400000000003,"000",0,0,0,6,0,0,0,0,0,"","R",null,null,2,23]
[84206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",38.166699999999999,38.166699999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[84234,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[84315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4.6903999999999995,4.6903999999999995,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
[84377,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[84442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",21.135399999999997,21.135399999999997,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[84449,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.74,25.74,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[84490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",14.1999,14.1999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[84540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7.9507999999999992,7.9507999999999992,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[84597,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.619599999999998,19.619599999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[84704,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",21.864699999999999,21.864699999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[85027,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.2520999999999987,9.2520999999999987,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[85049,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6.4064000000000005,6.4064000000000005,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[85244,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",29.200600000000001,29.200600000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[85247,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",32.804200000000002,32.804200000000002,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[85303,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.7912,19.7912,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[85337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",24.696099999999998,24.696099999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[85390,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",65.406000000000006,65.406000000000006,"000",0,0,0,6,0,0,0,0,0,"","R",null,null,2,23]
[85420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.3378999999999994,9.3378999999999994,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[85547,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",12.297999999999998,12.297999999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[85598,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.711400000000001,25.711400000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
[85705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",13.770900000000001,13.770900000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[85810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",16.688099999999999,16.688099999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
[86037,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
[86053,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
[86155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",22.8657,22.8657,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.5185,18.5185,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",11.711699999999999,11.711699999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86309,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.2520999999999987,9.2520999999999987,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",64.750399999999999,64.750399999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered ","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[86340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",21.564399999999999,21.564399999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",67.181399999999996,67.181399999999996,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86408,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,23]
[86485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,3,0,0,0,0,0,"","N",null,null,2,23]
[86602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",14.557399999999999,14.557399999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.446999999999999,18.446999999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86651,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.861699999999999,18.861699999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86654,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.861699999999999,18.861699999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86671,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.517499999999998,17.517499999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86696,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",27.670500000000001,27.670500000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86711,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[86735,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.6615,18.6615,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86759,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.068899999999999,26.068899999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86771,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",35.006399999999999,35.006399999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86806,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",68.053700000000006,68.053700000000006,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86812,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",36.908299999999997,36.908299999999997,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86828,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",91.791699999999992,91.791699999999992,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[86870,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,23]
[86910,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[86930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,23]
[86970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,23]
[87003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[87084,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",38.710099999999997,38.710099999999997,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",11.0253,11.0253,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",15.444000000000001,15.444000000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87164,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",33.892199999999995,33.892199999999995,"000",0,0,0,6,0,0,0,0,0,"","R",null,null,2,23]
[87187,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",57.443100000000001,57.443100000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87207,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8.5656999999999996,8.5656999999999996,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87255,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",48.419799999999995,48.419799999999995,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87274,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.131399999999999,17.131399999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.131399999999999,17.131399999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.1038,18.1038,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87336,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",22.88,22.88,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.2059,20.2059,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87449,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.131399999999999,17.131399999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87486,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",50.178699999999999,50.178699999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[87512,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",59.716799999999992,59.716799999999992,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87531,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",82.94,82.94,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87539,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",83.826599999999999,83.826599999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",28.671499999999998,28.671499999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87563,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[87623,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[87641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",50.178699999999999,50.178699999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87801,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",100.386,100.386,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87809,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",31.116800000000001,31.116800000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[87906,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",184.08389999999997,184.08389999999997,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[88014,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[88016,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[88104,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",74.325000000000003,74.325000000000003,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,23]
[88108,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",39.243600000000001,39.243600000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,23]
[88125,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",24.378599999999999,24.378599999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,23]
[88155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.9495,20.9495,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
[88162,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",206.92080000000001,206.92080000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,23]
[88173,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",123.08219999999999,123.08219999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,23]
[88182,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",67.189799999999991,67.189799999999991,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,23]
[88184,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",125.4606,125.4606,"000",0,0,0,3,0,0,0,0,0,"","R",null,"Y-CM",2,23]
[88239,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",210.95359999999999,210.95359999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
[88263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",214.91469999999998,214.91469999999998,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
[88283,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",98.097999999999985,98.097999999999985,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
[88304,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",55.892399999999995,55.892399999999995,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,23]
[88307,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",144.48780000000002,144.48780000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,23]
[88313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",148.65,148.65,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,23]
[88319,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",47.568000000000005,47.568000000000005,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,23]
[88323,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",152.2176,152.2176,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,23]
[88333,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",59.46,59.46,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,23]
[88342,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",123.08219999999999,123.08219999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,23]
[88348,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",136.1634,136.1634,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,23]
[88358,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,23]
[88362,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",400.7604,400.7604,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,23]
[88366,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",522.65339999999992,522.65339999999992,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,23]
[88368,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,23]
[88369,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,23]
[88377,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,23]
[88381,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",41.622,41.622,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,23]
[88720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[89051,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8.0079999999999991,8.0079999999999991,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2,23]
[89253,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[89272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[89321,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.2315,17.2315,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
[89329,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[89356,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
[90296,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,16]
[90393,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
[90473,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,16]
[90634,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
[90655,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
[90666,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,16]
[90670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,16]
[90686,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.526,20.526,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2,16]
[90698,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,16]
[90733,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",116.3,116.3,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2,16]
[90744,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
[90834,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",178.97459999999998,156.9744,"000",0,0,0,0,0,0,9,0,0,"","R",null,"Y-CM",2,17]
[90863,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,17]
[90876,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",187.29900000000001,168.27180000000001,"000",0,0,0,9,9,9,9,9,9,"","R",null,"Y-CM",2,17]
[90885,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,17]
[90945,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",152.2176,152.2176,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2]
[90957,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1376.499,1376.499,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2]
[90969,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",30.3246,30.3246,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2]
[91010,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",305.62439999999998,305.62439999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2]
[91030,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",189.08280000000002,189.08280000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2]
[91038,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",795.5748000000001,795.5748000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2]
[91065,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",152.2176,152.2176,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2]
[91110,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",1258.1736000000001,1258.1736000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[91120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",995.36039999999991,995.36039999999991,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[91132,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",46.378800000000005,46.378800000000005,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[91302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1.03E-2,1.03E-2,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
[92012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",161.7312,89.784599999999998,"000",0,0,0,0,0,2,0,0,0,"","R",null,null,2]
[92065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",96.325200000000009,96.325200000000009,"000",0,0,0,1,0,2,0,0,0,"","R",null,"Y-CM",2]
[92081,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",32.108400000000003,32.108400000000003,"000",0,0,0,1,7,2,0,0,0,"","R",null,null,2]
[92133,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",66.595200000000006,66.595200000000006,"000",0,0,0,1,7,2,0,0,0,"","R",null,null,2]
[92134,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",73.135800000000003,73.135800000000003,"000",0,0,0,1,7,2,0,0,0,"","R",null,null,2]
[92202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",27.946199999999997,25.567799999999998,"000",0,0,0,0,0,2,0,0,0,"","R",null,null,2]
[92235,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",155.19059999999999,155.19059999999999,"000",0,0,0,1,7,2,0,0,0,"","R",null,null,2]
[92265,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",156.37979999999999,156.37979999999999,"000",0,0,0,1,7,2,0,0,0,"","R",null,null,2]
[92283,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",83.244,83.244,"000",0,0,0,1,7,2,0,0,0,"","R",null,"Y-CM",2]
[92286,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",38.054400000000001,38.054400000000001,"000",0,0,0,1,7,2,0,0,0,"","R",null,null,2]
[92314,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",162.32580000000002,61.8384,"000",0,0,0,9,9,9,9,9,9,"","R",null,null,2]
[92355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
[92371,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
[92521,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",239.02919999999997,239.02919999999997,"000",0,0,0,7,5,0,0,0,0,"","R",null,null,2]
[92524,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",196.8126,196.8126,"000",0,0,0,7,5,0,0,0,0,"","R",null,null,2]
[92541,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",36.865200000000002,36.865200000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[92544,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",32.108400000000003,32.108400000000003,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[92547,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.6218,19.6218,"000",0,0,0,3,0,0,0,0,0,"","R",null,null,2]
[92550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",40.4328,40.4328,"000",0,0,0,7,0,2,0,0,0,"","R",null,null,2]
[92568,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",27.946199999999997,27.351600000000001,"000",0,0,0,7,0,2,0,0,0,"","R",null,null,2]
[92572,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",76.108800000000002,76.108800000000002,"000",0,0,0,3,0,2,0,0,0,"","R",null,null,2]
[92591,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,29]
[92594,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,29]
[92613,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled","000",0,0,0,0,0,0,0,0,0,"","Bundled",null,"Y-CM",2,29,26]
[92618,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,29]
[92650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",52.324800000000003,52.324800000000003,"000",0,0,0,0,0,2,0,0,0,"","R",null,"Y-CM",2,26]
[92924,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,2,0,0,0,0,"","X",null,null,2,26]
[92953,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1.7838000000000001,1.7838000000000001,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[92970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",328.2192,328.2192,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[92997,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1105.9560000000001,1105.9560000000001,"000",0,0,0,0,2,0,0,0,0,"","R",null,"Y-CM",2,26]
[93005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",11.2974,11.2974,"000",0,0,0,3,6,0,0,0,0,"","R",null,null,2,26]
[93224,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",138.54179999999999,138.54179999999999,"000",0,0,0,4,6,0,0,0,0,"","R",null,null,2,26]
[93229,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1656.5555999999999,1656.5555999999999,"000",0,0,0,3,6,0,0,0,0,"","R",null,null,2,26]
[93260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",141.51480000000001,141.51480000000001,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM",2,26]
[93268,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",341.89499999999998,341.89499999999998,"000",0,0,0,4,6,0,0,0,0,"","R",null,null,2,26]
[93281,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",158.75819999999999,158.75819999999999,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM",2,26]
[93282,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",76.703400000000002,76.703400000000002,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM",2,26]
[93286,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",26.757000000000001,26.757000000000001,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM",2,26]
[93287,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",39.838200000000001,39.838200000000001,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM",2,26]
[93291,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",62.433000000000007,62.433000000000007,"000",0,0,0,1,6,0,0,0,0,"","R",null,"Y-CM",2,26]
[93293,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",26.162400000000002,26.162400000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[93306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",367.46280000000002,367.46280000000002,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[93308,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",139.13639999999998,139.13639999999998,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[93317,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,null,2,26]
[93318,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",180.75839999999999,180.75839999999999,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[93350,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",225.35339999999999,225.35339999999999,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[93351,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",284.8134,284.8134,"000",0,0,0,1,6,0,9,9,9,"","R",null,null,2,26]
[93453,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2196.4523999999997,2196.4523999999997,"000",0,0,0,1,2,0,0,0,0,"","R",null,"Y-CM",2,26]
[93455,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",1447.2564,1447.2564,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[93459,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",1556.6628000000001,1556.6628000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[93461,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",718.27679999999998,718.27679999999998,"000",0,0,0,1,2,0,0,0,0,"","R",null,"Y-CM",2,26]
[93566,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",239.62380000000002,80.271000000000001,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,26]
[93571,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",125.4606,125.4606,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[93593,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,26]
[93594,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,26]
[93598,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2,26]
[93602,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[93609,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",482.22059999999999,482.22059999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[93616,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[93621,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",165.89340000000001,165.89340000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[93623,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[93641,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[93642,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",152.81219999999999,152.81219999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,26]
[93662,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,null,2,26]
[93701,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",50.540999999999997,50.540999999999997,"000",0,0,0,3,6,0,0,0,0,"","R",null,"Y-CM",2,26]
[93745,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,"Y-CM",2,26]
[93880,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",358.54380000000003,358.54380000000003,"000",0,0,0,1,6,2,0,0,0,"","R",null,null,2,26]
[93886,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",81.460200000000015,81.460200000000015,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[93892,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",588.654,588.654,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[93923,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",239.02919999999997,239.02919999999997,"000",0,0,0,1,6,2,0,0,0,"","R",null,null,2,26]
[93924,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",252.11040000000003,252.11040000000003,"000",0,0,0,1,6,2,0,0,0,"","R",null,null,2,26]
[93970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",352.59780000000001,352.59780000000001,"000",0,0,0,1,6,2,0,0,0,"","R",null,null,2,26]
[93971,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",223.56959999999998,223.56959999999998,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[93976,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",228.32640000000001,228.32640000000001,"000",0,0,0,1,6,0,0,0,0,"","R",null,null,2,26]
[93985,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",403.73340000000002,403.73340000000002,"000",0,0,0,1,6,2,0,0,0,"","R",null,"Y-CM",2,26]
[93998,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,0,0,0,1,1,"","N",null,null,2,26]
[94010,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",14.2704,14.2704,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[94070,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",49.351799999999997,49.351799999999997,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[94200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",27.946199999999997,27.946199999999997,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[94453,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",33.297600000000003,33.297600000000003,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2,26]
[94618,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",60.054600000000001,60.054600000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[94640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.811,20.811,"000",0,0,0,5,0,0,0,0,0,"","R",null,null,2]
[94681,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",17.243399999999998,17.243399999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[94727,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",58.865400000000001,58.865400000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[94729,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",15.4596,15.4596,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[94781,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,1,0,0,"","X",null,null,2]
[95004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7.1352000000000002,7.1352000000000002,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2]
[95079,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",150.43379999999999,120.1092,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2]
[95120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
[95149,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",222.97499999999999,5.3513999999999999,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2]
[95250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",275.2998,275.2998,"000",0,0,0,3,0,0,0,0,0,"","R",null,"Y-CM",2]
[95709,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,0,0,0,0,0,"","N",null,"Y-CM",2]
[95721,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",369.84120000000001,362.1114,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2]
[95782,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,1,0,0,0,0,0,"","X",null,null,2]
[95803,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",269.35380000000004,269.35380000000004,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2]
[95808,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1238.5518,1238.5518,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2]
[95810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1120.2264,1120.2264,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2]
[95816,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",708.76319999999998,708.76319999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",772.98,772.98,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95829,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",2797.5929999999998,2797.5929999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95861,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",145.08240000000001,145.08240000000001,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95864,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",187.89360000000002,187.89360000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95868,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",111.1902,111.1902,"000",0,0,0,1,0,2,0,0,0,"","R",null,null,2]
[95873,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",34.486799999999995,34.486799999999995,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95885,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",119.51459999999999,119.51459999999999,"000",0,0,0,1,0,3,0,0,0,"","R",null,null,2]
[95887,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",66.595200000000006,66.595200000000006,"000",0,0,0,1,0,3,0,0,0,"","R",null,null,2]
[95907,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",73.730400000000003,73.730400000000003,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95910,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",327.62459999999999,327.62459999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95921,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",162.92040000000003,162.92040000000003,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95923,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",232.48860000000002,232.48860000000002,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95927,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",278.86740000000003,278.86740000000003,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95933,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",156.9744,156.9744,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95938,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",594.00540000000001,594.00540000000001,"000",0,0,0,1,0,2,0,0,0,"","R",null,null,2]
[95954,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",556.54559999999992,556.54559999999992,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95957,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",297.89459999999997,297.89459999999997,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95961,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",308.00279999999998,308.00279999999998,"000",0,0,0,1,0,0,0,0,0,"","R",null,null,2]
