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["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)"},{"$f":"CodeLookup[[#Headers],[PCTC\n(26/TC)]]","v":"PCTC\n(26/TC)"}]
["Enter code --> ","01953",{"$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":58.35},{"$f":"CodeLookup[FACILITY SETTING]","v":58.35},{"$f":"CodeLookup[FOL UP]","v":0},{"$f":"CodeLookup[PRE OP\n(-56)]","v":0},{"$f":"CodeLookup[INTRA OP\n(-54)]","v":0},{"$f":"CodeLookup[POST OP\n(-55)]","v":0},{"$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":""},53,{"$f":"CodeLookup[MSI\n(-51)]","v":0},{"$f":"CodeLookup[BSI\n(-50)]","v":0},{"$f":"CodeLookup[ASI\n(-80)]","v":0},{"$f":"CodeLookup[CSI\n(-62)]","v":0},{"$f":"CodeLookup[TSI\n(-66)]","v":0},{"$f":"CodeLookup[ENDO\nBASE]","v":0},{"$f":"CodeLookup[FSI]","v":"F"},{"$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 4: Anesthesia 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":""}]
[]
[]
[]
[]
[]
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[{"$f":"CodeLookup[MARFS Chapters]","v":2},{"$f":"CodeLookup[MARFS Chapters2]","v":4},{"$f":"CodeLookup[MARFS Chapters3]","v":0}]
[{"$f":"IFERROR(VLOOKUP(A24,'MARFS_URL''s'!$B$2:$D$37,2,),\"\")","v":"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter2.pdf"},{"$f":"IFERROR(VLOOKUP(B24,'MARFS_URL''s'!$B$2:$D$37,2,),\"\")","v":"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter4.pdf"},{"$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$37,3,),\"\")","v":"Chapter 4: Anesthesia Services"},{"$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":"01953"}]

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[]
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["Professional Services Fee Schedule"]
[]
["CPT® Through Local Codes"]
[]
[]
[]
["Effective for Dates of Service on or After"]
[]
["2024-07-01"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
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[]
[]
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[]
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[]
["ANESTHESIA SERVICES FEE SCHEDULE                   "]
["FIELD KEY:  "]
["Column Title",null,"Column Description",null,null,"Column Values",null,"Value Definitions"]
["CPTÒ CODE",null,"2023 CPT® anesthesia code.",null,null,null,null,"2023 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-AMD",null,"Prior authorization required, contact associate medical director"]
[null,null,null,null,null,"Y-CM",null,"Prior authorization required, contact claims manager"]
[null,null,null,null,null,"Y-ND",null,"Prior authroization required, contact nursing director "]
[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"]
[null,null,null,null,null,"Y-UR",null,"Prior authorization and UR required "]
[]
["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,"2023 CPT® or HCPCS code",null,null,null,null,null,null,null,"2023 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 2023 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"]
[]
[]
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[]
[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-AMD",null,"Prior authorization from associate medical director required"]
[null,null,null,null,null,null,null,null,"Y-CM",null,"Prior authorization from claim manager required "]
[null,null,null,null,null,null,null,null,"Y-ND",null,"Prior authorization from nusring director required "]
[null,null,null,null,null,null,null,null,"Y-ONC",null,"Prior authorization from ONC required"]
[null,null,null,null,null,null,null,null,"Y-PHL",null,"Prior authroization from PHL 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,"2024 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,"2024 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":"2024 Professional Fee Schedule","index":2,"n_rows":20797,"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"]
["01953",null,"See CPT",null,58.35,null,58.35,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["01996",null,"See CPT",null,77.290000000000006,null,77.290000000000006,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["01999",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
[10004,null,"See CPT",null,95.97,null,77.97,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[10005,null,"See CPT",null,251.92,null,131.36000000000001,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[10006,null,"See CPT",null,110.96,null,89.97,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[10007,null,"See CPT",null,578.21,null,160.15,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[10008,null,"See CPT",null,266.31,null,91.17,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[10009,null,"See CPT",null,814.53,null,194.34,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[10010,null,"See CPT",null,445.65,null,127.76,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[10011,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,2,0,0,0,0,null,"N",null,"Y-CM"]
[10012,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
[10021,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[10030,null,"See CPT",null,1211.5999999999999,null,240.52,null,0,0,0,0,9,2,9,0,0,0,null,"R",null,"Y-CM"]
[10035,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,0,0,0,null,"X"]
[10036,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[10040,null,"See CPT",null,220.73,null,94.77,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[10060,null,"See CPT",null,240.52,null,200.93,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10061,null,"See CPT",null,403.07,null,344.29,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10080,null,"See CPT",null,479.24,null,197.33,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[10081,null,"See CPT",null,651.38,null,314.89999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[10120,null,"See CPT",null,289.10000000000002,null,199.13,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10121,null,"See CPT",null,497.83,null,339.49,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10140,null,"See CPT",null,321.49,null,220.73,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10160,null,"See CPT",null,245.32,null,180.54,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10180,null,"See CPT",null,494.24,null,330.49,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11000,null,"See CPT",null,112.16,null,49.78,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11001,null,"See CPT",null,51.58,null,26.99,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11004,null,"See CPT",null,1010.06,null,1010.06,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11005,null,"See CPT",null,1368.14,null,1368.14,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[11006,null,"See CPT",null,1241.5899999999999,null,1241.5899999999999,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11008,null,"See CPT",null,481.04,null,481.04,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[11010,null,"See CPT",null,839.72,null,505.03,null,10,0.1,0.8,0.1,0,2,2,1,0,0,null,"R"]
[11011,null,"See CPT",null,934.49,null,538.02,null,0,0,0,0,0,2,2,1,0,0,null,"R"]
[11012,null,"See CPT",null,1212.8,null,751.55,null,0,0,0,0,0,2,2,1,0,0,null,"R"]
[11042,null,"See CPT",null,245.92,null,110.96,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11043,null,"See CPT",null,434.26,null,278.31,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11044,null,"See CPT",null,577.01,null,406.66,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11045,null,"See CPT",null,74.38,null,44.99,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[11046,null,"See CPT",null,134.36000000000001,null,97.77,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[11047,null,"See CPT",null,220.73,null,173.34,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[11055,null,"See CPT",null,136.75,null,27.59,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11056,null,"See CPT",null,157.75,null,39.590000000000003,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11057,null,"See CPT",null,171.54,null,51.58,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11102,null,"See CPT",null,191.34,null,68.38,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11103,null,"See CPT",null,95.37,null,39.590000000000003,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11104,null,"See CPT",null,238.12,null,85.17,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11105,null,"See CPT",null,112.76,null,46.18,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11106,null,"See CPT",null,295.7,null,102.57,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11107,null,"See CPT",null,134.96,null,55.78,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11200,null,"See CPT",null,175.74,null,144.55000000000001,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11201,null,"See CPT",null,34.19,null,29.39,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[11300,null,"See CPT",null,191.94,null,61.78,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11301,null,"See CPT",null,230.92,null,92.97,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11302,null,"See CPT",null,260.31,null,108.56,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11303,null,"See CPT",null,287.3,null,128.96,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11305,null,"See CPT",null,199.73,null,67.180000000000007,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11306,null,"See CPT",null,232.72,null,88.17,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11307,null,"See CPT",null,262.11,null,112.76,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11308,null,"See CPT",null,275.31,null,125.96,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11310,null,"See CPT",null,220.13,null,82.77,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11311,null,"See CPT",null,259.11,null,113.96,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11312,null,"See CPT",null,294.5,null,134.96,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11313,null,"See CPT",null,341.89,null,174.54,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11400,null,"See CPT",null,244.72,null,159.55000000000001,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11401,null,"See CPT",null,296.89999999999998,null,198.53,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11402,null,"See CPT",null,326.29000000000002,null,216.53,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11403,null,"See CPT",null,374.88,null,280.11,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11404,null,"See CPT",null,423.46,null,307.10000000000002,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11406,null,"See CPT",null,597.4,null,458.85,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11420,null,"See CPT",null,241.12,null,154.75,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11421,null,"See CPT",null,302.89999999999998,null,203.93,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11422,null,"See CPT",null,339.49,null,254.92,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11423,null,"See CPT",null,388.07,null,293.89999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11424,null,"See CPT",null,448.05,null,337.09,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11426,null,"See CPT",null,612.4,null,494.24,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11440,null,"See CPT",null,274.11,null,203.33,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11441,null,"See CPT",null,330.49,null,251.32,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11442,null,"See CPT",null,366.48,null,275.91000000000003,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11443,null,"See CPT",null,430.06,null,334.69,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11444,null,"See CPT",null,532.02,null,418.66,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11446,null,"See CPT",null,717.36,null,585.4,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11450,null,"See CPT",null,813.93,null,487.64,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R"]
[11451,null,"See CPT",null,988.47,null,614.20000000000005,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R"]
[11462,null,"See CPT",null,792.34,null,465.44,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R"]
[11463,null,"See CPT",null,1001.67,null,617.79,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R"]