[95967,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",327.62459999999999,327.62459999999999,"000",0,0,0,1,0,0,0,0,0,"","R",null,"Y-CM",2,22]
[95977,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
[96002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,2,0,0,0,"","X",null,null,2]
[96121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",139.13639999999998,124.2714,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2]
[96132,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",231.89400000000001,185.51520000000002,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2]
[96138,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",64.216800000000006,64.216800000000006,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2]
[96170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
[96368,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",36.865200000000002,36.865200000000002,"000",0,0,0,5,0,0,0,0,0,"","R",null,null,2]
[96376,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,25]
[96415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",53.514000000000003,53.514000000000003,"000",0,0,0,5,0,0,0,0,0,"","R",null,null,2,25]
[96523,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49.351799999999997,49.351799999999997,"000",0,0,0,5,0,0,0,0,0,"","R",null,null,2,17]
[96912,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",188.48820000000001,188.48820000000001,"000",0,0,0,5,0,0,0,0,0,"","R",null,"Y-CM",2,25]
[96931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",318.7056,318.7056,"000",0,0,0,4,0,0,0,0,0,"","R",null,null,2,25]
[96935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",145.67700000000002,145.67700000000002,"000",0,0,0,3,0,0,0,0,0,"","R",null,null,2,25]
[97032,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.162400000000002,26.162400000000002,"000",0,0,0,7,5,0,0,0,0,"","R",null,null,2,25]
[97112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",61.8384,61.8384,"000",0,0,0,7,5,0,0,0,0,"","R",null,null,2,21]
[97150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",31.513800000000003,31.513800000000003,"000",0,0,0,7,5,0,0,0,0,"","R",null,null,2,25]
[97162,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",180.75839999999999,180.75839999999999,"000",0,0,0,7,5,0,0,0,0,"","R",null,null,2,10]
[97533,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",118.3254,118.3254,"000",0,0,0,7,5,0,0,0,0,"","R",null,null,2,23]
[97608,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",709.3578,44.000399999999999,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2,23]
[97761,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",75.514200000000002,75.514200000000002,"000",0,0,0,7,5,0,0,0,0,"","R",null,null,2]
[97803,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",57.676200000000001,49.351799999999997,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2]
[98941,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
[98967,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",42.2166,38.649000000000001,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,10]
[98980,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,10]
[99053,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",23.386305571200005,23.386305571200005,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,10]
[99100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,10]
[99173,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,10]
[99184,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,10]
[99192,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,10]
[99221,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",174.8124,174.8124,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,10]
[99234,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",226.54259999999999,226.54259999999999,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,10]
[99241,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",82.6494,55.892399999999995,"000",0,0,0,9,9,9,9,9,9,"","R",null,null,2,10]
[99253,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",199.191,199.191,"000",0,0,0,9,9,9,9,9,9,"","R",null,null,2,10]
[99305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",224.75879999999998,224.75879999999998,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,10]
[99316,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",181.35299999999998,181.35299999999998,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,10]
[99339,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",134.37959999999998,134.37959999999998,"000",0,0,0,9,9,9,9,9,9,"","R",null,null,2,10]
[99342,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",134.37959999999998,134.37959999999998,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2,10]
[99367,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",97.514399999999995,97.514399999999995,"000",0,0,0,9,9,9,9,9,9,"","R",null,null,2,10]
[99382,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,10]
[99387,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,10]
[99397,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,10]
[99416,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,3,0,0,0,0,0,"","X",null,null,2,10]
[99426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
[99449,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
[99452,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
[99469,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
[99479,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
[99486,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
[99494,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",112.97399999999999,73.730400000000003,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-ONC",2]
[99506,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
[99601,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",175.39729178400003,175.39729178400003,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["0006U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",370.85847169919998,370.85847169919998,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["0009U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0016M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0022U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0042T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,0,0,0,0,0,"","N",null,null,2]
["0075T",26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report","000",0,0,0,1,0,0,0,0,0,"","N",null,null,2]
["0086U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",286,286,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2]
["0094U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0102T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0105U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0115U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0118U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0134U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0137U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0146U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0155U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0165T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0184T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0210T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,3,0,0,0,0,0,"","N",null,null,2]
["0211U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,30]
["0219U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1036.75,1036.75,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2]
["0221T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,0,0,0,0,0,"","N",null,"Y-UR",2]
["0228U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0235T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,0,0,0,0,0,"","N",null,null,2,30]
["0263T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0266T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0289U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0292U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0304U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0312T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0332T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0349T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0379T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0393R",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ferry and bridge charges, non-vocational","State Rate","State Rate","000",0,0,0,9,9,9,9,9,9,"","S",null,null,2,30]
["0403T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0406A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Claimant - lodging (hotel/motel)","State Rate","State Rate","000",0,0,0,9,9,9,9,9,9,"","S",null,null,2]
["0415T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0417T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0428T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0435T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0446T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,2,0,1,0,0,"","X",null,null,2]
["0472T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0483T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,2,0,0,2,1,"","X",null,null,2]
["0486T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,1,9,2,9,9,9,"","X",null,null,2]
["0501F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["0502F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["0509F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["0517F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["0524T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,2,1,1,0,0,"","N",null,"Y-UR",2]
["0529F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["0537T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["0540F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["0555T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0556T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0562T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,30]
["0572T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,30]
["0581T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,30]
["0586T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["0622T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,2,1,0,0,0,"","X",null,null,2,27]
["0625T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,3,0,0,0,0,0,"","X",null,null,2]
["0633T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,1,0,3,0,0,0,"","X",null,null,2,27]
["0674T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,2,0,1,0,0,"","N",null,null,2]
["0681T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report","000",0,0,0,0,2,0,1,0,0,"","N",null,null,2,27]
["0693T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,27]
["0703T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,2,0,0,0,0,0,"","X",null,null,2]
["0711T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered","000",0,0,0,3,9,9,9,9,9,"","X",null,null,2,13]
["0813V",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Assessment services exception- intern",8.6860330127999994,8.6860330127999994,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,13]
["0841V",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Plan implementation services-intern",8.6860330127999994,8.6860330127999994,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,13]
["0845V",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Resume services - intern",8.6860330127999994,8.6860330127999994,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,13]
["1000F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,13]
["1007F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["1028M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Review of job offer/analysis by a/p",43.343629243200006,43.343629243200006,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,22]
["1039F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,12]
["1052F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,20]
["1067M","TF",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Assessment Impediments RTW (Moderate)","Contracted","Contracted","000",0,0,0,9,9,9,9,9,9,"","C",null,null,2]
["1073M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Activity prescription form, insurer requested",57.773477361600001,57.773477361600001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,27]
["1077M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Opioid req for subacute pain w/doc",66.675849926400005,66.675849926400005,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,27]
["1098M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Funct capacities eval, supplemental",138.68446980960005,138.68446980960005,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,22]
["1110F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["1124M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ime, other, by report","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,22]
["1130M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ime - terminated examination",413,413,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,34]
["1142M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"IME Rare add'l provider",1269.76,1269.76,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,13]
["1153M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Coord of hlth svcs, pt present, maint","Contracted","Contracted","000",0,0,0,9,9,9,9,9,9,"","C",null,null,2]
["1159F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,19]
["1170F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,19]
["1195M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Impairment rating by consult, complex",875.69,875.69,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,12]
["1220M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nurse case mgmt phone call per unit",11.66,11.66,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,20]
["1247M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"UR, advanced imaging, web-based","Contracted","Contracted","000",0,0,0,9,9,9,9,9,9,"","C",null,null,2]
["1279M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"CCM, VALUE BASE RECOVERY PHASE","Contracted","Contracted","000",0,0,0,9,9,9,9,9,9,"","C",null,null,2]
["1302W",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Stay at work tools & equipment","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["1490F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["1505F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["2002F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["2010M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pain clinic - evaluation",1284.6136796902097,1284.6136796902097,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,34]
["2018F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["2030F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["2050A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",48.384340804800004,48.384340804800004,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["3011F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3027F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3048F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3062F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3078F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3082F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3100F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3118F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3170F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3267F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3279F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3293F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3318F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3321F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3344F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3354F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3394F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3491F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3502F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3520F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3573F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3752F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["3761F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4003F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4018F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4044F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4051F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4066F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4079F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4100F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4134F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4148F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4167F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4180F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,36]
["4189F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,36]
["4221F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,33]
["4255F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4266F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,14]
["4301F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4320F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4526F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["4558F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["5005F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["5100F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,28,9]
["6030F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,28,9]
["6101F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2,28,9]
["8886H",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nursing facility special care (per day)",544.24,544.24,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,36]
["8889H",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nursing facility behavior only (per day)",356.11,356.11,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,36]
["8951H",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Post-acute brain injury rehab-full day",1121.6556752544,1121.6556752544,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,33]
["9002F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Tracking","Tracking","000",0,0,0,9,9,9,9,9,9,"","T",null,null,2]
["9973M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"INTERPRETER SCHEDULING ADMIN FEE","Contracted","Contracted","000",0,0,0,9,9,9,9,9,9,"","C",null,null,2,14]
["A0080",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Noninterest escort in non er","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["A0100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nonemergency transport taxi","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["A0180",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Noner transport lodgng recip","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["A0425",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ground mileage",15.028851233373123,15.028851233373123,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["A0428",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bls",406.71690720330383,406.71690720330383,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["A2002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mirragen adv wnd mat per sq","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28,9]
["A2007",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Restrata, per sq cm","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28,9]
["A4210",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nonneedle injection device",2010.5516265120002,2010.5516265120002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,28,9]
["A4218",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sterile saline or water","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4226",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Weekly supply maint cgs pump","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,28,9]
["A4236",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Silvr oxide batt glucose mon",2.9298999999999995,2.9298999999999995,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A4262",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Temporary tear duct plug","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4265",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Paraffin","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,"Y-CM",2,28,9]
["A4290",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sacral nerve stim test lead",292.82400000000001,292.82400000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,28,9]
["A4310",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Insert tray w/o bag/cath","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4328",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fem urinary collect pouch","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4336",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urethral insert","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4351",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Straight tip urine catheter","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4358",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urinary leg or abdomen bag","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4378",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Drainable rubber pch w/o fp","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4381",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urinary plastic pouch w/o fp","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4395",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ostomy pouch solid deodorant","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4402",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lubricant per ounce","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4415",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ost skn barr w/o conv >4 sqi","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4419",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ost pch for bar w flange/flt","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4433",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urine ost pch bar w lock fln","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4450",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-waterproof tape","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4495",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Thigh length surg stocking",34.162799999999997,34.162799999999997,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A4554",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disposable underpads","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A4575",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hyperbaric o2 chamber disps",756.46199999999999,756.46199999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A4595",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tens suppl 2 lead per month","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28,9]
["A4615",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cannula nasal",0.91670000000000007,0.91670000000000007,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A4619",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Face tent",4.2661999999999995,4.2661999999999995,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A4637",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Repl tip cane/crutch/walker",3.0766694927999998,3.0766694927999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A4640",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alternating pressure pad",92.945052326399988,92.945052326399988,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A4674",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Chem/antisept solution, 8oz",107.36880000000001,107.36880000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A4709",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Acid conc sol per gallon",53.684400000000004,53.684400000000004,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A4736",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Topical anesthetic, per gram","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,28,9]
["A4750",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Art or venous blood tubing",73.206000000000003,73.206000000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A4870",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Plumb/elec wk hm hemo equip","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,28,9]
["A4918",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Venous pressure clamp","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,28,9]
["A5061",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pouch drainable w barrier at","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A5082",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Continent stoma catheter","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A5131",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Appliance cleaner","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A5505",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diab shoe w/metatarsal bar",40.757100000000001,40.757100000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,28,9]
["A6022",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Collagen drsg>16<=48 sq in","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A6025",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Silicone gel sheet, each","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A6209",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Foam drsg <=16 sq in w/o bdr","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A6213",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Foam drg >16<=48 sq in w/bdr","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A6230",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gauze > 48 sq in water/salne","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A6237",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hydrocolld drg <=16 in w/bdr","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A6245",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hydrogel drg <= 16 in w/bdr","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A6252",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Absorpt drg >16 <=48 w/o bdr","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A6410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sterile eye pad","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A6413",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adhesive bandage, first-aid","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A6454",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Self-adher band w>=3\" <5\"/yd","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,28,9]
["A6460",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Synthetic drsg <= 16 sq in","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,28,9]
["A6511",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Compres burn garment panty",341.62799999999999,341.62799999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A6534",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gc stocking thighlngth 30-40",47.293399999999998,47.293399999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A6544",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gc stocking garter belt",105.4183,105.4183,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A7002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tubing used w suction pump",7.47,7.47,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A7020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Interface, cough stim device",34.527999999999999,34.527999999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A7027",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Combination oral/nasal mask",217.2525,217.2525,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A7041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Water seal drain container",93.482800000000012,93.482800000000012,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A7047",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Resp suction oral interface",187.2148,187.2148,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28,9]
["A7521",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Trach/laryn tube cuffed",59.276499999999999,59.276499999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["A8000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Soft protect helmet prefab",290.45328852000006,290.45328852000006,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["A9155",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Artificial saliva","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,9]
["A9275",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disp home glucose monitor",24.401999999999997,24.401999999999997,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["A9502",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tc99m tetrofosmin","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,9]
["A9505",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tl201 thallium","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-PHL",2,9]
["A9527",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Iodine i-125 sodium iodide",69.329899999999995,69.329899999999995,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,35]
["A9531",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"I131 max 100uci",31.2744,31.2744,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,35]
["A9548",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"In111 pentetate","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-PHL",2,35]
["A9556",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ga67 gallium","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,35]
["A9564",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"P32 chromic phosphate","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,35]
["A9576",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj prohance multipack",1.4690000000000001,1.4690000000000001,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,35]
["A9588",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fluciclovine f-18",757.08449999999993,757.08449999999993,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,35]
["A9595",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Piflu f-18, dia 1 millicurie","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,35]
["A9598",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pet dx for non-tumor id, noc","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,35]
["A4437",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Irr supply sleev disp per mo","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,35]
["B4104",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Additive for enteral formula",1.7512999999999999,1.7512999999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,35]
["B4153",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ef hydrolyzed/amino acids",1.8437000000000001,1.8437000000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,35]
["B4178",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Parenteral sol amino acid >",75.292999999999992,75.292999999999992,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,35]
["B4199",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Parenteral sol > 100gm prote",418.1182,418.1182,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,35]
["B9006","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Parenteral infus pump statio",3301.7062000000001,3301.7062000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,35]
["C1714",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cath, trans atherectomy, dir","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,35]
["C1716",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brachytx, non-str, gold-198","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,35]
["C1731",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cath, ep, 20 or more elec","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,35]
["C1756",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cath, pacing, transesoph","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,35]
["C1761",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cath, trans intra litho/coro","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,35]
["C1776",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Joint device (implantable)","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,35]
["C1783",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ocular imp, aqueous drain de","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,35]
["C1818",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Integrated keratoprosthesis","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,35]
["C1825",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gen, neuro, carot sinus baro","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,35]
["C1831",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Personalized interbody cage","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,35]
["C1880",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vena cava filter","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,35]
["C1887",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Catheter, guiding","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,35]
["C1898",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lead, pmkr, other than trans","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,35]
["C2621",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pmkr, other than sing/dual","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,35]
["C2628",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Catheter, occlusion","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,35]
["C2642",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brachytx, stranded, c-131","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,35]
["C5272",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Low cost skin substitute app","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,35]
["C5274",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Low cost skin substitute app","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["C8909",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mra w/cont, chest","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2]
["C8919",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mra w/o cont, pelvis","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2]
["C8929",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tte w or wo fol wcon,doppler","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2]
["C9047",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, caplacizumab-yhdp","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["C9059",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, meloxicam",2.0335917887999999,2.0335917887999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["C9094",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj., susvimo, 0.1 mg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["C9254",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, lacosamide","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["C9354",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Veritas collagen matrix, cm2","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2]
["C9459",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flutemetamol f18","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["C9487",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ustekinumab iv inj, 1 mg","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["C9608",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Perc d-e cor revasc chro add","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["C9755",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rf magnetic-guide av fistula","Facility Only",10158.293424000001,"000",0,0,0,9,9,9,9,9,9,"","O",null,"Y-ONC",2]
["C9762",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cardiac mri seg dys strain","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-UR",2]
["C9771",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nsl/sins cryo post nasal tis","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-ONC",2]
["C9780",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Insert cv cath inf & sup app","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["C9783",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Blind cor sinus reducer impl","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["D0190",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Screening of a patient",102.176,102.176,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D0251",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Extraoral posterior image",84.048000000000016,84.048000000000016,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D0340",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"2d cephalometric image",139.25600000000003,139.25600000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D0381",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cone beam ct capt mandible",400.464,400.464,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D0393",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Trtmnt simulation 3d image",347.72800000000001,347.72800000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D0418",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Analysis of saliva sample","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["D0473",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Micro exam, prep & report","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["D0476",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spec stains for microorganis","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["D0600",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-ionizing diag proc",84.048000000000002,84.048000000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D0701",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pano radio image","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,8]
["D1120",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental prophylaxis child","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["D1351",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental sealant per tooth","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["D1552",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Recement space maint - man","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,8]
["D1704",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Moderna Covid-19 vaccine administration - second dose","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["D2330",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Resin one surface-anterior",200.232,200.232,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D2335",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Resin 4/> surf or w incis an",373.27200000000005,373.27200000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D2510",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental inlay metalic 1 surf","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["D2642",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental onlay porcelin 2 surf","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["D2721",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crown resin w/ base metal",1162.664,1162.664,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D2780",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crown 3/4 cast hi noble met",1292.856,1292.856,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D2920",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Re-cement or re-bond crown",140.08000000000001,140.08000000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D2950",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Core build-up incl any pins",317.24,317.24,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D2960",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Laminate labial veneer",802.57600000000002,802.57600000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D2971",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Add proc construct new crown",346.08,346.08,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D3120",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pulp cap indirect",102.176,102.176,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D3331",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-surg tx root canal obs",760.55200000000013,760.55200000000013,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D3410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Apicoectomy - anterior",875.91200000000015,875.91200000000015,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D3431",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Biological materials",653.43200000000013,653.43200000000013,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D3910",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Isolation- tooth w rubb dam","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,8]
["D4241",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gngvl flap w rootplan 1-3 th",767.14400000000012,767.14400000000012,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D4265",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bio mtrls to aid soft/os reg",675.68000000000006,675.68000000000006,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D4268",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surgical revision procedure",935.24,935.24,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D4285",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-auto graft addl tooth",1125.5840000000001,1125.5840000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D4920",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Unscheduled dressing change",124.42400000000001,124.42400000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D5222",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Immed man part denture resin",1863.8879999999999,1863.8879999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D5282",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Remove unil part denture,max",1348.0640000000001,1348.0640000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D5611",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rep resin part dent base man",264.50400000000002,264.50400000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D5720",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dentures rebase part maxill",664.96800000000007,664.96800000000007,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D5750",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Denture reln cmplt max lab",554.55200000000002,554.55200000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D5761",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Denture reln part mand lab",545.48800000000006,545.48800000000006,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D5863",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Overdenture complete max",2665.64,2665.64,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D5912",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Facial moulage complete",631.18400000000008,631.18400000000008,"000",0,0,0,0,0,0,0,0,0,"","F",null,"Y-CM",2,8]
["D5928",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Orbital replacement","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,8]
["D5937",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Trismus appliance",830.5920000000001,830.5920000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D5983",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Radiation applicator","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,8]
["D5992",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adjust max prost appliance",207.64800000000002,207.64800000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D6055",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant connecting bar",3556.3840000000005,3556.3840000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D6065",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant supported crown",1729.576,1729.576,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D6073",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Abutment supported retainer",1579.6080000000002,1579.6080000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D6076",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant supported retainer",1767.48,1767.48,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D6092",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Recement supp crown",177.16,177.16,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D6100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Removal of implant",871.79200000000014,871.79200000000014,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D6115",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implnt/abut fixed dent mand",11892.792000000001,11892.792000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D6122",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Retain metal fpd noble alloy",1817.7440000000001,1817.7440000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC",2,8]
["D6212",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bridge noble metal cast",1241.7680000000003,1241.7680000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D6253",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Provisional pontic",848.72,848.72,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D6604",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cst bse mtl inlay 2 surfaces","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["D6607",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cst noble mtl inlay >=3 surf","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["D6720",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Retain crown resin w hi nble",1259.8960000000002,1259.8960000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D6780",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crown 3/4 high noble metal",1264.0160000000001,1264.0160000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D6920",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental connector bar",1239.296,1239.296,"000",0,0,0,0,0,0,0,0,0,"","F",null,"Y-CM",2,8]
["D7111",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Extraction coronal remnants",159.85600000000002,159.85600000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D7272",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tooth transplantation",888.27200000000016,888.27200000000016,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D7292",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Screw retained plate",3300.9440000000004,3300.9440000000004,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D7300",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rem anchorage dev w/o flap","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,8]
["D7320",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alveoplasty w/o extraction",547.13600000000008,547.13600000000008,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D7465",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lesion destruction",489.45600000000007,489.45600000000007,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D7485",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surg reduct osseoustuberosit",1055.5439999999999,1055.5439999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D7610",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Maxilla open reduct simple",5055.24,5055.24,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D7671",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alveolus open reduction",1906.7360000000001,1906.7360000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D7820",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Closed tmp manipulation",777.03200000000015,777.03200000000015,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D7840",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Removal of tmj condyle",6150.3360000000011,6150.3360000000011,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D7880",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Occlusal orthotic appliance",1247.5360000000001,1247.5360000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D7910",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dent sutur recent wnd to 5cm",350.2,350.2,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D7945",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bone cutting body mandible",8091.68,8091.68,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D7953",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bone replacement graft",791.04,791.04,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D7983",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Closure of salivary fistula",1742.76,1742.76,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D7997",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Appliance removal",396.34399999999999,396.34399999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D8660",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Preorthodontic tx visit",516.64800000000002,516.64800000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D8680",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Orthodontic retention",549.60800000000006,549.60800000000006,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D9211",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Regional block anesthesia","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,8]
["D9219",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eval mod/deep sed/gen anest",124.42400000000002,124.42400000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D9420",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospital/asc call",372.44800000000004,372.44800000000004,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D9910",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dent appl desensitizing med",77.456000000000003,77.456000000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,8]
["D9944",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Occ guard, hard, full arch",675.68000000000006,675.68000000000006,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,8]
["D9951",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Limited occlusal adjustment",230.72,230.72,"000",0,0,0,0,0,0,0,0,0,"","F",null,null,2,8]
["D9990",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Trans or sign language svcs","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["D9996",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Teledentistry dent review","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,8]
["E0118","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Crutch substitute",762.14726400000018,762.14726400000018,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0135","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Walker folding adjust/fixed",72.481100000000012,72.481100000000012,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0147","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Walker variable wheel resist",553.51170000000002,553.51170000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0154","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Walker platform attachment",67.259,67.259,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0160","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sitz type bath or equipment",37.914300000000004,37.914300000000004,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0170","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Commode chair electric",1671.9802276320004,1671.9802276320004,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0185","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Gel pressure mattress pad",38.346899999999998,38.346899999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0189","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Lambswool sheepskin pad",55.661200000000001,55.661200000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Heat lamp without stand","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["E0205",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Heat lamp with stand","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["E0241","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Bath tub wall rail",42.359284281600004,42.359284281600004,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0244","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Toilet seat raised",57.676124563200013,57.676124563200013,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0250","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hosp bed fixed ht w/ mattres",86.52,86.52,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E0266","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hosp bed total elec w/o matt",165.80939999999998,165.80939999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E0275","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Bed pan standard",17.9117,17.9117,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0291","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hosp bed fx ht w/o rail w/o",557.53899999999999,557.53899999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E0297","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hosp bed total elect w/o mat",1312.7350000000001,1312.7350000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E0301","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hd hosp bed, 350-600 lbs",2422.663,2422.663,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E0316","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Bed safety enclosure",221.45000000000002,221.45000000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0328",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped hospital bed, manual","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["E0371","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Nonpower mattress overlay",355.20580000000001,355.20580000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0441","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Stationary o2 contents, gas",84.610398787200012,84.610398787200012,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E0457","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Chest shell",1682.8404731424002,1682.8404731424002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0465","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Home vent invasive interface",1022.4089,1022.4089,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0481","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Intrpulmnry percuss vent sys","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,9]
["E0482","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Cough stimulating device",541.90359999999998,541.90359999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E0570","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Nebulizer with compression",135.75399999999999,135.75399999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0572","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Aerosol compressor adjust pr",41.0867,41.0867,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0585","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Nebulizer w/ compressor & he",35.638000000000005,35.638000000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0616","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Cardiac event recorder","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,9]
["E0621","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Patient lift sling or seat",10.773800000000001,10.773800000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0630","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Patient lift hydraulic","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-PHL",2,9]
["E0640","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Fixed patient lift system","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,9]
["E0642","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Dynamic standing frame"," By Report "," By Report ","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,9]
["E0660","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pneumatic appliance full leg",20.950199999999999,20.950199999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0666","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pneumatic appliance half leg",174.01849999999999,174.01849999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0669","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Seg pneumatic appli half leg",23.102900000000002,23.102900000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0693",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Uvl sys panel 6 ft","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["E0740",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-implant pelv flr e-stim","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["E0748","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Elec osteogen stim spinal",490.24910000000006,490.24910000000006,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC",2,9]
["E0760","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Osteogen ultrasound stimltor",407.41650000000004,407.41650000000004,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC",2,9]
["E0779","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Amb infusion pump mechanical",208.98699999999997,208.98699999999997,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0786","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Implantable pump replacement",1006.3100000000001,1006.3100000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E0791","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Parenteral infusion pump sta",359.05800000000005,359.05800000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0856","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Cervic collar w air bladders",193.94900000000001,193.94900000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0890","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Traction frame attach pelvic",151.71900000000002,151.71900000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0930","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Fracture frame free standing",575.56400000000008,575.56400000000008,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0942","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Cervical head harness/halter",25.008400000000002,25.008400000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0948","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Fracture frame attachmnts ce",73.892200000000003,73.892200000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0957","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"W/c medial thigh support",145.0137,145.0137,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0967","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Man wc rim/projection rep ea",82.760499999999993,82.760499999999993,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0968","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair commode seat",22.011100000000003,22.011100000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E0978","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"W/c acc,saf belt pelv strap",37.450800000000001,37.450800000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0982","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Back upholstery, replacement",5.2942,5.2942,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E0986","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Man w/c push-rim powr system",6129.7360000000008,6129.7360000000008,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E1002","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwr seat tilt",420.88889999999998,420.88889999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E1005","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwr seat recline pwr",5687.7630000000008,5687.7630000000008,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E1012",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ctr mount pwr elev leg rest",1135.4473216944002,1135.4473216944002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E1030","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"W/c vent tray gimbaled",1265.664,1265.664,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E1031","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Rollabout chair with casters",56.773600000000002,56.773600000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E1060","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair detachable arms",156.56,156.56,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E1085","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hemi-wheelchair fixed arms",520.7337,520.7337,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E1088","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair lightweight det a",189.99380000000002,189.99380000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E1110","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair semi-recl detach",113.1249,113.1249,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E1150","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair standard w/ leg r",1027.94,1027.94,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E1180","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair amputee w/ foot r",108.5414,108.5414,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E1223","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair spec size w foot",932.66499999999996,932.66499999999996,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E1225","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Manual semi-reclining back",504.7,504.7,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E1227","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair spec sz spec ht a",34.9788,34.9788,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E1238",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fld ped wc adjstabl w/o seat","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["E1260","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair lightwt foot rest",272.88739999999996,272.88739999999996,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E1298","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair spec seat depth/w",533.8696000000001,533.8696000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E1356","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Batt pack/cart, port conc","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-PHL",2,9]