[11470,null,"See CPT",null,858.91,null,533.22,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[11471,null,"See CPT",null,1028.6600000000001,null,651.38,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[11600,null,"See CPT",null,374.28,null,227.92,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11601,null,"See CPT",null,433.06,null,275.31,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11602,null,"See CPT",null,463.05,null,299.3,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11603,null,"See CPT",null,525.41999999999996,null,356.28,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11604,null,"See CPT",null,584.80999999999995,null,391.07,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11606,null,"See CPT",null,837.32,null,577.01,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11620,null,"See CPT",null,376.07,null,229.72,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11621,null,"See CPT",null,434.26,null,276.51,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11622,null,"See CPT",null,478.64,null,313.10000000000002,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11623,null,"See CPT",null,557.21,null,385.07,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11624,null,"See CPT",null,632.79,null,436.65,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11626,null,"See CPT",null,758.15,null,530.22,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11640,null,"See CPT",null,386.27,null,236.32,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11641,null,"See CPT",null,448.65,null,287.89999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11642,null,"See CPT",null,506.23,null,336.49,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11643,null,"See CPT",null,591.4,null,417.46,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11644,null,"See CPT",null,728.76,null,515.83000000000004,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11646,null,"See CPT",null,939.29,null,708.96,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11719,null,"See CPT",null,26.99,null,13.2,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11720,null,"See CPT",null,62.38,null,25.19,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11721,null,"See CPT",null,83.97,null,42.59,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11730,null,"See CPT",null,218.33,null,97.77,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11732,null,"See CPT",null,61.78,null,30.59,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11740,null,"See CPT",null,110.36,null,60.58,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11750,null,"See CPT",null,304.7,null,189.54,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11755,null,"See CPT",null,230.92,null,109.76,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[11760,null,"See CPT",null,349.68,null,203.33,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11762,null,"See CPT",null,542.82000000000005,null,345.48,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11765,null,"See CPT",null,316.69,null,174.54,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11770,null,"See CPT",null,668.78,null,341.29,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11771,null,"See CPT",null,1180.4100000000001,null,832.52,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11772,null,"See CPT",null,1446.72,null,1074.24,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11900,null,"See CPT",null,108.56,null,54.58,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11901,null,"See CPT",null,131.96,null,82.77,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11920,null,"See CPT",null,379.07,null,208.73,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11921,null,"See CPT",null,417.46,null,239.32,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11922,null,"See CPT",null,115.76,null,52.18,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[11950,null,"See CPT",null,152.94999999999999,null,94.17,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11951,null,"See CPT",null,202.73,null,131.96,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11952,null,"See CPT",null,270.51,null,185.34,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11954,null,"See CPT",null,298.10000000000002,null,202.13,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11960,null,"See CPT",null,1897.77,null,1897.77,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[11970,null,"See CPT",null,1042.45,null,1042.45,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R"]
[11971,null,"See CPT",null,1029.8599999999999,null,1029.8599999999999,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R"]
[11976,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[11980,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
[11981,null,"See CPT",null,187.74,null,112.76,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[11982,null,"See CPT",null,206.33,null,131.36000000000001,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[11983,null,"See CPT",null,262.70999999999998,null,185.94,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[12001,null,"See CPT",null,177.54,null,80.37,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12002,null,"See CPT",null,214.13,null,105.56,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12004,null,"See CPT",null,248.32,null,131.36000000000001,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12005,null,"See CPT",null,330.49,null,168.54,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12006,null,"See CPT",null,380.87,null,206.33,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12007,null,"See CPT",null,430.66,null,256.70999999999998,null,0,0,0,0,0,2,0,1,1,0,null,"R"]
[12011,null,"See CPT",null,210.53,null,99.57,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12013,null,"See CPT",null,218.33,null,103.17,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12014,null,"See CPT",null,266.31,null,133.16,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12015,null,"See CPT",null,320.89,null,166.74,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12016,null,"See CPT",null,405.46,null,226.12,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12017,null,"See CPT",null,272.91000000000003,null,272.91000000000003,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[12018,null,"See CPT",null,307.10000000000002,null,307.10000000000002,null,0,0,0,0,0,2,0,2,0,0,null,"R"]
[12020,null,"See CPT",null,566.21,null,347.88,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12021,null,"See CPT",null,332.89,null,262.11,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12031,null,"See CPT",null,499.03,null,281.31,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12032,null,"See CPT",null,575.80999999999995,null,353.88,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12034,null,"See CPT",null,632.79,null,379.07,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12035,null,"See CPT",null,732.36,null,443.25,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12036,null,"See CPT",null,812.13,null,515.83000000000004,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12037,null,"See CPT",null,909.9,null,598,null,10,0.1,0.8,0.1,0,2,0,0,1,0,null,"R"]
[12041,null,"See CPT",null,500.23,null,268.70999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12042,null,"See CPT",null,586.6,null,362.28,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12044,null,"See CPT",null,724.56,null,394.67,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12045,null,"See CPT",null,777.34,null,505.03,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12046,null,"See CPT",null,938.09,null,583.01,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[12047,null,"See CPT",null,1025.06,null,644.79,null,10,0.1,0.8,0.1,0,2,0,2,1,0,null,"R"]
[12051,null,"See CPT",null,536.82000000000005,null,313.7,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12052,null,"See CPT",null,596.20000000000005,null,368.88,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12053,null,"See CPT",null,687.37,null,397.07,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12054,null,"See CPT",null,721.56,null,403.07,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12055,null,"See CPT",null,946.48,null,553.62,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12056,null,"See CPT",null,1088.6400000000001,null,707.16,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[12057,null,"See CPT",null,1135.42,null,769.54,null,10,0.1,0.8,0.1,0,2,0,2,1,0,null,"R"]
[13100,null,"See CPT",null,642.99,null,368.28,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13101,null,"See CPT",null,749.15,null,454.65,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13102,null,"See CPT",null,217.13,null,129.56,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[13120,null,"See CPT",null,669.38,null,427.06,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13121,null,"See CPT",null,801.33,null,472.64,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13122,null,"See CPT",null,236.32,null,148.75,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[13131,null,"See CPT",null,730.56,null,443.85,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13132,null,"See CPT",null,884.71,null,553.62,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13133,null,"See CPT",null,312.5,null,226.72,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[13151,null,"See CPT",null,794.14,null,509.23,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13152,null,"See CPT",null,930.89,null,613,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13153,null,"See CPT",null,342.49,null,245.92,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[13160,null,"See CPT",null,1461.11,null,1461.11,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14000,null,"See CPT",null,1198.4000000000001,null,938.09,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14001,null,"See CPT",null,1519.89,null,1208,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14020,null,"See CPT",null,1326.76,null,1056.25,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14021,null,"See CPT",null,1629.06,null,1313.56,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14040,null,"See CPT",null,1428.72,null,1157.6099999999999,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14041,null,"See CPT",null,1732.82,null,1410.73,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14060,null,"See CPT",null,1441.32,null,1233.79,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14061,null,"See CPT",null,1871.38,null,1516.29,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14301,null,"See CPT",null,2021.93,null,1599.07,null,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R"]
[14302,null,"See CPT",null,387.47,null,387.47,null,0,0,0,0,0,0,0,2,0,0,null,"R"]
[14350,null,"See CPT",null,1248.78,null,1248.78,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15002,null,"See CPT",null,639.99,null,396.47,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[15003,null,"See CPT",null,128.36000000000001,null,80.37,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[15004,null,"See CPT",null,731.76,null,469.64,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[15005,null,"See CPT",null,212.93,null,160.15,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[15040,null,"See CPT",null,492.44,null,227.32,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15050,null,"See CPT",null,1103.03,null,851.72,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15100,null,"See CPT",null,1617.06,null,1318.36,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15101,null,"See CPT",null,346.08,null,199.73,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15110,null,"See CPT",null,1541.49,null,1309.3599999999999,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15111,null,"See CPT",null,204.53,null,180.54,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15115,null,"See CPT",null,1497.7,null,1276.97,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15116,null,"See CPT",null,277.11,null,246.52,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15120,null,"See CPT",null,1577.47,null,1271.58,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15121,null,"See CPT",null,386.27,null,238.72,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15130,null,"See CPT",null,1346.55,null,1107.83,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15131,null,"See CPT",null,177.54,null,160.75,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15135,null,"See CPT",null,1624.86,null,1399.33,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15136,null,"See CPT",null,175.14,null,160.75,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15150,null,"See CPT",null,1293.77,null,1166.01,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15151,null,"See CPT",null,212.33,null,192.54,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15152,null,"See CPT",null,266.31,null,248.32,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15155,null,"See CPT",null,1471.31,null,1341.15,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15156,null,"See CPT",null,285.5,null,265.70999999999998,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15157,null,"See CPT",null,317.29000000000002,null,289.7,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15200,null,"See CPT",null,1572.68,null,1244.5899999999999,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15201,null,"See CPT",null,261.51,null,137.35,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15220,null,"See CPT",null,1448.52,null,1133.6199999999999,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15221,null,"See CPT",null,241.72,null,124.16,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15240,null,"See CPT",null,1745.42,null,1480.91,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15241,null,"See CPT",null,325.69,null,193.14,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15260,null,"See CPT",null,1876.77,null,1569.08,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15261,null,"See CPT",null,382.67,null,245.32,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15271,null,"See CPT",null,289.7,null,151.75,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[15272,null,"See CPT",null,45.58,null,29.99,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15273,null,"See CPT",null,574.01,null,350.28,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[15274,null,"See CPT",null,151.15,null,79.17,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15275,null,"See CPT",null,298.10000000000002,null,168.54,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[15276,null,"See CPT",null,59.38,null,44.39,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15277,null,"See CPT",null,632.79,null,398.87,null,0,0,0,0,0,2,0,1,1,0,null,"R"]
[15278,null,"See CPT",null,176.34,null,99.57,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15570,null,"See CPT",null,1689.04,null,1341.15,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15572,null,"See CPT",null,1647.05,null,1361.55,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15574,null,"See CPT",null,1653.65,null,1366.34,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15576,null,"See CPT",null,1462.31,null,1199,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15600,null,"See CPT",null,646.58000000000004,null,401.27,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15610,null,"See CPT",null,701.17,null,460.65,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15620,null,"See CPT",null,848.72,null,613,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15630,null,"See CPT",null,877.51,null,645.38,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15650,null,"See CPT",null,1023.86,null,754.55,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15730,null,"See CPT",null,2678.71,null,1690.84,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15731,null,"See CPT",null,2089.1,null,1840.19,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15733,null,"See CPT",null,1888.77,null,1888.77,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15734,null,"See CPT",null,2733.29,null,2733.29,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15736,null,"See CPT",null,2239.65,null,2239.65,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15738,null,"See CPT",null,2317.63,null,2317.63,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15740,null,"See CPT",null,1896.57,null,1557.68,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15750,null,"See CPT",null,1721.43,null,1721.43,null,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R"]