["E1392","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Portable oxygen concentrator",498.4,498.4,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E1570","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Adjustable chair for esrd pt","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,9]
["E1592","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Auto interm peritoneal dialy","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,9]
["E1620","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Replacement blood pump","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,9]
["E1700","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Jaw motion rehab system",36.946100000000001,36.946100000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["E1806","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sps wrist device",133.488,133.488,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2000","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Gastric suction pump hme mdl",65.312299999999993,65.312299999999993,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,9]
["E2202","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Seat width 24-27 in",55.877500000000005,55.877500000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2206","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Man wc whl lock comp repl ea",47.699300000000001,47.699300000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2214","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pneumatic caster tire each",41.612000000000002,41.612000000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2218","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Foam propulsion tire each",56.279200000000003,56.279200000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2224","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Propulsion whl excl tire rep",105.0291,105.0291,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2292",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Planar seat for ped size wc","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["E2301","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwr standing","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,23]
["E2324","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Chin cup interface",47.596299999999999,47.596299999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2325","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sip and puff interface",145.28150000000002,145.28150000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2331","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Attendant control","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,28]
["E2359","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Gr34 sealed leadacid battery",206.55619999999999,206.55619999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2361","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"22nf sealed leadacid battery",14.2552,14.2552,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,26]
["E2364","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"U1nonsealed leadacid battery",131.59280000000001,131.59280000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,23]
["E2370","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwr wc dr wh motor/gear comb",74.345400000000012,74.345400000000012,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2377","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Expandable controller, initl",513.04300000000001,513.04300000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,26]
["E2382","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Tube, pneum wheel drive tire",2.1114999999999999,2.1114999999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,26]
["E2386","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Foam filled drive wheel tire",14.110999999999999,14.110999999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2392","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Solid caster tire, integrate",53.724799999999995,53.724799999999995,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,26]
["E2396","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Caster fork",6.9010000000000007,6.9010000000000007,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2504","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sgd prerec msg>20min <=40min",198.80029999999999,198.80029999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,25]
["E2508","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sgd spelling phys contact",4507.0018999999993,4507.0018999999993,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2607","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Skin pro/pos wc cus wd <22in",275.36019999999996,275.36019999999996,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["E2615","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pos back post/lat wdth <22in",450.16150000000005,450.16150000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,35]
["E2622","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Adj skin pro w/c cus wd<22in",348.42839999999995,348.42839999999995,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,35]
["E2629","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Friction dampening arm supp",1158.8839,1158.8839,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["G0028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc med rsn no scr tob","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G0034",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pall serv during meas","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G0046",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No mrs 90 days post stk","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G0049",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Main hemo in-cntr","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G0065",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Chiropractic ss","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,35]
["G0077",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Care manag h vst new pt 30 m","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["G0083",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Care man h v ext pt 45 m","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,23]
["G0090",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adm iv chemo 1st home visit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,11]
["G0117",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glaucoma scrn hgh risk direc","Bundled","Bundled","000",0,0,0,0,0,0,0,0,0,"","Bundled",null,null,2]
["G0121",53,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Colon ca scrn not hi rsk ind",317.51639999999998,162.92040000000003,"000",0,0,0,0,2,0,1,0,0,"","R",null,null,2]
["G0141",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scr c/v cyto,autosys and md",39.838200000000001,39.838200000000001,"000",0,0,0,0,0,0,0,0,0,"","R",null,null,2]
["G0145",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scr c/v cyto,thinlayer,rescr",37.880699999999997,37.880699999999997,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2]
["G0176",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Opps/php;activity therapy","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G0202",26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Scr mammo bi incl cad","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G0206",26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Dx mammo incl cad uni",76.703188161600011,76.703188161600011,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,23]
["G0235","TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pet not otherwise specified","Not Covered","Not Covered","000",0,0,0,1,9,9,9,9,9,"","X",null,null,2]
["G0249",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Provide inr test mater/equip",88.000799999999998,88.000799999999998,"000",0,0,0,3,0,0,0,0,0,"","R",null,null,2]
["G0260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj for sacroiliac jt anesth","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2]
["G0282",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Elect stim wound care not pd","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["G0289",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Arthro, loose body + chondro",149.83920000000001,149.83920000000001,"000",0,0,0,0,0,1,0,0,0,"","R",null,null,2]
["G0329",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Electromagntic tx for ulcers","Not Covered","Not Covered","000",0,0,0,7,5,0,0,0,0,"","X",null,null,2]
["G0340",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Robt lin-radsurg fractx 2-5","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["G0384",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lev 5 hosp type b ed visit","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2]
["G0402",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Initial preventive exam","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["G0410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Grp psych partial hosp 45-50","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2]
["G0421",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ed svc ckd grp per session",47.568000000000005,47.568000000000005,"000",0,0,0,0,0,0,0,0,0,"","R",null,"Y-CM",2]
["G0437",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tobacco-use counsel>10min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G0442",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Annual alcohol screen 15 min","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["G0460",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Autologous prp for ulcers","Not Covered","Not Covered","000",0,0,0,0,2,0,1,0,0,"","X",null,null,2]
["G0466",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fqhc visit new patient","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,26]
["G0482",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Drug test def 15-21 classes",284.19819999999999,284.19819999999999,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-ONC",2,26]
["G0496",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lpn care train/edu in hh","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G0507",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Care manage serv minimum 20",93.977901388800007,62.879090788800013,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["G0913",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Improve visual funct","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G1010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cdsm stanson","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G1013",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cdsm evidencecare","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G1027",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt hemo < 3mo","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Post-d/c h vst new pt 45 m","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["G2023",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Specimen collect covid-19",33.547800000000002,4.1622000000000003,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2]
["G2067",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med assist tx meth wk","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2075",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med tx meds nos","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2087",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Off base opioid tx, 60 m","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["G2100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt 66+ frailty and med dem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt 66+ frailty and adv ill","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2128",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No aspirin med rsn","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2137",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bk pain vas 6-20wk > 3","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2167",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Res change sc < 0","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2168",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Svs by pt in home health","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2181",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bmi not doc medrsn ptref","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2188",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt 50 yrs w/clin ind hd","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Unhlthy etoh rcvd couns","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2207",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rsn no trtmt chem her2","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G2251",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brief chkin, 5-10, non-e/m","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2]
["G4001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diagnostic rad ss","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G4017",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nutrition/dietician ss","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G4018",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ob/gyn ss","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G4031",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Radiation oncology ss","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G4038",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vascular surgery ss","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G6008",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Radiation treatment delivery",338.32740000000001,338.32740000000001,"000",0,0,0,3,0,0,0,0,0,"","R",null,"Y-CM",2]
["G6015",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Radiation tx delivery imrt",681.41160000000002,681.41160000000002,"000",0,0,0,3,0,0,0,0,0,"","R",null,"Y-CM",2]
["G8405",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Low extemity neur not perfor","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8416",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt inelig footwear evaluatio","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8473",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ace/arb thxpy rx'd","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8474",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ace/arb not rx'd; doc reas","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8539",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc funct and care plan","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8561",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt inelig for ref oto eval","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8577",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reop req bld grft oth","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8633",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pharm ther osteo rx","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8659",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rafscrs lbi scor >= 0","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8662",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rafs crs lbi no scor no surv","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8722",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med reas pt, pn, not doc","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8723",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spec sit not prim tumor","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8754",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dias bp less 90","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8817",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc reas no statin med disch","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8841",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No sleep apnea assess","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8852",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pos air press prescribe","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8875",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Breast cancer dx min invsive","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8878",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sent lymph node biopsy","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8915",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt not trans to hosp at d/c","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8918",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt w/o preop order iv ab pro","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8941",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eld maltreatment doc as pos","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G8964",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Csi any other than pci 2 yr","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mccd, risk adj hi, initial","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9012",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Other specified case mgmt","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["G9058",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc prac mgmt disagree w/gui","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9061",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc prac cond noadd by guide","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9077",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx prostate t1no progres","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9080",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx prostate w/rise psa","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9089",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx colon extent unknown","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9101",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx gastric p r1-r2noprog","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx head/neck t3-4 noprog","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9124",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx cml acceler phase","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9137",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx nhl relapse/refractor","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9157",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transesoph doppl cardiac mon","Not Covered","Not Covered","000",0,0,0,2,9,9,9,0,0,"","X",null,null,2]
["G9213",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No doc of dsm-iv","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9226",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"3 comp foot exam completed","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9243",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc viral load <200","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9278",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc no daily aspirin","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9287",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No antibio w in 10d of sympt","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9296",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc share dec prior proc","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9313",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amoxic not presc as 1st line","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9322",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No doc count of ct in 12mo","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9355",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No early ind/delivery","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9358",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pp eval/edu not perf","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9380",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Off assis eol iss","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9403",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc reas no 30 day f/u","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Admit w/in 180d req remov","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9422",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rpt doc class histo type","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9451",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"1x scrn hcv infect","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9459",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tob non-user","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9478",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Othe therapist at hospice","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9497",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rec inst no smoke day surg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9506",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bio imm resp mod presc","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9517",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No impr vis acuit w/in 90d","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9530",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt mbht hd ct ord ec prov","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9549",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc med rsn for f/u imag","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9594",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt mbht hd ct ord ec prov","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9605",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surv score no improv w/tx","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9618",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc scr uter mal or us/samp","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9622",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No unheal etoh user","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9629",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med rsn no rpt bowel inj","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9646",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt w/90d mrs 0-2","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9658",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Toc tool incl elem not used","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9687",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice anytime msmt per","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9699",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Long inhal bronchdil no pres","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9708",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bilat mast/hx bi /unilat mas","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9718",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice anytime msmt per","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9725",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt w/hosp anytime msmt per","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9729",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt unbl cmplt hip fs prom","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9741",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt w/hosp anytime msmt per","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9754",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Incid pulm nodule","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9767",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hosp new dx cva consid evst","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9777",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt no antiemet pre/intraop","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9786",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Path report not sent","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["G9805",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt w/hosp anytime msmt per","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9812",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt died during inpt/30d aft","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9820",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc chlam scr test w/follow","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9840",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gene testing performed","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9847",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt recd chemo last 14d life","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9876",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"2 em core ms mo 7-9 no wl","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9891",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Em session reporting","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9899",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scrn mam perf rslts doc","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9911",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Node neg pre/post syst ther","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9918",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No funct stat perf, rsn nos","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9922",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sfty cncrns scrn nd mit recs","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9938",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt 66+ snp or ltc pos","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9948",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adtl spine proc on same date","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9964",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt recv >=1 well-chld visit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9988",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pall serv during meas","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["G9996",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc pt pal or hospice","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["H0009",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol and/or drug services","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,16]
["H0016",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol and/or drug services","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["H0020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol and/or drug services","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,16]
["H0030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol and/or drug hotline","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["H0037",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Comm psy sup tx pgm per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["H0049",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol/drug screening","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,16]
["H1004",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Follow up home visit/prental","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,16]
["H2016",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Comp comm supp svc, per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["H2028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sex offend tx svc, 15 min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["H2029",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sex offend tx svc, per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["H2037",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dev delay prev dp ch, 15 min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J0180",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Agalsidase beta injection",198.73599999999999,198.73599999999999,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J0200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alatrofloxacin mesylate","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J0248",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, remdesivier, 1 mg","Facility Only",578.44800000000009,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,16]
["J0280",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Aminophyllin 250 mg inj",11.571,11.571,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J0350",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection anistreplase 30 u","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J0475",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Baclofen 10 mg injection",179.649,179.649,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J0476",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Baclofen intrathecal trial",64.396000000000001,64.396000000000001,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J0520",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bethanechol chloride inject","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J0588",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Incobotulinumtoxin a",5.0629999999999997,5.0629999999999997,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2,16]
["J0593",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj., lanadelumab-flyo, 1 mg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J0630",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Calcitonin salmon injection",2644.43,2644.43,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J0642",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, khapzory, 0.5 mg",1.3180000000000001,1.3180000000000001,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-ONC",2,16]
["J0706",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Caffeine citrate injection","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J0741",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, cabote rilpivir 2mg 3mg",21.1768,21.1768,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,16]