[15756,null,"See CPT",null,4159.6099999999997,null,4159.6099999999997,null,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R"]
[15757,null,"See CPT",null,4133.82,null,4133.82,null,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R"]
[15758,null,"See CPT",null,4117.63,null,4117.63,null,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R"]
[15760,null,"See CPT",null,1585.27,null,1293.17,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15769,null,"See CPT",null,888.3,null,888.3,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[15770,null,"See CPT",null,1252.98,null,1252.98,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15771,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X"]
[15772,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,1,0,0,null,"X"]
[15773,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X"]
[15774,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,1,0,0,null,"X"]
[15775,null,"See CPT",null,702.37,null,463.65,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[15776,null,"See CPT",null,948.28,null,634.59,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[15777,null,"See CPT",null,385.07,null,385.07,null,0,0,0,0,0,0,1,1,0,0,null,"R"]
[15778,null,"See CPT",null,686.77,null,686.77,null,0,0,0,0,0,2,0,2,1,0,null,"R"]
[15780,null,"See CPT",null,1598.47,null,1238.5899999999999,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15781,null,"See CPT",null,1010.06,null,797.73,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15782,null,"See CPT",null,921.29,null,695.17,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15783,null,"See CPT",null,852.92,null,666.98,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15786,null,"See CPT",null,434.26,null,248.92,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[15787,null,"See CPT",null,56.38,null,29.99,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15788,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"X"]
[15789,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"X"]
[15792,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"X"]
[15793,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"X"]
[15819,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"X"]
[15820,null,"See CPT",null,1094.6400000000001,null,968.08,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15821,null,"See CPT",null,1169.01,null,1029.8599999999999,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15822,null,"See CPT",null,872.11,null,747.95,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[15823,null,"See CPT",null,1172.01,null,1031.06,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[15824,null,"See CPT",null,1632.14,null,1632.14,null,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM"]
[15825,null,"See CPT",null,1403.36,null,1403.36,null,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM"]
[15826,null,"See CPT",null,1327.08,null,1327.08,null,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM"]
[15828,null,"See CPT",null,4545.6099999999997,null,4545.6099999999997,null,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM"]
[15829,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,2,1,0,0,0,null,"N",null,"Y-CM"]
[15830,null,"See CPT",null,2149.08,null,2149.08,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[15832,null,"See CPT",null,1699.83,null,1699.83,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[15833,null,"See CPT",null,1621.26,null,1621.26,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15834,null,"See CPT",null,1650.05,null,1650.05,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15835,null,"See CPT",null,1717.23,null,1717.23,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15836,null,"See CPT",null,1476.11,null,1476.11,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15837,null,"See CPT",null,1622.46,null,1326.76,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15838,null,"See CPT",null,1207.4000000000001,null,1207.4000000000001,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15839,null,"See CPT",null,1665.04,null,1364.55,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15840,null,"See CPT",null,1865.38,null,1865.38,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15841,null,"See CPT",null,3259.91,null,3259.91,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15842,null,"See CPT",null,4918.3599999999997,null,4918.3599999999997,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15845,null,"See CPT",null,1962.55,null,1962.55,null,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R"]
[15847,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,2,1,0,null,"N",null,"Y-CM"]
[15851,null,"See CPT",null,103.77,null,119.96,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[15852,null,"See CPT",null,80.37,null,80.37,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[15853,null,"See CPT",null,22.19,null,22.19,null,0,0,0,0,5,0,0,1,0,0,null,"R"]
[15854,null,"See CPT",null,30.59,null,30.59,null,0,0,0,0,5,0,0,1,0,0,null,"R"]
[15860,null,"See CPT",null,190.14,null,190.14,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[15876,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[15877,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[15878,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,0,0,0,null,"X"]
[15879,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,0,0,0,null,"X"]
[15920,null,"See CPT",null,1166.01,null,1166.01,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15922,null,"See CPT",null,1479.11,null,1479.11,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15931,null,"See CPT",null,1293.17,null,1293.17,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15933,null,"See CPT",null,1609.26,null,1609.26,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15934,null,"See CPT",null,1817.39,null,1817.39,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15935,null,"See CPT",null,2132.89,null,2132.89,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15936,null,"See CPT",null,1644.65,null,1644.65,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15937,null,"See CPT",null,1901.37,null,1901.37,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15940,null,"See CPT",null,1303.3699999999999,null,1303.3699999999999,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15941,null,"See CPT",null,1716.03,null,1716.03,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15944,null,"See CPT",null,1729.22,null,1729.22,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15945,null,"See CPT",null,1886.97,null,1886.97,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15946,null,"See CPT",null,2946.82,null,2946.82,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15950,null,"See CPT",null,1184.6099999999999,null,1184.6099999999999,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15951,null,"See CPT",null,1667.44,null,1667.44,null,90,0.1,0.71,0.19,0,2,0,0,1,0,null,"R"]
[15952,null,"See CPT",null,1695.63,null,1695.63,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15953,null,"See CPT",null,1866.58,null,1866.58,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15956,null,"See CPT",null,2178.4699999999998,null,2178.4699999999998,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15958,null,"See CPT",null,2159.2800000000002,null,2159.2800000000002,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15999,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[16000,null,"See CPT",null,149.35,null,82.17,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[16020,null,"See CPT",null,162.55000000000001,null,103.77,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[16025,null,"See CPT",null,294.5,null,203.93,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[16030,null,"See CPT",null,368.88,null,239.92,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[16035,null,"See CPT",null,352.08,null,352.08,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[16036,null,"See CPT",null,146.94999999999999,null,146.94999999999999,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[17000,null,"See CPT",null,128.36000000000001,null,103.77,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17003,null,"See CPT",null,12.6,null,3.6,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17004,null,"See CPT",null,317.89,null,182.94,null,10,0.1,0.8,0.1,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17106,null,"See CPT",null,650.78,null,515.23,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17107,null,"See CPT",null,844.52,null,671.18,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17108,null,"See CPT",null,1192.4000000000001,null,978.27,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[17110,null,"See CPT",null,217.73,null,130.16,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17111,null,"See CPT",null,253.72,null,156.55000000000001,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17250,null,"See CPT",null,166.14,null,69.58,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[17260,null,"See CPT",null,188.94,null,131.36000000000001,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17261,null,"See CPT",null,282.51,null,162.55000000000001,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17262,null,"See CPT",null,338.29,null,204.53,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17263,null,"See CPT",null,365.88,null,226.12,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17264,null,"See CPT",null,392.27,null,241.12,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17266,null,"See CPT",null,444.45,null,282.51,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17270,null,"See CPT",null,284.31,null,177.54,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17271,null,"See CPT",null,315.49,null,194.94,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17272,null,"See CPT",null,357.48,null,224.33,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17273,null,"See CPT",null,395.87,null,253.12,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17274,null,"See CPT",null,461.25,null,308.3,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17276,null,"See CPT",null,533.82000000000005,null,371.28,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17280,null,"See CPT",null,267.51,null,161.94999999999999,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17281,null,"See CPT",null,340.69,null,218.93,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17282,null,"See CPT",null,388.67,null,251.92,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17283,null,"See CPT",null,458.25,null,314.3,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17284,null,"See CPT",null,519.42999999999995,null,364.68,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17286,null,"See CPT",null,663.98,null,494.84,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17311,null,"See CPT",null,1286.57,null,644.79,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17312,null,"See CPT",null,783.34,null,343.09,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17313,null,"See CPT",null,1211,null,578.21,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17314,null,"See CPT",null,750.95,null,317.89,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17315,null,"See CPT",null,149.94999999999999,null,90.57,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17340,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[17360,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[17380,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[17999,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[19000,null,"See CPT",null,189.54,null,75.569999999999993,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[19001,null,"See CPT",null,48.58,null,37.79,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[19020,null,"See CPT",null,885.3,null,584.21,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R"]
[19030,null,"See CPT",null,308.89999999999998,null,135.55000000000001,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19081,null,"See CPT",null,941.69,null,290.89999999999998,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19082,null,"See CPT",null,728.16,null,145.75,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19083,null,"See CPT",null,939.29,null,275.31,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19084,null,"See CPT",null,717.36,null,137.35,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19085,null,"See CPT",null,1445.52,null,320.29000000000002,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19086,null,"See CPT",null,1123.43,null,159.55000000000001,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19100,null,"See CPT",null,279.51,null,122.96,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19101,null,"See CPT",null,612.4,null,409.06,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19105,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,1,0,0,null,"X"]
[19110,null,"See CPT",null,913.5,null,654.38,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19112,null,"See CPT",null,868.51,null,602.79999999999995,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19120,null,"See CPT",null,968.08,null,769.54,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19125,null,"See CPT",null,1064.6500000000001,null,849.32,null,90,0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[19126,null,"See CPT",null,283.70999999999998,null,283.70999999999998,null,0,0,0,0,0,0,0,1,1,0,null,"R",null,"Y-CM"]
[19281,null,"See CPT",null,455.25,null,175.74,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19282,null,"See CPT",null,324.49,null,88.17,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19283,null,"See CPT",null,488.24,null,177.54,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19284,null,"See CPT",null,359.28,null,88.77,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19285,null,"See CPT",null,695.77,null,149.94999999999999,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19286,null,"See CPT",null,571.01,null,75.569999999999993,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19287,null,"See CPT",null,1202.5999999999999,null,224.33,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19288,null,"See CPT",null,929.69,null,112.16,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19294,null,"See CPT",null,291.5,null,291.5,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19296,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,0,0,0,null,"X"]
[19297,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[19298,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,0,0,0,null,"X"]
[19300,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"X"]
[19301,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"X"]
[19302,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X"]
[19303,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X"]
[19305,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X"]
[19306,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X"]
[19307,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X"]
[19316,null,"See CPT",null,1461.11,null,1461.11,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19318,null,"See CPT",null,2007.53,null,2007.53,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19325,null,"See CPT",null,1142.02,null,1142.02,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19328,null,"See CPT",null,1026.26,null,1026.26,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19330,null,"See CPT",null,1193,null,1193,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19340,null,"See CPT",null,1401.73,null,1401.73,null,90,0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[19342,null,"See CPT",null,1407.73,null,1407.73,null,90,0.1,0.71,0.19,0,2,1,0,1,0,null,"R",null,"Y-CM"]
[19350,null,"See CPT",null,1554.08,null,1246.3800000000001,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19355,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"X"]
[19357,null,"See CPT",null,2150.2800000000002,null,2150.2800000000002,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19361,null,"See CPT",null,2850.85,null,2850.85,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19364,null,"See CPT",null,4945.3500000000004,null,4945.3500000000004,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19367,null,"See CPT",null,3234.72,null,3234.72,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19368,null,"See CPT",null,3947.88,null,3947.88,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19369,null,"See CPT",null,3670.78,null,3670.78,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19370,null,"See CPT",null,1243.3900000000001,null,1243.3900000000001,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19371,null,"See CPT",null,1314.16,null,1314.16,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19380,null,"See CPT",null,1491.7,null,1491.7,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19396,null,"See CPT",null,512.83000000000004,null,260.31,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19499,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,2,1,0,1,1,null,"N"]
[20100,null,"See CPT",null,1083.8399999999999,null,1083.8399999999999,null,10,0.1,0.8,0.1,0,2,1,2,0,0,null,"R"]
[20101,null,"See CPT",null,1088.04,null,380.27,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20102,null,"See CPT",null,1157.01,null,466.04,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20103,null,"See CPT",null,1057.45,null,632.19000000000005,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[20150,null,"See CPT",null,1846.78,null,1846.78,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[20200,null,"See CPT",null,407.86,null,172.74,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20205,null,"See CPT",null,571.01,null,280.70999999999998,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20206,null,"See CPT",null,418.06,null,103.77,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20220,null,"See CPT",null,439.05,null,157.15,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20225,null,"See CPT",null,717.96,null,232.12,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20240,null,"See CPT",null,254.92,null,254.92,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20245,null,"See CPT",null,620.79,null,620.79,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20250,null,"See CPT",null,719.76,null,719.76,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20251,null,"See CPT",null,769.54,null,769.54,null,10,0.1,0.8,0.1,0,2,0,2,0,0,null,"R"]
[20500,null,"See CPT",null,233.32,null,166.14,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20501,null,"See CPT",null,269.31,null,64.78,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20520,null,"See CPT",null,412.66,null,276.51,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20525,null,"See CPT",null,876.31,null,456.45,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20526,null,"See CPT",null,153.55000000000001,null,103.17,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20527,null,"See CPT",null,163.75,null,119.96,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20550,null,"See CPT",null,107.96,null,70.180000000000007,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20551,null,"See CPT",null,107.36,null,69.58,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20552,null,"See CPT",null,98.37,null,67.180000000000007,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[20553,null,"See CPT",null,113.36,null,76.17,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[20555,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[20560,null,"See CPT",null,48.58,null,26.99,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[20561,null,"See CPT",null,69.58,null,40.19,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[20600,null,"See CPT",null,100.77,null,64.78,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20604,null,"See CPT",null,155.94999999999999,null,82.77,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20605,null,"See CPT",null,103.17,null,67.180000000000007,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20606,null,"See CPT",null,169.14,null,94.17,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20610,null,"See CPT",null,121.16,null,82.77,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20611,null,"See CPT",null,186.54,null,106.76,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20612,null,"See CPT",null,122.36,null,74.98,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20615,null,"See CPT",null,481.04,null,302.3,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20650,null,"See CPT",null,437.85,null,311.89999999999998,null,10,0.1,0.8,0.1,0,2,0,1,1,0,null,"R"]
[20660,null,"See CPT",null,427.66,null,427.66,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20661,null,"See CPT",null,985.47,null,985.47,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20662,null,"See CPT",null,981.27,null,981.27,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20663,null,"See CPT",null,907.5,null,907.5,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[20664,null,"See CPT",null,1648.25,null,1648.25,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20665,null,"See CPT",null,222.53,null,182.94,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[20670,null,"See CPT",null,678.97,null,271.70999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20680,null,"See CPT",null,1128.82,null,779.74,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20690,null,"See CPT",null,1101.83,null,1101.83,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20692,null,"See CPT",null,2090.3000000000002,null,2090.3000000000002,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20693,null,"See CPT",null,836.72,null,836.72,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20694,null,"See CPT",null,816.93,null,643.59,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20696,null,"See CPT",null,2146.6799999999998,null,2146.6799999999998,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20697,null,"See CPT",null,3432.66,null,3432.66,null,0,0,0,0,3,0,0,2,1,0,null,"R"]
[20700,null,"See CPT",null,151.75,null,151.75,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20701,null,"See CPT",null,115.16,null,115.16,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20702,null,"See CPT",null,255.51,null,255.51,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20703,null,"See CPT",null,187.14,null,187.14,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20704,null,"See CPT",null,269.31,null,269.31,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20705,null,"See CPT",null,222.53,null,222.53,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20802,null,"See CPT",null,4993.93,null,4993.93,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20805,null,"See CPT",null,5921.23,null,5921.23,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20808,null,"See CPT",null,7130.42,null,7130.42,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20816,null,"See CPT",null,3738.55,null,3738.55,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20822,null,"See CPT",null,3241.92,null,3241.92,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20824,null,"See CPT",null,3746.35,null,3746.35,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20827,null,"See CPT",null,3326.49,null,3326.49,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20838,null,"See CPT",null,5070.71,null,5070.71,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20900,null,"See CPT",null,726.96,null,328.09,null,0,0,0,0,0,2,0,2,1,0,null,"R"]
[20902,null,"See CPT",null,498.43,null,498.43,null,0,0,0,0,0,2,0,2,1,0,null,"R"]
[20910,null,"See CPT",null,899.1,null,899.1,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20912,null,"See CPT",null,901.5,null,901.5,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20920,null,"See CPT",null,748.55,null,748.55,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[20922,null,"See CPT",null,1149.82,null,922.49,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20924,null,"See CPT",null,942.89,null,942.89,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20930,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
[20931,null,"See CPT",null,196.13,null,196.13,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[20932,null,"See CPT",null,1352.55,null,1352.55,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[20933,null,"See CPT",null,1240.3900000000001,null,1240.3900000000001,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[20934,null,"See CPT",null,1350.75,null,1350.75,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[20936,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
[20937,null,"See CPT",null,296.89999999999998,null,296.89999999999998,null,0,0,0,0,0,0,0,2,1,0,null,"R"]
[20938,null,"See CPT",null,325.69,null,325.69,null,0,0,0,0,0,0,0,2,1,0,null,"R"]
[20939,null,"See CPT",null,124.16,null,124.16,null,0,0,0,0,0,0,1,0,0,0,null,"R",null,"Y-UR"]
[20950,null,"See CPT",null,505.63,null,163.15,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[20955,null,"See CPT",null,4451.12,null,4451.12,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20956,null,"See CPT",null,4799.6000000000004,null,4799.6000000000004,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20957,null,"See CPT",null,5003.53,null,5003.53,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20962,null,"See CPT",null,4885.97,null,4885.97,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20969,null,"See CPT",null,4947.1499999999996,null,4947.1499999999996,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20970,null,"See CPT",null,5176.2700000000004,null,5176.2700000000004,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20972,null,"See CPT",null,5160.68,null,5160.68,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[20973,null,"See CPT",null,5447.98,null,5447.98,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20974,null,"See CPT",null,158.35,null,94.17,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-UR"]
[20975,null,"See CPT",null,319.69,null,319.69,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[20979,null,"See CPT",null,107.36,null,57.58,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-UR"]
[20982,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,1,0,0,null,"X"]
[20983,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,1,0,0,null,"X"]
[20985,null,"See CPT",null,259.11,null,259.11,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20999,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[21010,null,"See CPT",null,1372.94,null,1372.94,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[21011,null,"See CPT",null,710.16,null,490.64,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21012,null,"See CPT",null,632.19000000000005,null,632.19000000000005,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21013,null,"See CPT",null,1007.06,null,749.15,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21014,null,"See CPT",null,968.68,null,968.68,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21015,null,"See CPT",null,1292.57,null,1292.57,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[21016,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X"]
[21025,null,"See CPT",null,1483.91,null,1227.79,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21026,null,"See CPT",null,1009.46,null,801.93,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21029,null,"See CPT",null,1450.32,null,1163.6099999999999,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[21030,null,"See CPT",null,862.51,null,673.58,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[21031,null,"See CPT",null,725.76,null,511.63,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[21032,null,"See CPT",null,704.77,null,488.24,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[21034,null,"See CPT",null,2411.1999999999998,null,2074.71,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21040,null,"See CPT",null,872.11,null,675.97,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[21044,null,"See CPT",null,1596.07,null,1596.07,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21045,null,"See CPT",null,2209.66,null,2209.66,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21046,null,"See CPT",null,1830.59,null,1830.59,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR"]