["J0742",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj imip 4 cilas 4 releb 2mg",2.3130000000000002,2.3130000000000002,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J0795",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Corticorelin ovine triflutal","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J0890",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Peginesatide injection","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J0896",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj luspatercept-aamt 0.25mg",37.399000000000001,37.399000000000001,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-ONC",2,16]
["J1100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dexamethasone sodium phos",0.112,0.112,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J1165",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Phenytoin sodium injection",0.437,0.437,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J1260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dolasetron mesylate",5.86,5.86,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J1324",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Enfuvirtide injection",0.66,0.66,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J1410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj estrogen conjugate 25 mg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J1428",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, eteplirsen, 10 mg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J1452",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intraocular fomivirsen na","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J1458",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Galsulfase injection","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J1560",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gamma globulin > 10 cc inj",464.27100000000002,464.27100000000002,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J1571",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hepagam b im injection",76.105000000000004,76.105000000000004,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2,16]
["J1627",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, granisetron, xr, 0.1 mg",6.5659999999999998,6.5659999999999998,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,28,16]
["J1655",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tinzaparin sodium injection","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J1729",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj hydroxyprogst capoat nos","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J1740",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ibandronate sodium injection",45.64,45.64,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J1826",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Interferon beta-1a inj",952.64,952.64,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2,16]
["J1850",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Kanamycin sulfate 75 mg inj","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J1955",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj levocarnitine per 1 gm",22.459,22.459,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J1980",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hyoscyamine sulfate inj",28.890999999999998,28.890999999999998,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J2185",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Meropenem",0.69299999999999995,0.69299999999999995,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J2300",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj nalbuphine hydrochloride",2.6110000000000002,2.6110000000000002,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J2350",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, ocrelizumab, 1 mg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J2355",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oprelvekin injection",426.92,426.92,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J2501",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Paricalcitol",0.80200000000000005,0.80200000000000005,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J2507",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pegloticase injection","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28,16]
["J2650",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prednisolone acetate inj","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J2680",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fluphenazine decanoate 25 mg",10.885999999999999,10.885999999999999,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J2778",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ranibizumab injection","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J2795",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ropivacaine hcl injection",6.9000000000000006E-2,6.9000000000000006E-2,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J2820",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sargramostim injection",54.040999999999997,54.040999999999997,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J2860",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, siltuximab","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J3060",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, taliglucerase alfa 10 u","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J3105",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Terbutaline sulfate inj",2.9729999999999999,2.9729999999999999,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J3262",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tocilizumab injection",5.819,5.819,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2,16]
["J3285",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Treprostinil injection","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J3357",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ustekinumab sub cu inj, 1 mg",166.315,166.315,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2,16]
["J3370",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vancomycin hcl injection",2.7360000000000002,2.7360000000000002,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J3430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vitamin k phytonadione inj",3.488,3.488,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J3480",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj potassium chloride",0.154,0.154,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J3535",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Metered dose inhaler drug","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,16]
["J7050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Normal saline solution infus",0.63900000000000001,0.63900000000000001,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J7181",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Factor xiii recomb a-subunit",15.678000000000001,15.678000000000001,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2,16]
["J7185",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Xyntha inj",1.2549999999999999,1.2549999999999999,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J7198",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Anti-inhibitor",2.2109999999999999,2.2109999999999999,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2,16]
["J7203",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Factor ix recomb gly rebinyn","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J7297",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Liletta, 52 mg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J7308",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Aminolevulinic acid hcl top","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["J7315",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ophthalmic mitomycin",361.87,361.87,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2,16]
["J7324",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Orthovisc inj per dose",154.749,154.749,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2,16]
["J7500",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Azathioprine oral 50mg",8.1029999999999998,8.1029999999999998,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["J7503",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tacrol envarsus ex rel oral",1.5149999999999999,1.5149999999999999,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["J7518",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mycophenolic acid","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["J7604",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Acetylcysteine comp unit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["J7620",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Albuterol ipratrop non-comp",0.125,0.125,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["J7631",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cromolyn sodium noncomp unit",2.403,2.403,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["J7638",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dexamethasone comp unit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["J7645",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ipratropium bromide comp","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["J7677",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Revefenacin inh non-com 1mcg",0.189,0.189,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["J7682",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tobramycin non-comp unit",23.771000000000001,23.771000000000001,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["J8520",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Capecitabine, oral, 150 mg",0.40799999999999997,0.40799999999999997,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["J8562",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oral fludarabine phosphate","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["J9015",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Aldesleukin injection",4683.6000000000004,4683.6000000000004,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["J9021",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, aspara, rylaze, 0.1 mg",108.52080000000001,108.52080000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["J9042",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brentuximab vedotin inj","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["J9045",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Carboplatin injection",2.7679999999999998,2.7679999999999998,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["J9144",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Daratumumab, hyaluronidase",44.877000000000002,44.877000000000002,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-ONC",2]
["J9160",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Denileukin diftitox inj","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["J9173",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj., durvalumab, 10 mg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["J9201",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"In gemcitabine hcl nos 200mg",3.9769999999999999,3.9769999999999999,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["J9213",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Interferon alfa-2a inj","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,"Y-CM",2]
["J9217",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Leuprolide acetate suspnsion",168.691,168.691,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["J9260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Methotrexate sodium inj",2.36,2.36,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["J9268",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pentostatin injection",2065.317,2065.317,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["J9301",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Obinutuzumab inj","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["J9307",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pralatrexate injection",321.08800000000002,321.08800000000002,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["J9311",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj rituximab, hyaluronidase","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["J9348",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj. naxitamab-gqgk, 1 mg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["J9370",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vincristine sulfate 1 mg inj",4.9850000000000003,4.9850000000000003,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["J9400",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, ziv-aflibercept, 1mg",8.2219999999999995,8.2219999999999995,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["K0006","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Heavy duty wheelchair",116.28700000000001,116.28700000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["K0009","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Other manual wheelchair/base",93.688800000000001,93.688800000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["K0015","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Detach non-adj ht armrst rep",179.42600000000002,179.42600000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["K0019","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Arm pad repl, each",17.077399999999997,17.077399999999997,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["K0020","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Fixed adjust armrest pair",5.0263999999999998,5.0263999999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["K0042","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Standard size ftplate rep ea",3.3577999999999997,3.3577999999999997,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["K0050","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Ratchet assembly replacement",3.4711000000000003,3.4711000000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["K0052","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Swingaway detach ftrest repl",9.1464000000000016,9.1464000000000016,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["K0105","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Iv hanger",12.051,12.051,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["K0462","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Temporary replacement eqpmnt","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,9]
["K0605","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Repl batt lithium 4.5 v",18.097100000000001,18.097100000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["K0672","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Removable soft interface le",90.181142251200001,90.181142251200001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["K0743","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Portable home suction pump","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,9]
["K0813","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 1 std port seat/back",350.62230000000005,350.62230000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["K0816","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 1 std cap chair",437.39980000000003,437.39980000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["K0825","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 2 hd cap chair",594.62929999999994,594.62929999999994,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["K0831","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp2 std seat elevate cap","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,9]
["K0838","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 2 hd sing pow opt cap",5742.0440000000008,5742.0440000000008,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["K0842","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp2 std mult pow opt cap",5708.6720000000005,5708.6720000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["K0849","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 3 std cap chair",8277.2860000000001,8277.2860000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["K0852","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 3 vhd seat/back",1153.8575000000001,1153.8575000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["K0858","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp3 hd sing pow opt s/b",1146.5445000000002,1146.5445000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["K0861","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp3 std mult pow opt s/b",925.57860000000005,925.57860000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["K0870","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 4 hd seat/back","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,9]
["K0884","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp4 std mult pow opt s/b","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,9]
["K0898","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Power wheelchair noc","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,9]
["K1002","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Ces system w/supplies access","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["K1013","U",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Enema tube, any, replac only","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,9]
["K1016",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Trans elec nerv for trigemin","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["K1028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Control unit neuromuscul osa","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["L0112",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cranial cervical orthosis",1772.7252000000001,1772.7252000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L0200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cerv col supp adj bar & thor",802.30439999999999,802.30439999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L0466",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tlso r fram soft ant pre cst",572.45429999999999,572.45429999999999,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L0482",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tlso rigid lined custom fab",2058.1713,2058.1713,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L0622",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sio flex pelvisacral custom",389.1474,389.1474,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L0632",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lso sag rigid frame cust","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,9]
["L0635",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lso sagit rigid panel prefab",1338.3752999999999,1338.3752999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L0820",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Halo cervical into body jack",3276.3387000000002,3276.3387000000002,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L0859",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mri compatible system",1478.1648,1478.1648,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L1001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ctlso infant immobilizer","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["L1090",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lumbar sling",120.6015,120.6015,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L1210",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lateral thoracic extension",317.48759999999999,317.48759999999999,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L1610",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ho frejka cov only pre cst",53.271300000000004,53.271300000000004,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L1680",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pelvic & hip control thigh c",1971.1979999999999,1971.1979999999999,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L1690",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Combination bilateral ho",2449.2251999999999,2449.2251999999999,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L1843",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ko single upright pre cst",1136.4462000000001,1136.4462000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L1845",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ko double upright pre cst",1029.9650999999999,1029.9650999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L1907",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Afo supramalleolar custom",712.68659999999988,712.68659999999988,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L1950",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Afo spiral molded to pt plas",1205.0433,1205.0433,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L2010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Kafo sng solid stirrup w/o j",1481.3136,1481.3136,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L2090",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hkafo unilat torsion ball br",709.40250000000003,709.40250000000003,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L2128",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Kafo fem fx cast molded to p",2774.1420000000003,2774.1420000000003,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L2136",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Kafo femoral fx cast rigid",1434.9302999999998,1434.9302999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L2265",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Long tongue stirrup",142.9014,142.9014,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L2275",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Plastic mod low ext pad/line",189.77669999999998,189.77669999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L2380",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Torsion straight knee joint",152.0772,152.0772,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L2415",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Knee joint cam lock each joi",153.83609999999999,153.83609999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L2540",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Thigh/wght bear lacer molded",647.06610000000001,647.06610000000001,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L2650",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pelv & thor control gluteal",194.14320000000001,194.14320000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L2768",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ortho sidebar disconnect",165.00450000000001,165.00450000000001,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L2795",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Knee control full kneecap",127.80929999999999,127.80929999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3031",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Foot lamin/prepreg composite",161.2038,161.2038,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Foot arch supp premold metat",59.593500000000006,59.593500000000006,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3203",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oxford w/ supinator/pronator","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["L3212",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Benesch boot pair infant","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["L3230",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom shoes depth inlay",438.94400000000002,438.94400000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3320",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoe lift elev heel/sole cor",159.1216,159.1216,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3370",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoe sole wedge between sole",62.779199999999996,62.779199999999996,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3455",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoe heel new leather standa",51.561599999999999,51.561599999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3530",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ortho shoe add half sole",40.2333,40.2333,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3560",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"O shoe add horseshoe toe tap",29.015699999999999,29.015699999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3660",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"So 8 ab rstr can/web pre ots",122.02829999999999,122.02829999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3702",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eo w/o joints cf",332.83800000000002,332.83800000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3766",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ewhfo w/joint(s) cf",1565.1258,1565.1258,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L3912",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hfo flexion glove pre ots",150.14609999999999,150.14609999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3921",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hfo w/joint(s) cf",370.25459999999998,370.25459999999998,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L3935",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fo nontorsion joint cf",254.63460000000001,254.63460000000001,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L3976",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sewhfo airplane w/o jnts cf",1936.6472999999999,1936.6472999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L3980",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Up ext fx orthos humeral nos",367.06889999999999,367.06889999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L4045",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Replace non-molded thigh lac",401.50889999999998,401.50889999999998,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L4100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Repl leath cuff kafo prox th",168.74369999999999,168.74369999999999,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L4392",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Replace afo soft interface",29.310899999999997,29.310899999999997,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L5010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mold socket ank hgt w/ toe f",1637.76,1637.76,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5250",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hip canad sing axi cons fric",8610.4319999999989,8610.4319999999989,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Postop dsg bk ea add cast ch",691.54560000000004,691.54560000000004,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5530",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prep bk ptb thermopls molded",2699.6864,2699.6864,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5560",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prep ak ischial plast molded",2907.8271999999997,2907.8271999999997,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5617",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ak/bk self-aligning unit ea",738.89279999999997,738.89279999999997,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L5629",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Below knee acrylic socket",427.50720000000001,427.50720000000001,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5643",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hip flex inner socket ext fr",2403.6480000000001,2403.6480000000001,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5650",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tot contact ak/knee disart s",772.04480000000001,772.04480000000001,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5670",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bk molded supracondylar susp",398.45120000000003,398.45120000000003,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5681",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intl custm cong/latyp insert",1737.1392000000001,1737.1392000000001,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L5694",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ak pelvic control belt pad/l",324.1216,324.1216,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5697",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ak/knee disartic pelvic band",143.9872,143.9872,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5706",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom shape cvr knee disart",1334.7967999999998,1334.7967999999998,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L5724",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Knee-shin exo fluid swing ph",2160.64,2160.64,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5814",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Endo knee-shin hydral swg ph",4904.6528000000008,4904.6528000000008,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L5830",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Endo knee-shin pneum/swg pha",3312.3328000000001,3312.3328000000001,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5920",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Endo ak/hip alignable system",713.77919999999995,713.77919999999995,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5940",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Endo bk ultra-light material",838.97600000000011,838.97600000000011,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5978",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ft prosth multiaxial ankl/ft",475.96800000000002,475.96800000000002,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L5981",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flex-walk sys low ext prosth",4406.5408000000007,4406.5408000000007,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L6000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Part hand thumb rem",2383.232,2383.232,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L6130",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Elbow stump activated lock h",4643.2767999999996,4643.2767999999996,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L6384",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Postop dsg cast chg shlder/t",2741.6704,2741.6704,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L6570",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scap thorac prosth tiss shap",7130.5983999999999,7130.5983999999999,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L6615",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disconnect locking wrist uni",287.50080000000003,287.50080000000003,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L6621",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flex/ext wrist w/wo friction",3020.672,3020.672,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L6647",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoulder lock actuator",685.70880000000011,685.70880000000011,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L6655",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Standard control cable extra",134.7328,134.7328,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L6682",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Test sock elbw disart/above",407.15519999999998,407.15519999999998,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,9]