[21047,null,"See CPT",null,2222.86,null,2222.86,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21048,null,"See CPT",null,1844.98,null,1844.98,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR"]
[21049,null,"See CPT",null,2110.6999999999998,null,2110.6999999999998,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21050,null,"See CPT",null,1605.06,null,1605.06,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[21060,null,"See CPT",null,1452.12,null,1452.12,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[21070,null,"See CPT",null,1137.82,null,1137.82,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[21073,null,"See CPT",null,719.76,null,445.65,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[21076,null,"See CPT",null,1602.07,null,1286.57,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[21077,null,"See CPT",null,3914.89,null,3163.35,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21079,null,"See CPT",null,2690.1,null,2128.69,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21080,null,"See CPT",null,3071.58,null,2402.1999999999998,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21081,null,"See CPT",null,2843.05,null,2205.46,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21082,null,"See CPT",null,2658.91,null,2036.32,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21083,null,"See CPT",null,2529.96,null,1882.77,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21084,null,"See CPT",null,2883.24,null,2176.67,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21085,null,"See CPT",null,1269.18,null,884.11,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[21086,null,"See CPT",null,2908.43,null,2330.8200000000002,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21087,null,"See CPT",null,2908.43,null,2330.8200000000002,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21088,null,"See CPT",null,"By Report",null,"By Report",null,90,0.1,0.69,0.21,0,0,0,0,0,0,null,"N"]
[21089,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,1,1,1,null,"N"]
[21100,null,"See CPT",null,1175.6099999999999,null,666.98,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21110,null,"See CPT",null,1628.46,null,1344.75,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21116,null,"See CPT",null,406.66,null,80.97,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[21120,null,"See CPT",null,1252.98,null,953.08,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[21121,null,"See CPT",null,1184.6099999999999,null,984.27,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21122,null,"See CPT",null,1393.34,null,1393.34,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21123,null,"See CPT",null,1569.68,null,1569.68,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21125,null,"See CPT",null,4948.3500000000004,null,1233.19,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21127,null,"See CPT",null,7683.44,null,1428.12,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21137,null,"See CPT",null,1389.14,null,1389.14,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21138,null,"See CPT",null,1685.44,null,1685.44,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21139,null,"See CPT",null,2006.93,null,2006.93,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21141,null,"See CPT",null,2458.58,null,2458.58,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21142,null,"See CPT",null,2522.16,null,2522.16,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21143,null,"See CPT",null,2598.33,null,2598.33,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21145,null,"See CPT",null,2849.05,null,2849.05,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21146,null,"See CPT",null,2975.61,null,2975.61,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21147,null,"See CPT",null,3128.56,null,3128.56,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21150,null,"See CPT",null,3017.59,null,3017.59,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21151,null,"See CPT",null,3316.89,null,3316.89,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21154,null,"See CPT",null,3570.01,null,3570.01,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21155,null,"See CPT",null,3955.68,null,3955.68,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21159,null,"See CPT",null,4729.42,null,4729.42,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21160,null,"See CPT",null,5125.8900000000003,null,5125.8900000000003,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21172,null,"See CPT",null,3844.12,null,3844.12,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21175,null,"See CPT",null,4028.26,null,4028.26,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21179,null,"See CPT",null,2779.47,null,2779.47,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21180,null,"See CPT",null,3100.37,null,3100.37,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21181,null,"See CPT",null,1368.74,null,1368.74,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[21182,null,"See CPT",null,3852.52,null,3852.52,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21183,null,"See CPT",null,4187.8,null,4187.8,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21184,null,"See CPT",null,4502.7,null,4502.7,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21188,null,"See CPT",null,2910.23,null,2910.23,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21193,null,"See CPT",null,2265.44,null,2265.44,null,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR"]
[21194,null,"See CPT",null,2618.73,null,2618.73,null,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-UR"]
[21195,null,"See CPT",null,2472.98,null,2472.98,null,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-UR"]
[21196,null,"See CPT",null,2639.72,null,2639.72,null,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR"]
[21198,null,"See CPT",null,1858.18,null,1858.18,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21199,null,"See CPT",null,1864.18,null,1864.18,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21206,null,"See CPT",null,1787.4,null,1787.4,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21208,null,"See CPT",null,3101.57,null,1363.95,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21209,null,"See CPT",null,1498.3,null,1132.42,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21210,null,"See CPT",null,3337.89,null,1404.13,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21215,null,"See CPT",null,7792,null,1458.71,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[21230,null,"See CPT",null,1378.94,null,1378.94,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21235,null,"See CPT",null,1390.94,null,1067.04,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21240,null,"See CPT",null,1931.96,null,1931.96,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[21242,null,"See CPT",null,1872.58,null,1872.58,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[21243,null,"See CPT",null,3096.17,null,3096.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[21244,null,"See CPT",null,1868.98,null,1868.98,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21245,null,"See CPT",null,2288.84,null,1753.82,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21246,null,"See CPT",null,1566.08,null,1566.08,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21247,null,"See CPT",null,2906.03,null,2906.03,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21248,null,"See CPT",null,1830.59,null,1463.51,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21249,null,"See CPT",null,2471.7800000000002,null,2037.52,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21255,null,"See CPT",null,2471.1799999999998,null,2471.1799999999998,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21256,null,"See CPT",null,2281.64,null,2281.64,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21260,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X"]
[21261,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X"]
[21263,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X"]
[21267,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[21268,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[21270,null,"See CPT",null,1906.16,null,1378.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21275,null,"See CPT",null,1556.48,null,1556.48,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21280,null,"See CPT",null,1103.6300000000001,null,1103.6300000000001,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21282,null,"See CPT",null,753.95,null,753.95,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[21295,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"X"]
[21296,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"X"]
[21299,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[21315,null,"See CPT",null,290.89999999999998,null,109.16,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[21320,null,"See CPT",null,410.86,null,173.94,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[21325,null,"See CPT",null,842.72,null,842.72,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21330,null,"See CPT",null,1007.66,null,1007.66,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21335,null,"See CPT",null,1339.95,null,1339.95,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21336,null,"See CPT",null,1199.5999999999999,null,1199.5999999999999,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21337,null,"See CPT",null,793.54,null,568.61,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21338,null,"See CPT",null,1263.78,null,1263.78,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21339,null,"See CPT",null,1422.73,null,1422.73,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21340,null,"See CPT",null,1396.33,null,1396.33,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21343,null,"See CPT",null,2025.52,null,2025.52,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21344,null,"See CPT",null,2565.94,null,2565.94,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21345,null,"See CPT",null,1514.5,null,1196,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21346,null,"See CPT",null,1912.76,null,1912.76,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[21347,null,"See CPT",null,1929.56,null,1929.56,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21348,null,"See CPT",null,2016.53,null,2016.53,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21355,null,"See CPT",null,849.92,null,615.99,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[21356,null,"See CPT",null,1031.6600000000001,null,753.95,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[21360,null,"See CPT",null,983.07,null,983.07,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21365,null,"See CPT",null,1985.94,null,1985.94,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21366,null,"See CPT",null,2342.2199999999998,null,2342.2199999999998,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[21385,null,"See CPT",null,1357.95,null,1357.95,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21386,null,"See CPT",null,1279.97,null,1279.97,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21387,null,"See CPT",null,1416.13,null,1416.13,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21390,null,"See CPT",null,1490.5,null,1490.5,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21395,null,"See CPT",null,1849.78,null,1849.78,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21400,null,"See CPT",null,417.46,null,324.49,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21401,null,"See CPT",null,968.68,null,621.39,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21406,null,"See CPT",null,1086.8399999999999,null,1086.8399999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21407,null,"See CPT",null,1193.5999999999999,null,1193.5999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21408,null,"See CPT",null,1662.65,null,1662.65,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[21421,null,"See CPT",null,1218.19,null,1023.86,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21422,null,"See CPT",null,1157.01,null,1157.01,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21423,null,"See CPT",null,1470.71,null,1470.71,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21431,null,"See CPT",null,1298.57,null,1298.57,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21432,null,"See CPT",null,1321.96,null,1321.96,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21433,null,"See CPT",null,3165.74,null,3165.74,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21435,null,"See CPT",null,2585.14,null,2585.14,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21436,null,"See CPT",null,3726.56,null,3726.56,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21440,null,"See CPT",null,1455.71,null,1159.4100000000001,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21445,null,"See CPT",null,1470.71,null,1184.6099999999999,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21450,null,"See CPT",null,1125.22,null,911.7,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21451,null,"See CPT",null,1458.71,null,1211,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21452,null,"See CPT",null,1406.53,null,875.11,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21453,null,"See CPT",null,2080.11,null,1764.01,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21454,null,"See CPT",null,909.9,null,909.9,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[21461,null,"See CPT",null,3498.03,null,2005.13,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[21462,null,"See CPT",null,3721.76,null,2182.0700000000002,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21465,null,"See CPT",null,1473.71,null,1473.71,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21470,null,"See CPT",null,2151.48,null,2151.48,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21480,null,"See CPT",null,270.51,null,55.78,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[21485,null,"See CPT",null,1830.59,null,1490.5,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21490,null,"See CPT",null,1452.72,null,1452.72,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21497,null,"See CPT",null,1347.15,null,1115.6300000000001,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21499,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[21501,null,"See CPT",null,924.89,null,632.79,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21502,null,"See CPT",null,927.89,null,927.89,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21510,null,"See CPT",null,833.72,null,833.72,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21550,null,"See CPT",null,506.23,null,290.3,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[21552,null,"See CPT",null,824.73,null,824.73,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21554,null,"See CPT",null,1343.55,null,1343.55,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21555,null,"See CPT",null,818.73,null,574.01,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[21556,null,"See CPT",null,980.67,null,980.67,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[21557,null,"See CPT",null,1754.42,null,1754.42,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21558,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X"]
[21600,null,"See CPT",null,1053.8499999999999,null,1053.8499999999999,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21601,null,"See CPT",null,2080.11,null,2080.11,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[21602,null,"See CPT",null,2786.07,null,2786.07,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[21603,null,"See CPT",null,3045.18,null,3045.18,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[21610,null,"See CPT",null,2205.46,null,2205.46,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21615,null,"See CPT",null,1120.43,null,1120.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[21616,null,"See CPT",null,1273.3800000000001,null,1273.3800000000001,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[21620,null,"See CPT",null,921.89,null,921.89,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21627,null,"See CPT",null,1011.86,null,1011.86,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21630,null,"See CPT",null,2412.4,null,2412.4,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21632,null,"See CPT",null,2183.27,null,2183.27,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21685,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X"]
[21700,null,"See CPT",null,635.19000000000005,null,635.19000000000005,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[21705,null,"See CPT",null,942.89,null,942.89,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[21720,null,"See CPT",null,993.27,null,993.27,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21725,null,"See CPT",null,1015.46,null,1015.46,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21740,null,"See CPT",null,1832.99,null,1832.99,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21742,null,"See CPT",null,"By Report ",null,"By Report ",null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"N",null,"Y-UR"]
[21743,null,"See CPT",null,"By Report ",null,"By Report ",null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"N",null,"Y-UR"]
[21750,null,"See CPT",null,1213.4000000000001,null,1213.4000000000001,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21811,null,"See CPT",null,1054.45,null,1054.45,null,0,0,0,0,0,2,1,2,0,0,null,"R"]
[21812,null,"See CPT",null,1272.78,null,1272.78,null,0,0,0,0,0,2,1,2,0,0,null,"R"]
[21813,null,"See CPT",null,1740.02,null,1740.02,null,0,0,0,0,0,2,1,2,0,0,null,"R"]
[21820,null,"See CPT",null,291.5,null,287.89999999999998,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21825,null,"See CPT",null,1016.06,null,1016.06,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21899,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,0,1,1,null,"N",null,"Y-UR"]
[21920,null,"See CPT",null,486.44,null,287.89999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[21925,null,"See CPT",null,933.89,null,708.96,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21930,null,"See CPT",null,946.48,null,679.57,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21931,null,"See CPT",null,864.91,null,864.91,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21932,null,"See CPT",null,1218.19,null,1218.19,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21933,null,"See CPT",null,1351.95,null,1351.95,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21935,null,"See CPT",null,1863.58,null,1863.58,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[21936,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X"]
[22010,null,"See CPT",null,1791,null,1791,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[22015,null,"See CPT",null,1752.02,null,1752.02,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[22100,null,"See CPT",null,1750.22,null,1750.22,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22101,null,"See CPT",null,1624.86,null,1624.86,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22102,null,"See CPT",null,1428.12,null,1428.12,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22103,null,"See CPT",null,239.92,null,239.92,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22110,null,"See CPT",null,1951.15,null,1951.15,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22112,null,"See CPT",null,2093.3000000000002,null,2093.3000000000002,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22114,null,"See CPT",null,2093.3000000000002,null,2093.3000000000002,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22116,null,"See CPT",null,250.12,null,250.12,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22206,null,"See CPT",null,4436.12,null,4436.12,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22207,null,"See CPT",null,4349.75,null,4349.75,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22208,null,"See CPT",null,1046.05,null,1046.05,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22210,null,"See CPT",null,3268.91,null,3268.91,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22212,null,"See CPT",null,2777.67,null,2777.67,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22214,null,"See CPT",null,2777.07,null,2777.07,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22216,null,"See CPT",null,644.79,null,644.79,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22220,null,"See CPT",null,2964.81,null,2964.81,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22222,null,"See CPT",null,3219.13,null,3219.13,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22224,null,"See CPT",null,2904.83,null,2904.83,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22226,null,"See CPT",null,638.79,null,638.79,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22310,null,"See CPT",null,589,null,561.41,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[22315,null,"See CPT",null,1686.64,null,1449.72,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[22318,null,"See CPT",null,3011.6,null,3011.6,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22319,null,"See CPT",null,3330.69,null,3330.69,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22325,null,"See CPT",null,2709.3,null,2709.3,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22326,null,"See CPT",null,2760.88,null,2760.88,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22327,null,"See CPT",null,2819.66,null,2819.66,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22328,null,"See CPT",null,499.03,null,499.03,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22505,null,"See CPT",null,239.32,null,239.32,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[22510,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[22511,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[22512,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,1,0,0,null,"X"]
[22513,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[22514,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[22515,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,1,0,0,null,"X"]
[22526,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,9,9,9,9,9,9,null,"X"]
[22527,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[22532,null,"See CPT",null,3262.31,null,3262.31,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22533,null,"See CPT",null,3033.19,null,3033.19,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22534,null,"See CPT",null,641.19000000000005,null,641.19000000000005,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22548,null,"See CPT",null,3571.21,null,3571.21,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22551,null,"See CPT",null,3085.97,null,3085.97,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22552,null,"See CPT",null,703.57,null,703.57,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22554,null,"See CPT",null,2307.4299999999998,null,2307.4299999999998,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22556,null,"See CPT",null,3066.78,null,3066.78,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22558,null,"See CPT",null,2771.08,null,2771.08,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22585,null,"See CPT",null,576.41,null,576.41,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22586,null,"See CPT",null,3691.77,null,3691.77,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22590,null,"See CPT",null,2903.63,null,2903.63,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22595,null,"See CPT",null,2778.27,null,2778.27,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22600,null,"See CPT",null,2391.4,null,2391.4,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22610,null,"See CPT",null,2353.02,null,2353.02,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22612,null,"See CPT",null,2879.64,null,2879.64,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22614,null,"See CPT",null,695.17,null,695.17,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22630,null,"See CPT",null,2838.85,null,2838.85,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22632,null,"See CPT",null,569.21,null,569.21,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22633,null,"See CPT",null,3283.31,null,3283.31,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22634,null,"See CPT",null,860.71,null,860.71,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22800,null,"See CPT",null,2503.5700000000002,null,2503.5700000000002,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22802,null,"See CPT",null,3847.12,null,3847.12,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22804,null,"See CPT",null,4409.7299999999996,null,4409.7299999999996,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22808,null,"See CPT",null,3319.29,null,3319.29,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22810,null,"See CPT",null,3656.98,null,3656.98,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22812,null,"See CPT",null,4010.26,null,4010.26,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22818,null,"See CPT",null,3905.9,null,3905.9,null,90,0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22819,null,"See CPT",null,4497.3,null,4497.3,null,90,0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22830,null,"See CPT",null,1514.5,null,1514.5,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22836,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,0,2,1,null,"X"]
[22837,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,0,2,1,null,"X"]
[22838,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,0,2,1,null,"X"]
[22840,null,"See CPT",null,1344.75,null,1344.75,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22841,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B",null,"Y-UR"]
[22842,null,"See CPT",null,1355.55,null,1355.55,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22843,null,"See CPT",null,1451.52,null,1451.52,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22844,null,"See CPT",null,1751.42,null,1751.42,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22845,null,"See CPT",null,1289.57,null,1289.57,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22846,null,"See CPT",null,1342.35,null,1342.35,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22847,null,"See CPT",null,1431.12,null,1431.12,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22848,null,"See CPT",null,640.59,null,640.59,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22849,null,"See CPT",null,2379.41,null,2379.41,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22850,null,"See CPT",null,1356.75,null,1356.75,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22852,null,"See CPT",null,1308.76,null,1308.76,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22853,null,"See CPT",null,457.65,null,457.65,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22854,null,"See CPT",null,595,null,595,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22855,null,"See CPT",null,2024.92,null,2024.92,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22856,null,"See CPT",null,2949.82,null,2949.82,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22857,null,"See CPT",null,3184.94,null,3184.94,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22858,null,"See CPT",null,899.7,null,899.7,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22859,null,"See CPT",null,592,null,592,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22860,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,2,2,0,null,"X"]
[22861,null,"See CPT",null,4183.6099999999997,null,4183.6099999999997,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22862,null,"See CPT",null,4195,null,4195,null,90,0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22864,null,"See CPT",null,3742.15,null,3742.15,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22865,null,"See CPT",null,4095.43,null,4095.43,null,90,0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22867,null,"See CPT",null,1958.35,null,1958.35,null,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[22868,null,"See CPT",null,430.66,null,430.66,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22869,null,"See CPT",null,801.33,null,801.33,null,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[22870,null,"See CPT",null,212.33,null,212.33,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22899,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,2,1,1,null,"N",null,"Y-UR"]