["L6693",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lockingelbow forearm cntrbal",3749.2736,3749.2736,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L6711",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped term dev, hook, vol open","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["L6805",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Term dev modifier wrist unit",568.98559999999998,568.98559999999998,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,23]
["L6905",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hand restoration multiple fi",2633.4720000000002,2633.4720000000002,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,23]
["L6940",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Elbow disarticulation switch",13598.131200000002,13598.131200000002,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,23]
["L7045",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pediatric electric hook","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X","Y",null,2,16]
["L7181",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Electronic elbo simultaneous",52914.995199999998,52914.995199999998,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,16]
["L7366",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Battery chrgr 12 volt utah/e",906.08640000000003,906.08640000000003,"000",0,0,0,9,9,9,9,9,9,"","F","Y","Y-CM",2,16]
["L7499",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Upper extremity prosthes nos","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N","Y","Y-CM",2,16]
["L8020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mastectomy form",324.096,324.096,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,23]
["L8041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Midfacial prosthesis",3979.9935999999998,3979.9935999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,24]
["L8310",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Truss double w/ standard pad",197.47839999999999,197.47839999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,24]
["L8420",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prosthetic sock multi ply bk",26.982399999999998,26.982399999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L8505",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Artificial larynx, accessory","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,9]
["L8509",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Trach-esoph voice pros md in",144.2176,144.2176,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,9]
["L8612",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Aqueous shunt prosthesis",974.29759999999999,974.29759999999999,"000",0,0,0,9,9,9,9,9,9,"","F","Y",null,2,9]
["L8615",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Coch implant headset replace",595.62239999999997,595.62239999999997,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["L8629",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cid transmit coil and cable",236.45439999999999,236.45439999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,9]
["L8679",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Imp neurosti pls gn any type","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,9]
["L8689",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"External recharg sys intern",2278.0032000000001,2278.0032000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,28]
["L8696",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ext antenna phren nerve stim","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28]
["M0240",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"CASIRI AND IMDEV REPEAT",463.5,463.5,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,28]
["M0243",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"CASIRIVI AND IMDEVI INFUSION",463.5,463.5,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,28]
["M1009",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dc eoc doc med rec","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28]
["M1012",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dc eoc doc med rec","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28]
["M1020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adl pt mj dep ds no rs 12 mo","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,24]
["M1041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt cr ft inf lm or pt id sl","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["M1057",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Aspirin not used, no rsn","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["M1070",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt not scrn fut fall no rsn","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["M1116",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Start eoc doc med rec","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["M1118",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oc ni pt 1-2 vis","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["M1134",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oc ni pt self dc 1-2 vis","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["M1142",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Emerge cases","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["P2028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cephalin floculation test",7.0785,7.0785,"000",0,0,0,9,9,9,9,9,9,"","L",null,null,2]
["P9019",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Platelets, each unit","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["P9034",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Platelets, pheresis","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["P9041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Albumin (human),5%, 50ml",10.49,10.49,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["P9055",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Plt, aph/pher, l/r, cmv-neg","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["P9057",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rbc, frz/deg/wsh, l/r, irrad","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["Q0081",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Infusion ther other than che","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,11]
["Q0085",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Chemo by both infusion and o","Facility Only",0,"000",0,0,0,9,9,9,9,9,9,"","O",null,null,2,11]
["Q0144",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Azithromycin dihydrate, oral","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["Q0173",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Trimethobenzamide hcl 250mg",1.08,1.08,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["Q0247",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sotrovimab",2465.8200000000002,2465.8200000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,26]
["Q0481",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Microprcsr cu elec vad, rep","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,26]
["Q0493",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Emr pwr cbl combo vad, rep","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,30]
["Q0499",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Belt/vest elec/combo vad rep","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,30]
["Q0512",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Px sup fee anti-can sub pres","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["Q0515",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sermorelin acetate injection","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["Q2037",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fluvirin vacc, 3 yrs & >, im","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["Q2054",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lisocabtagene mara car pos t","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2,24]
["Q4006",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup long arm adult fbrg",32.898200000000003,32.898200000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,24]
["Q4013",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup gauntlet plaster",17.7469,17.7469,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,24]
["Q4025",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup hip spica plaster",42.549300000000002,42.549300000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,24]
["Q4031",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup lng leg ped plaster","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,24]
["Q4043",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup lng leg splnt ped p","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4046",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup sht leg splnt fbrgl",21.022300000000001,21.022300000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["Q4101",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Apligraf",30.417999999999999,30.417999999999999,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["Q4110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Primatrix",40.328000000000003,40.328000000000003,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["Q4117",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hyalomatrix","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4133",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Grafix stravix prime pl sqcm","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4146",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tensix, 1cm","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4152",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dermapure 1 square cm","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4164",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Helicoll, per square cm","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4167",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Truskin, per sq centimeter","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4174",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Palingen or promatrx","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4205",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Membrane graft or wrap sq cm","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4213",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ascent, 0.5 mg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4229",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cogenex amnio memb per sq cm","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4239",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amnio-maxx or lite per sq cm","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q4247",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amniotext patch, per sq cm","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q5001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice or home hlth in home","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,36]
["Q5004",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice in snf","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,36]
["Q5010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice home care in hospice","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,36]
["Q5119",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj ruxience, 10 mg",49.816000000000003,49.816000000000003,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-ONC",2,16]
["Q9002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Va chaplain counsel individu","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["Q9962",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hocm 300-349mg/ml iodine,1ml",0.18,0.18,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["Q9992",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Buprenorphine xr over 100 mg",1781.309,1781.309,"000",0,0,0,9,9,9,9,9,9,"","D",null,null,2]
["R0075",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transport port x-ray multipl",32.2778611584,32.2778611584,"000",0,0,0,3,0,0,0,0,0,"","F",null,null,2]
["R0398",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"TRAINING, OPTION 2, JOB PLACEMENT ",10.19082,10.19082,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,30]
["S0013",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Esketamine, nasal spray",11.58,11.58,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-ONC",2]
["S0028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, famotidine, 20 mg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,16]
["S0088",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Imatinib 100 mg",3.14,3.14,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["S0108",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mercaptopurine 50 mg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S0145",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Peg interferon alfa-2a/180",1021.49,1021.49,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["S0170",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Anastrozole 1 mg",0.13,0.13,"000",0,0,0,9,9,9,9,9,9,"","D",null,"Y-CM",2]
["S0178",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lomustine 10 mg","By report","By report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,28]
["S0207",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Paramedicintercep nonhospals","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S0215",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nonemerg transp mileage","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S0260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"H&p for surgery","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S0316",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Follow-up/reassessment","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S0500",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dispos cont lens","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,11]
["S0515",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scleral lens liquid bandage","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S0595",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"New lenses in pts old frame","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S0810",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Photorefractive keratectomy","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S1016",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-pvc intravenous administ","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S2061",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Donor lobectomy (lung)","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S2067",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Breast \"stacked\" diep/gap","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S2117",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Arthroereisis, subtalar","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S2208",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Minimally invasive direct co","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S2266",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Induced abortion 29-31 wks","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S2348",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Decompress disc rf lumbar","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S3000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bilat dil retinal exam","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S3630",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eosinophil blood count","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S3846",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gene test beta-thalassemia","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S3852",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dna analysis apoe alzheimer","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S4014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Compl zift case rate","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S4027",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Store prev froz embryos","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S4042",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ovulation mgmt per cycle","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S5000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prescription drug, generic","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S5108",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Homecare train pt 15 min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S5116",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nonfamily hc train/session","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S5150",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Unskilled respite care /15m","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S5161",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Emer rspns sys serv permonth","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["S5520",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit picc insert kit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S5553",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Insulin long acting 5 u","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28]
["S8030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tantalum ring application","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8080",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scintimammography","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28]
["S8185",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flutter device","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
["S8265",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Haberman feeder","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,23]
["S8270",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Enuresis alarm","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,30]
["S8301",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Infect control supplies nos","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,30]
["S8415",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Supplies for home delivery","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8420",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom gradient sleev/glov","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8421",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ready gradient sleev/glov","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8422",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom grad sleeve med","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8423",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom grad sleeve heavy","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8424",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ready gradient sleeve","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8425",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom grad glove med","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8426",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom grad glove heavy","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8427",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ready gradient glove","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8428",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ready gradient gauntlet","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8429",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gradient pressure wrap","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Padding for comprssn bdg","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8431",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Compression bandage","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S8450",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Splint digit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8451",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Splint wrist or ankle","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8452",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Splint elbow","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8460",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Camisole post-mast","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8490",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"100 insulin syringes","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8930",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Auricular electrostimulation","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8940",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hippotherapy per session","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8948",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Low-level laser trmt 15 min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8950",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Complex lymphedema therapy,","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8990",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt or manip for maint","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S8999",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Resuscitation bag","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home uterine monitor with or","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9007",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ultrafiltration monitor","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9024",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Paranasal sinus ultrasound","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9025",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Omnicardiogram/cardiointegra","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9034",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eswl for gallstones","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9055",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Procuren or other growth fac","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9056",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Coma stimulation per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9061",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Medical supplies and equipme","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9083",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urgent care center global","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9088",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Services provided in urgent","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9090",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vertebral axial decompressio","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9097",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home visit wound care","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9098",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home phototherapy visit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Telemonitoring/home per mnth","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9117",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Back school visit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9122",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home health aide or certifie",33.051876,33.051876,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC",2]
["S9123",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nursing care in home rn",66.459510374399997,66.459510374399997,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC",2]
["S9124",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nursing care, in the home; b",48.005746588800001,48.005746588800001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-ONC",2]
["S9125",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Respite care, in the home, p","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9126",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice care, in the home, p","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9127",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Social work visit, in the ho","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9128",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Speech therapy, in the home,","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9129",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Occupational therapy, in the","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9131",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt in the home per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9140",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diabetic management program,","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9141",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diabetic management program,","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9145",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Insulin pump initiation","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9150",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Evaluation by ocularist","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9152",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Speech therapy, re-eval","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9208",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home mgmt preterm labor","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9209",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home mgmt pprom","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9211",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home mgmt gest hypertension","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9212",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hm postpar hyper per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9213",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hm preeclamp per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9214",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hm gest dm per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9325",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit pain mgmt per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9326",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit cont pain per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9327",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit int pain per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9328",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit pain imp pump diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9329",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit chemo per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9330",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit cont chem diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9331",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit intermit chemo diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9335",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht hemodialysis diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9336",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit cont anticoag diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9338",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit immunotherapy diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9339",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit periton dialysis diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9340",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit enteral per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9341",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit enteral grav diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9342",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit enteral pump diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9343",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit enteral bolus nurs","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9345",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit anti-hemophil diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9346",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit alpha-1-proteinas diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9347",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit longterm infusion diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9348",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit sympathomim diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9349",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tocolysis diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9351",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit cont antiemetic diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9353",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit cont insulin diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9355",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit chelation diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9357",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit enzyme replace diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9359",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit anti-tnf per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9361",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit diuretic infus diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9363",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit anti-spasmotic diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9364",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tpn total diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9365",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tpn 1 liter diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9366",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tpn 2 liter diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9367",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tpn 3 liter diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9368",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tpn over 3l diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9370",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj antiemetic diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9372",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj anticoag diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9373",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit hydra total diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9374",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit hydra 1 liter diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9375",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit hydra 2 liter diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9376",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit hydra 3 liter diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9377",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit hydra over 3l diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9379",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit noc per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9381",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit high risk/escort","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9401",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Anticoag clinic per session","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pharmacy comp/disp serv","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9432",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med food non inborn err meta","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9433",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Medical food oral 100% nutr","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9434",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mod solid food suppl","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9435",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Medical foods for inborn err","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9436",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lamaze class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9437",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Childbirth refresher class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9438",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cesarean birth class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9439",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vbac class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9441",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Asthma education","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9442",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Birthing class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9443",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lactation class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9444",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Parenting class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9445",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt education noc individ",44.652483532799998,44.652483532799998,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["S9446",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt education noc group","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9447",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Infant safety class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9449",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Weight mgmt class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9451",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Exercise class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9452",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nutrition class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9453",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Smoking cessation class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9454",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Stress mgmt class","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9455",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diabetic management program,","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9460",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diabetic management program,","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28,28]