[22900,null,"See CPT",null,1042.45,null,1042.45,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22901,null,"See CPT",null,1221.19,null,1221.19,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22902,null,"See CPT",null,887.7,null,620.79,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22903,null,"See CPT",null,810.93,null,810.93,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22904,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,1,null,"X"]
[22905,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,1,null,"X"]
[22999,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,0,1,1,null,"N",null,"Y-UR"]
[23000,null,"See CPT",null,1047.25,null,675.37,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23020,null,"See CPT",null,1288.3699999999999,null,1288.3699999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23030,null,"See CPT",null,831.32,null,473.84,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[23031,null,"See CPT",null,822.33,null,416.86,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[23035,null,"See CPT",null,1264.3800000000001,null,1264.3800000000001,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23040,null,"See CPT",null,1338.15,null,1338.15,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23044,null,"See CPT",null,1056.25,null,1056.25,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23065,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"X"]
[23066,null,"See CPT",null,1088.6400000000001,null,696.37,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[23071,null,"See CPT",null,777.94,null,777.94,null,90,0.1,0.8,0.1,0,2,1,2,0,0,null,"R"]
[23073,null,"See CPT",null,1284.77,null,1284.77,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[23075,null,"See CPT",null,974.08,null,616.59,null,90,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23076,null,"See CPT",null,1010.06,null,1010.06,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23077,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[23078,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[23100,null,"See CPT",null,957.28,null,957.28,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23101,null,"See CPT",null,864.91,null,864.91,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23105,null,"See CPT",null,1202,null,1202,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23106,null,"See CPT",null,950.08,null,950.08,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23107,null,"See CPT",null,1244.5899999999999,null,1244.5899999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23120,null,"See CPT",null,1108.43,null,1108.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23125,null,"See CPT",null,1325.56,null,1325.56,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23130,null,"See CPT",null,1163.01,null,1163.01,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23140,null,"See CPT",null,1045.45,null,1045.45,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[23145,null,"See CPT",null,1300.3699999999999,null,1300.3699999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23146,null,"See CPT",null,1172.01,null,1172.01,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[23150,null,"See CPT",null,1248.78,null,1248.78,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23155,null,"See CPT",null,1486.9,null,1486.9,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23156,null,"See CPT",null,1269.78,null,1269.78,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23170,null,"See CPT",null,1063.45,null,1063.45,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[23172,null,"See CPT",null,1073.6400000000001,null,1073.6400000000001,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23174,null,"See CPT",null,1431.12,null,1431.12,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23180,null,"See CPT",null,1232.5899999999999,null,1232.5899999999999,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23182,null,"See CPT",null,1261.3800000000001,null,1261.3800000000001,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23184,null,"See CPT",null,1385.54,null,1385.54,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23190,null,"See CPT",null,1081.44,null,1081.44,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23195,null,"See CPT",null,1393.34,null,1393.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23200,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[23210,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[23220,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[23330,null,"See CPT",null,574.01,null,316.08999999999997,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[23333,null,"See CPT",null,891.9,null,891.9,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[23334,null,"See CPT",null,1954.15,null,1954.15,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23335,null,"See CPT",null,2327.8200000000002,null,2327.8200000000002,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23350,null,"See CPT",null,307.7,null,89.37,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[23395,null,"See CPT",null,2368.61,null,2368.61,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[23397,null,"See CPT",null,2101.1,null,2101.1,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[23400,null,"See CPT",null,1799.4,null,1799.4,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23405,null,"See CPT",null,1149.22,null,1149.22,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[23406,null,"See CPT",null,1358.55,null,1358.55,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[23410,null,"See CPT",null,1522.89,null,1522.89,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23412,null,"See CPT",null,1582.27,null,1582.27,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23415,null,"See CPT",null,1305.76,null,1305.76,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23420,null,"See CPT",null,1807.8,null,1807.8,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23430,null,"See CPT",null,1388.54,null,1388.54,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23440,null,"See CPT",null,1407.73,null,1407.73,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23450,null,"See CPT",null,1747.22,null,1747.22,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23455,null,"See CPT",null,1818.59,null,1818.59,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23460,null,"See CPT",null,2011.13,null,2011.13,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23462,null,"See CPT",null,1966.14,null,1966.14,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23465,null,"See CPT",null,2061.5100000000002,null,2061.5100000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23466,null,"See CPT",null,2078.31,null,2078.31,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23470,null,"See CPT",null,2201.87,null,2201.87,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23472,null,"See CPT",null,2645.12,null,2645.12,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23473,null,"See CPT",null,2938.42,null,2938.42,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23474,null,"See CPT",null,3169.34,null,3169.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23480,null,"See CPT",null,1522.89,null,1522.89,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[23485,null,"See CPT",null,1761.61,null,1761.61,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23490,null,"See CPT",null,1596.07,null,1596.07,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23491,null,"See CPT",null,1877.97,null,1877.97,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23500,null,"See CPT",null,437.25,null,448.05,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23505,null,"See CPT",null,698.17,null,645.98,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23515,null,"See CPT",null,1346.55,null,1346.55,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23520,null,"See CPT",null,471.44,null,467.84,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23525,null,"See CPT",null,773.74,null,704.17,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23530,null,"See CPT",null,1082.04,null,1082.04,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[23532,null,"See CPT",null,1175.6099999999999,null,1175.6099999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[23540,null,"See CPT",null,466.64,null,463.05,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23545,null,"See CPT",null,704.17,null,628.59,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23550,null,"See CPT",null,1073.6400000000001,null,1073.6400000000001,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23552,null,"See CPT",null,1215.19,null,1215.19,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23570,null,"See CPT",null,459.45,null,475.04,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23575,null,"See CPT",null,796.53,null,732.36,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23585,null,"See CPT",null,1803,null,1803,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23600,null,"See CPT",null,653.78,null,618.99,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23605,null,"See CPT",null,906.9,null,819.33,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23615,null,"See CPT",null,1641.05,null,1641.05,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23616,null,"See CPT",null,2273.84,null,2273.84,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[23620,null,"See CPT",null,531.41999999999996,null,508.03,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23625,null,"See CPT",null,749.15,null,680.77,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23630,null,"See CPT",null,1458.11,null,1458.11,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23650,null,"See CPT",null,647.17999999999995,null,581.21,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23655,null,"See CPT",null,779.14,null,779.14,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23660,null,"See CPT",null,1099.43,null,1099.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23665,null,"See CPT",null,842.12,null,770.14,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23670,null,"See CPT",null,1620.06,null,1620.06,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23675,null,"See CPT",null,1063.45,null,956.68,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23680,null,"See CPT",null,1707.63,null,1707.63,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23700,null,"See CPT",null,366.48,null,366.48,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23800,null,"See CPT",null,1898.37,null,1898.37,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23802,null,"See CPT",null,2366.81,null,2366.81,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23900,null,"See CPT",null,2539.5500000000002,null,2539.5500000000002,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[23920,null,"See CPT",null,2072.91,null,2072.91,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23921,null,"See CPT",null,892.5,null,892.5,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[23929,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,0,2,0,2,1,1,null,"B",null,"Y-UR"]
[23930,null,"See CPT",null,678.37,null,399.47,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23931,null,"See CPT",null,578.80999999999995,null,304.7,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23935,null,"See CPT",null,970.48,null,970.48,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24000,null,"See CPT",null,903.3,null,903.3,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,"Y-UR"]
[24006,null,"See CPT",null,1334.56,null,1334.56,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,"Y-UR"]
[24065,null,"See CPT",null,492.44,null,304.7,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[24066,null,"See CPT",null,1186.4000000000001,null,793.54,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24071,null,"See CPT",null,751.55,null,751.55,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24073,null,"See CPT",null,1277.57,null,1277.57,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24075,null,"See CPT",null,1003.47,null,617.19000000000005,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24076,null,"See CPT",null,1019.66,null,1019.66,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24077,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X"]
[24079,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[24100,null,"See CPT",null,797.73,null,797.73,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24101,null,"See CPT",null,950.68,null,950.68,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24102,null,"See CPT",null,1157.6099999999999,null,1157.6099999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24105,null,"See CPT",null,690.97,null,690.97,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24110,null,"See CPT",null,1111.43,null,1111.43,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24115,null,"See CPT",null,1375.34,null,1375.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24116,null,"See CPT",null,1594.87,null,1594.87,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24120,null,"See CPT",null,1004.07,null,1004.07,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24125,null,"See CPT",null,1169.6099999999999,null,1169.6099999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24126,null,"See CPT",null,1219.3900000000001,null,1219.3900000000001,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24130,null,"See CPT",null,965.08,null,965.08,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[24134,null,"See CPT",null,1393.94,null,1393.94,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24136,null,"See CPT",null,1185.8,null,1185.8,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24138,null,"See CPT",null,1295.57,null,1295.57,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24140,null,"See CPT",null,1312.96,null,1312.96,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24145,null,"See CPT",null,1116.23,null,1116.23,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24147,null,"See CPT",null,1183.4100000000001,null,1183.4100000000001,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24149,null,"See CPT",null,2194.0700000000002,null,2194.0700000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24150,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[24152,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[24155,null,"See CPT",null,1579.27,null,1579.27,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24160,null,"See CPT",null,2309.23,null,2309.23,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24164,null,"See CPT",null,1350.75,null,1350.75,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24200,null,"See CPT",null,416.86,null,265.11,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[24201,null,"See CPT",null,1172.01,null,758.15,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24220,null,"See CPT",null,359.28,null,119.36,null,0,0,0,0,0,2,1,0,0,0,null,"R"]