["S9465",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diabetic management program,","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28,28]
["S9470",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nutritional counseling, diet","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9472",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cardiac rehabilitation progr","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,28,28]
["S9473",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pulmonary rehabilitation pro","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9474",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Enterostomal therapy by a re","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9475",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ambulatory setting substance","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9476",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vestibular rehab per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9480",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intensive outpatient psychia","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["S9482",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Family stabilization 15 min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9484",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crisis intervention per hour","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9485",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crisis intervention mental h","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9490",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit corticosteroid/diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9494",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic total diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9497",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q3h diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9500",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q24h diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9501",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q12h diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9502",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q8h diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9503",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q6h diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9504",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q4h diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9529",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Venipuncture home/snf","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9537",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht hem horm inj diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9538",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit blood products diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9542",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj noc per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9558",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj growth horm diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9559",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit inj interferon diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9560",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj hormone diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9562",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj palivizumab diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9590",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht irrigation diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9810",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht pharm per hour","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9900",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Christian sci pract visit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9901",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Christian sci nurse visit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9960",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Air ambulanc nonemerg fixed","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9961",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Air ambulan nonemerg rotary","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9970",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Health club membership yr","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9975",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transplant related per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9976",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lodging per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9977",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Meals per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9981",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med record copy admin",28.913781124800003,28.913781124800003,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["S9982",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med record copy per page",0.57329981280000009,0.57329981280000009,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["S9986",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Not medically necessary svc","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9988",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Serv part of phase i trial","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9989",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Services outside us","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9990",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Services provided as part of","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9991",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Services provided as part of","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9992",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transportation costs to and","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9994",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lodging costs (e.g. hotel ch","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9996",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Meals for clinical trial par","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["S9999",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sales tax","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Private duty/independent nsg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nursing assessment/evaluatn","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rn services up to 15 minutes","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lpn/lvn services up to 15min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1004",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nsg aide service up to 15min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1005",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Respite care service 15 min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1006",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Family/couple counseling","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1007",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Treatment plan development","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1009",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Child sitting services","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Meals when receive services","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1012",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol/substance abuse skil","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1013",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sign lang/oral interpreter","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Telehealth transmit, per min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1015",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Clinic service","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["T1016",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Case management","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1017",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Targeted case management","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1018",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"School-based iep ser bundled","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1019",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Personal care ser per 15 min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Personal care ser per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1021",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hh aide or cn aide per visit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1022",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contracted services per day","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1023",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Program intake assessment","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1024",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Team evaluation & management","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1025",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped compr care pkg, per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1026",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped compr care pkg, per hour","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1027",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Family training & counseling","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home environment assessment","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1029",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dwelling lead investigation","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rn home care per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1031",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lpn home care per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Comm bh clinic svc per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Comm bh clinic svc per month","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1502",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Medication admin visit","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1503",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med admin, not oral/inject","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1505",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Elec med comp dev, noc","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T1999",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Noc retail items andsupplies","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; patient attend/escort","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; encounter/trip","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2004",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; commerc carrier pass","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2005",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; stretcher van","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2007",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-emer transport wait time","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pasrr level i","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2011",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pasrr level ii","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2012",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil ed waiver, per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2013",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil ed waiver per hour","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil prevoc waiver, per d","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2015",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil prevoc waiver per hr","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2016",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil res waiver per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2017",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil res waiver 15 min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2018",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil sup empl waiver/diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2019",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil sup empl waiver 15min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Day habil waiver per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2021",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Day habil waiver per 15 min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2022",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Case management, per month","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2023",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Targeted case mgmt per month","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2024",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Serv asmnt/care plan waiver","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2025",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Waiver service, nos","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2026",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Special childcare waiver/d","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2027",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spec childcare waiver 15 min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Special supply, nos waiver","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2029",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Special med equip, noswaiver","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Assist living waiver/month","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2031",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Assist living waiver/diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2032",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Res care, nos waiver/month","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2033",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Res, nos waiver per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2034",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crisis interven waiver/diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2035",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Utility services waiver","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2036",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Camp overnite waiver/session","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2037",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Camp day waiver/session","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2038",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Comm trans waiver/service","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2039",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vehicle mod waiver/service","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Financial mgt waiver/15min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Support broker waiver/15 min","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2042",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice routine home care","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2043",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice continuous home care","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2044",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice respite care","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2045",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice general care","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2046",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice long term care, r&b","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2047",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hab prevo waiver per 15","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2048",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bh ltc res r&b, per diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2049",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; stretcher van, mileage","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Financial mgt waiver/diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2051",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Support broker waiver/diem","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T2101",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Breast milk proc/store/dist","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T4521",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size brief/diaper sm","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4522",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size brief/diaper med","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4523",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size brief/diaper lg","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4524",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size brief/diaper xl","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4525",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size pull-on sm","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4526",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size pull-on med","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4527",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size pull-on lg","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4528",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size pull-on xl","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4529",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped size brief/diaper sm/med","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T4530",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped size brief/diaper lg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T4531",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped size pull-on sm/med","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T4532",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped size pull-on lg","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T4533",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Youth size brief/diaper","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4534",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Youth size pull-on","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4535",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disposable liner/shield/pad","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4536",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reusable pull-on any size","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4537",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reusable underpad bed size","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4538",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diaper serv reusable diaper","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T4539",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reuse diaper/brief any size","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4540",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reusable underpad chair size","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4541",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Large disposable underpad","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4542",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Small disposable underpad","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4543",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult disp brief/diap abv xl","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T4544",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adlt disp und/pull on abv xl","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T4545",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Incon disposable penile wrap","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2]
["T5001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Position seat spec orth need","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["T5999",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Supply, nos","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["U0001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"2019-ncov diagnostic p",51.365600000000001,51.365600000000001,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
["U0002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Covid-19 lab test non-cdc",73.3733,73.3733,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
["U0003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"SARS-COV-2 DNA/RNA HIGH THROUGHPUT",107.25,107.25,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
["U0004",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"2019-NCOV ANY TECHNIQUE HIGH THROUGHPUT",107.25,107.25,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
["U0005",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Infec agen detec ampli probe",35.75,35.75,"000",0,0,0,9,9,9,9,9,9,"","L",null,"Y-CM",2,23]
["V0028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Travel, vocational services, claimant","State Rate","State Rate","000",0,0,0,9,9,9,9,9,9,"","S",null,null,2,30]
["V2020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vision svcs frames purchases",76.755600000000001,76.755600000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2025",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eyeglasses delux frames","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V2100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens spher single plano 4.00",48.482100000000003,48.482100000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2101",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Single visn sphere 4.12-7.00",49.862299999999998,49.862299999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2102",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Singl visn sphere 7.12-20.00",62.850600000000007,62.850600000000007,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2103",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylindr 4.00d/12-2.00d",46.051300000000005,46.051300000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2104",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylindr 4.00d/2.12-4d",47.400600000000004,47.400600000000004,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2105",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.00d/4.25-6d",53.467299999999994,53.467299999999994,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2106",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.00d/>6.00d",57.360700000000001,57.360700000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2107",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.25d/12-2d",49.718100000000007,49.718100000000007,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2108",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.25d/2.12-4d",48.513000000000005,48.513000000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2109",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.25d/4.25-6d",59.554600000000001,59.554600000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.25d/over 6d",52.962600000000002,52.962600000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2111",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylindr 7.25d/.25-2.25",55.208000000000006,55.208000000000006,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2112",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylindr 7.25d/2.25-4d",61.161400000000008,61.161400000000008,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2113",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylindr 7.25d/4.25-6d",72.244200000000006,72.244200000000006,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2114",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder over 12.00d",78.712600000000009,78.712600000000009,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2115",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens lenticular bifocal",95.058700000000016,95.058700000000016,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2118",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens aniseikonic single",89.712999999999994,89.712999999999994,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2121",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lenticular lens, single",100.4147,100.4147,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2199",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens single vision not oth c","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V2200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens spher bifoc plano 4.00d",68.989400000000003,68.989400000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2201",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphere bifocal 4.12-7.0",69.267499999999998,69.267499999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2202",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphere bifocal 7.12-20.",76.178799999999995,76.178799999999995,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2203",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl bifocal 4.00d/.1",67.691599999999994,67.691599999999994,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2204",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.00d/2.1",68.021200000000007,68.021200000000007,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2205",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.00d/4.2",70.390200000000007,70.390200000000007,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2206",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.00d/ove",70.946399999999997,70.946399999999997,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2207",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.25-7d/.",66.167199999999994,66.167199999999994,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2208",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.25-7/2.",64.920900000000003,64.920900000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2209",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.25-7/4.",74.932500000000005,74.932500000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2210",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.25-7/ov",84.975000000000009,84.975000000000009,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2211",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifo 7.25-12/.25-",92.782399999999996,92.782399999999996,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2212",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl bifo 7.25-12/2.2",93.482800000000012,93.482800000000012,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2213",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl bifo 7.25-12/4.2",90.032299999999992,90.032299999999992,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2214",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl bifocal over 12.",94.523099999999999,94.523099999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2215",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens lenticular bifocal",113.5472,113.5472,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2218",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens aniseikonic bifocal",118.86200000000001,118.86200000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2219",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens bifocal seg width over",48.1937,48.1937,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2220",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens bifocal add over 3.25d",39.088500000000003,39.088500000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2221",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lenticular lens, bifocal",104.854,104.854,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2299",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens bifocal speciality","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V2300",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphere trifocal 4.00d",81.720200000000006,81.720200000000006,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2301",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphere trifocal 4.12-7.",85.871100000000013,85.871100000000013,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2302",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphere trifocal 7.12-20",88.775700000000001,88.775700000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2303",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy trifocal 4.0/.12-",81.205200000000005,81.205200000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2304",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy trifocal 4.0/2.25",75.0458,75.0458,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2305",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy trifocal 4.0/4.25",84.573300000000003,84.573300000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2306",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl trifocal 4.00/>6",86.787800000000004,86.787800000000004,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2307",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy trifocal 4.25-7/.",88.250400000000013,88.250400000000013,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2308",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifocal 4.25-7/2.",97.860300000000009,97.860300000000009,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2309",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifocal 4.25-7/4.",101.1769,101.1769,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2310",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifocal 4.25-7/>6",96.614000000000004,96.614000000000004,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2311",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifo 7.25-12/.25-",96.449200000000005,96.449200000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2312",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifo 7.25-12/2.25",99.322900000000004,99.322900000000004,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2313",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifo 7.25-12/4.25",111.40479999999999,111.40479999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2314",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl trifocal over 12",116.3488,116.3488,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2315",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens lenticular trifocal",131.69579999999999,131.69579999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2318",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens aniseikonic trifocal",158.78479999999999,158.78479999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2319",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens trifocal seg width > 28",53.755699999999997,53.755699999999997,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2320",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens trifocal add over 3.25d",64.179299999999998,64.179299999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2321",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lenticular lens, trifocal",127.31830000000001,127.31830000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2399",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens trifocal speciality","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V2410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens variab asphericity sing",114.845,114.845,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens variable asphericity bi",119.92290000000001,119.92290000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2499",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Variable asphericity lens","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V2500",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens pmma spherical",117.30670000000001,117.30670000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2501",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens pmma-toric/prism",134.02360000000002,134.02360000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2502",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens pmma bifocal",165.10900000000001,165.10900000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2503",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens pmma color vision",162.20439999999999,162.20439999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2510",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct gas permeable sphericl",150.36970000000002,150.36970000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2511",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct toric prism ballast",172.57650000000001,172.57650000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2512",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens gas permbl bifocl",203.9194,203.9194,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2513",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens extended wear",186.93470000000002,186.93470000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2520",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens hydrophilic",126.60760000000001,126.60760000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2521",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens hydrophilic toric",196.55490000000003,196.55490000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2522",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens hydrophil bifocl",191.28130000000002,191.28130000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2523",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens hydrophil extend",166.45830000000001,166.45830000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2524",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens hydrophil photoch","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V2525",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cl, hydrophilic, dual focus","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V2530",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens gas impermeable",241.43200000000002,241.43200000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2531",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens gas permeable",575.40949999999998,575.40949999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2]
["V2599",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens/es other type","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V2600",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hand held low vision aids","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2610",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Single lens spectacle mount","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2615",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Telescop/othr compound lens","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2623",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Plastic eye prosth custom",1164.6313,1164.6313,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2624",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Polishing artifical eye",87.86930000000001,87.86930000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2625",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Enlargemnt of eye prosthesis",534.20949999999993,534.20949999999993,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2626",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reduction of eye prosthesis",287.9674,287.9674,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2627",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scleral cover shell",1859.7885999999999,1859.7885999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2628",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fabrication & fitting",439.1302,439.1302,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2629",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prosthetic eye other type","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2630",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Anter chamber intraocul lens",128.85300000000001,128.85300000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2631",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Iris support intraoclr lens",128.85300000000001,128.85300000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2632",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Post chmbr intraocular lens",128.85300000000001,128.85300000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2700",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Balance lens",47.421199999999999,47.421199999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2702",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Deluxe lens feature","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2710",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glass/plastic slab off prism",69.411699999999996,69.411699999999996,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2715",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prism lens/es",15.470599999999999,15.470599999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2718",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fresnell prism press-on lens",30.910300000000003,30.910300000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2730",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Special base curve",22.8248,22.8248,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2744",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tint photochromatic lens/es",19.662700000000001,19.662700000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2745",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tint, any color/solid/grad",13.2973,13.2973,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2750",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Anti-reflective coating",20.661799999999999,20.661799999999999,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2755",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Uv lens/es",19.250700000000002,19.250700000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2756",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eye glass case","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2760",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scratch resistant coating",17.334899999999998,17.334899999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2761",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mirror coating","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2762",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Polarization, any lens",63.334700000000005,63.334700000000005,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2770",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Occluder lens/es",21.321000000000002,21.321000000000002,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2780",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oversize lens/es",13.565100000000001,13.565100000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2781",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Progressive lens per lens","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2782",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens, 1.54-1.65 p/1.60-1.79g",68.412599999999998,68.412599999999998,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2783",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens, >= 1.66 p/>=1.80 g",77.116100000000003,77.116100000000003,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2784",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens polycarb or equal",50.150700000000001,50.150700000000001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2]
["V2785",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Corneal tissue processing","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2786",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Occupational multifocal lens","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2787",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Astigmatism-correct function","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V2788",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Presbyopia-correct function","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V2790",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amniotic membrane","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2797",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vis item/svc in other code","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V2799",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Misc vision item or service","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V5008",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing screening",89.919316226694221,89.919316226694221,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,5]
["V5010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Assessment for hearing aid","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,5]
["V5011",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid fitting/checking","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,5]
["V5014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid repair/modifying",59.949888950746086,59.949888950746086,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-PHL",2,5]
["V5020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Conformity evaluation","Bundled","Bundled","000",0,0,0,9,9,9,9,9,9,"","Bundled",null,null,2,5]
["V5030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Body-worn hearing aid air","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Body-worn hearing aid bone","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural in ear","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5060",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Behind ear hearing aid","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5070",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glasses air conduction","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V5080",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glasses bone conduction","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V5090",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid dispensing fee","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,5]
["V5095",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant mid ear hearing pros","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,5]
["V5100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Body-worn bilat hearing aid","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid dispensing fee","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,5]
["V5120",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Body-worn binaur hearing aid","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5130",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"In ear binaural hearing aid","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5140",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Behind ear binaur hearing ai","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5150",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glasses binaural hearing aid","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V5160",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dispensing fee binaural",1702.5415361248697,1702.5415361248697,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,5]
["V5171",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural ite","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5172",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural itc","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5181",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural bte","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5190",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural glasses","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disp fee contralateral monau",1020.4612056258048,1020.4612056258048,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,5]
["V5211",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural ite/ite","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5212",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural ite/itc","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5213",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural ite/bte","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5214",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural itc/itc","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5215",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural itc/bte","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5221",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural bte/bte","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5230",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural glasses","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2]
["V5240",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disp fee contralateral binau",1020.4612056258048,1020.4612056258048,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,5]
["V5241",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dispensing fee, monaural",851.27076806243485,851.27076806243485,"000",0,0,0,9,9,9,9,9,9,"","F",null,"Y-CM",2,5]
["V5242",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, monaural, cic","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5243",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, monaural, itc","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5244",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, mon, cic","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5245",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, mon, itc","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5246",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, mon, ite","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5247",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, mon, bte","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5248",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, binaural, cic","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5249",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, binaural, itc","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5250",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, bin, cic","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5251",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, bin, itc","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5252",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, bin, ite","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5253",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, bin, bte","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5254",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing id, digit, mon, cic","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5255",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, mon, itc","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5256",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, mon, ite","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5257",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, mon, bte","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5258",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, bin, cic","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5259",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, bin, itc","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, bin, ite","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5261",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, bin, bte","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-CM",2,5]
["V5262",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, disp, monaural","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,5]
["V5263",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, disp, binaural","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,5]
["V5264",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ear mold/insert","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-PHL",2,5]
["V5265",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ear mold/insert, disp","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,5]
["V5266",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Battery for hearing device",1.0482678907272001,1.0482678907272001,"000",0,0,0,9,9,9,9,9,9,"","F",null,null,2,5]
["V5267",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid sup/access/dev","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,"Y-PHL",2,5]
["V5268",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald telephone amplifier","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5269",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alerting device, any type","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5270",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald, tv amplifier, any type","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5271",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald, tv caption decoder","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5272",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tdd","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5273",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald for cochlear implant","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5274",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald unspecified","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5275",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ear impression","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,5]
["V5281",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm system, monaural","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5282",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm system binaural","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5283",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald neck, loop ind receiver","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5284",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm ear level receiver","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5285",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm aud input receiver","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5286",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald blu tooth fm/dm receiver","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5287",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm receiver, nos","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5288",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm transmitter ald","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5289",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm adapt/boot couplin","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5290",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald transmitter microphone","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2]
["V5298",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid noc","Not Covered","Not Covered","000",0,0,0,9,9,9,9,9,9,"","X",null,null,2,5]
["V5299",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing service","Not Covered","Not Covered","000",0,0,0,0,0,0,0,0,0,"","X",null,null,2,5]
["V5336",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Repair communication device","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V5362",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Speech screening","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V5363",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Language screening","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]
["V5364",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dysphagia screening","By Report","By Report","000",0,0,0,9,9,9,9,9,9,"","N",null,null,2]

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{"sheet":"MARFS_URL's","index":7,"n_rows":43,"n_cols":4,"rows_kept":43,"cut":false,"hidden":true,"merged":[]}
[null,"Chapter number","URL","Friendly Text"]
[null,1,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter1.pdf","Chapter 1: Introduction"]
[null,2,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter2.pdf","Chapter 2: Information for All Providers"]
[null,3,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter3.pdf","Chapter 3: Ambulance Services"]
[null,4,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter4.pdf","Chapter 4: Ambulance, Taxi, and Other Transportation Services"]
[null,5,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter5.pdf","Chapter 5: Audiology and Hearing Services"]
[null,6,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter6.pdf","Chapter 6: Biofeedback, Electrocardiograms (EKG), Electrodiagnostic services, & Extracorporeal Shockwave Therapy (ESWT)"]
[null,7,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter7.pdf","Chapter 7: Chiropractic Services"]
[null,8,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter8.pdf","Chapter 8: Dental Services"]
[null,9,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter9.pdf","Chapter 9: Durable Medical Equipment (DME)"]
[null,10,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter10.pdf","Chapter 10: Evaluation and Management (E/M) Services"]
[null,11,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter11.pdf","Chapter 11: Home Health Services"]
[null,12,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter12.pdf","Chapter 12: Impairment Rating Services"]
[null,13,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter13.pdf","Chapter 13: Independent Medical Exams (IME)"]
[null,14,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter14.pdf","Chapter 14: Language Access Services"]
[null,15,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter15.pdf","Chapter 15: Medical Testimony"]
[null,16,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter16.pdf","Chapter 16: Medication Administration and Injections"]
[null,17,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter17.pdf","Chapter 17: Mental Health Services"]
[null,18,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter18.pdf","Chapter 18: Modifications to Home and Vehicle"]
[null,19,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MARFSChapter19.pdf","Chapter 19: Naturopathic Physicians and Acupuncture Services"]
[null,20,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter20.pdf","Chapter 20: Nurse Case Management"]
[null,21,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter21.pdf","Chapter 21: Obesity Treatment"]
[null,22,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter22.pdf","Chapter 22: Other Services"]
[null,23,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter23.pdf","Chapter 23: Pathology and Laboratory Services"]
[null,24,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter24.pdf","Chapter 24: Pharmacy Services"]
[null,25,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter25.pdf","Chapter 25: Physical Medicine Services"]
[null,26,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter26.pdf","Chapter 26: Radiology Services"]
[null,27,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter27.pdf","Chapter 27: Reports and Forms"]
[null,28,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter28.pdf","Chapter 28: Supplies, Materials, and Bundled Services"]
[null,29,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter29.pdf","Chapter 29: Surgery Services"]
[null,30,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter30.pdf","Chapter 30: Vocational Services"]
[null,31,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter31.pdf","Chapter 31: Washington RBRVS Payment System"]
[null,32,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter32.pdf","Chapter 32: Ambulatory Surgery Centers (ASCs)"]
[null,33,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter33.pdf","Chapter 33: Brain Injury Rehabilitation Services"]
[null,34,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter34.pdf","Chapter 34: Chronic Pain Management"]
[null,35,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter35.pdf","Chapter 35: Hospitals"]
[null,36,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2022/2022MarfsChapter36.pdf","Chapter 36: Nursing Home and Other Residential Care Services"]
[]
[null,"Authcode","url","Name"]
[null,"Y-CM","https://lni.wa.gov/patient-care/authorizations-referrals/authorization/claim-manager-authorizations","Claim Manager Authorizations"]
[null,"Y-UR","https://lni.wa.gov/patient-care/authorizations-referrals/authorization/utilization-review","Utilization Review"]
[null,"Y-ONC","https://lni.wa.gov/patient-care/authorizations-referrals/authorization/occupational-nurse-consultant-authorization","Occupational Nurse Consultant Authorization"]
[null,"Y-PHL","https://lni.wa.gov/patient-care/authorizations-referrals/authorization/provider-hotline-authorizations","Provider Hotline Authorizations"]

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["CODE","Modifiers","Modcheck","Short Description (HCPCS and Local Only)","NON-FACILITY SETTING","FACILITY SETTING","FOL UP","PRE OP\n(-56)","INTRA OP\n(-54)","POST OP\n(-55)","PCTC\n(26/TC)","MSI\n(-51)","BSI\n(-50)","ASI\n(-80)","CSI\n(-62)","TSI\n(-66)","ENDO\nBASE","FSI","LIC REQ","Prior Auth","MARFS Chapters","MARFS Chapters2","MARFS Chapters3"]
["58662",null,"N","See CPT","Not Covered","Not Covered ","090",0.09,0.84,7.0000000000000007E-2,0,3,0,2,2,0,49320,"X",null,null,2,29]