[24300,null,"See CPT",null,849.92,null,849.92,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24301,null,"See CPT",null,1398.13,null,1398.13,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[24305,null,"See CPT",null,1090.44,null,1090.44,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[24310,null,"See CPT",null,894.9,null,894.9,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[24320,null,"See CPT",null,1451.52,null,1451.52,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[24330,null,"See CPT",null,1340.55,null,1340.55,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24331,null,"See CPT",null,1460.51,null,1460.51,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24332,null,"See CPT",null,1158.21,null,1158.21,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[24340,null,"See CPT",null,1121.6300000000001,null,1121.6300000000001,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24341,null,"See CPT",null,1410.73,null,1410.73,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24342,null,"See CPT",null,1440.72,null,1440.72,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24343,null,"See CPT",null,1342.95,null,1342.95,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24344,null,"See CPT",null,2050.7199999999998,null,2050.7199999999998,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24345,null,"See CPT",null,1336.35,null,1336.35,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24346,null,"See CPT",null,2050.7199999999998,null,2050.7199999999998,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24357,null,"See CPT",null,788.74,null,788.74,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24358,null,"See CPT",null,1001.07,null,1001.07,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24359,null,"See CPT",null,1242.79,null,1242.79,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24360,null,"See CPT",null,1674.64,null,1674.64,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24361,null,"See CPT",null,1862.38,null,1862.38,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24362,null,"See CPT",null,1958.95,null,1958.95,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24363,null,"See CPT",null,2657.71,null,2657.71,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24365,null,"See CPT",null,1199.5999999999999,null,1199.5999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24366,null,"See CPT",null,1270.3800000000001,null,1270.3800000000001,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24370,null,"See CPT",null,2814.26,null,2814.26,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24371,null,"See CPT",null,3228.72,null,3228.72,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24400,null,"See CPT",null,1540.29,null,1540.29,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24410,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[24420,null,"See CPT",null,1979.34,null,1979.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24430,null,"See CPT",null,1949.95,null,1949.95,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24435,null,"See CPT",null,2005.13,null,2005.13,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24470,null,"See CPT",null,1258.98,null,1258.98,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24495,null,"See CPT",null,1740.02,null,1740.02,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24498,null,"See CPT",null,1608.06,null,1608.06,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24500,null,"See CPT",null,710.16,null,651.98,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24505,null,"See CPT",null,974.08,null,866.11,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24515,null,"See CPT",null,1637.45,null,1637.45,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24516,null,"See CPT",null,1591.87,null,1591.87,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[24530,null,"See CPT",null,748.55,null,683.17,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24535,null,"See CPT",null,1193,null,1089.8399999999999,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24538,null,"See CPT",null,1481.51,null,1481.51,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24545,null,"See CPT",null,1721.43,null,1721.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24546,null,"See CPT",null,1917.56,null,1917.56,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[24560,null,"See CPT",null,652.58000000000004,null,575.21,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24565,null,"See CPT",null,1043.6500000000001,null,948.28,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24566,null,"See CPT",null,1356.15,null,1356.15,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24575,null,"See CPT",null,1372.94,null,1372.94,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24576,null,"See CPT",null,692.77,null,614.20000000000005,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24577,null,"See CPT",null,1071.24,null,971.08,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24579,null,"See CPT",null,1555.88,null,1555.88,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24582,null,"See CPT",null,1535.49,null,1535.49,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24586,null,"See CPT",null,2005.73,null,2005.73,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24587,null,"See CPT",null,2008.13,null,2008.13,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24600,null,"See CPT",null,728.76,null,656.18,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24605,null,"See CPT",null,910.5,null,910.5,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24615,null,"See CPT",null,1330.96,null,1330.96,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24620,null,"See CPT",null,1115.03,null,1115.03,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24635,null,"See CPT",null,1267.98,null,1267.98,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24640,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"X"]
[24650,null,"See CPT",null,520.63,null,483.44,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24655,null,"See CPT",null,874.51,null,783.94,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24665,null,"See CPT",null,1236.79,null,1236.79,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24666,null,"See CPT",null,1368.14,null,1368.14,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24670,null,"See CPT",null,574.61,null,523.63,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24675,null,"See CPT",null,890.1,null,801.93,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24685,null,"See CPT",null,1228.99,null,1228.99,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24800,null,"See CPT",null,1552.88,null,1552.88,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24802,null,"See CPT",null,1853.98,null,1853.98,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24900,null,"See CPT",null,1375.34,null,1375.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24920,null,"See CPT",null,1365.14,null,1365.14,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24925,null,"See CPT",null,1071.24,null,1071.24,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24930,null,"See CPT",null,1437.12,null,1437.12,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24931,null,"See CPT",null,1719.63,null,1719.63,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24935,null,"See CPT",null,2264.25,null,2264.25,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24940,null,"See CPT",null,2074.52,null,2074.52,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"F",null,"Y-UR"]
[24999,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,0,1,1,null,"N",null,"Y-UR"]
[25000,null,"See CPT",null,664.58,null,664.58,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25001,null,"See CPT",null,666.38,null,666.38,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25020,null,"See CPT",null,1405.33,null,1405.33,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25023,null,"See CPT",null,2454.38,null,2454.38,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[25024,null,"See CPT",null,1451.52,null,1451.52,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25025,null,"See CPT",null,2260.0500000000002,null,2260.0500000000002,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[25028,null,"See CPT",null,1317.76,null,1317.76,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25031,null,"See CPT",null,701.77,null,701.77,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25035,null,"See CPT",null,1108.43,null,1108.43,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25040,null,"See CPT",null,1048.45,null,1048.45,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25065,null,"See CPT",null,486.44,null,295.7,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[25066,null,"See CPT",null,698.17,null,698.17,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25071,null,"See CPT",null,789.34,null,789.34,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25073,null,"See CPT",null,1002.27,null,1002.27,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25075,null,"See CPT",null,982.47,null,594.4,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25076,null,"See CPT",null,974.68,null,974.68,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25077,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"X"]
[25078,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X"]
[25085,null,"See CPT",null,849.92,null,849.92,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25100,null,"See CPT",null,667.58,null,667.58,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25101,null,"See CPT",null,772.54,null,772.54,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25105,null,"See CPT",null,922.49,null,922.49,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25107,null,"See CPT",null,1167.81,null,1167.81,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25109,null,"See CPT",null,1011.26,null,1011.26,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25110,null,"See CPT",null,659.78,null,659.78,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25111,null,"See CPT",null,623.19000000000005,null,623.19000000000005,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25112,null,"See CPT",null,744.35,null,744.35,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25115,null,"See CPT",null,1418.53,null,1418.53,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25116,null,"See CPT",null,1142.02,null,1142.02,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25118,null,"See CPT",null,730.56,null,730.56,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25119,null,"See CPT",null,949.48,null,949.48,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25120,null,"See CPT",null,949.48,null,949.48,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25125,null,"See CPT",null,1121.03,null,1121.03,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25126,null,"See CPT",null,1128.82,null,1128.82,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25130,null,"See CPT",null,857.71,null,857.71,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25135,null,"See CPT",null,1059.8499999999999,null,1059.8499999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25136,null,"See CPT",null,941.69,null,941.69,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25145,null,"See CPT",null,984.87,null,984.87,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25150,null,"See CPT",null,1066.44,null,1066.44,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25151,null,"See CPT",null,1099.43,null,1099.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25170,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[25210,null,"See CPT",null,934.49,null,934.49,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[25215,null,"See CPT",null,1165.4100000000001,null,1165.4100000000001,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25230,null,"See CPT",null,821.73,null,821.73,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25240,null,"See CPT",null,816.93,null,816.93,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25246,null,"See CPT",null,369.48,null,131.36000000000001,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[25248,null,"See CPT",null,801.33,null,801.33,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25250,null,"See CPT",null,1007.06,null,1007.06,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25251,null,"See CPT",null,1343.55,null,1343.55,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25259,null,"See CPT",null,834.92,null,834.92,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25260,null,"See CPT",null,1196,null,1196,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[25263,null,"See CPT",null,1193.5999999999999,null,1193.5999999999999,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[25265,null,"See CPT",null,1408.33,null,1408.33,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[25270,null,"See CPT",null,935.09,null,935.09,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[25272,null,"See CPT",null,1054.45,null,1054.45,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[25274,null,"See CPT",null,1246.98,null,1246.98,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[25275,null,"See CPT",null,1261.3800000000001,null,1261.3800000000001,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25280,null,"See CPT",null,1066.44,null,1066.44,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[25290,null,"See CPT",null,827.12,null,827.12,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[25295,null,"See CPT",null,995.07,null,995.07,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[25300,null,"See CPT",null,1294.97,null,1294.97,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25301,null,"See CPT",null,1208.5999999999999,null,1208.5999999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25310,null,"See CPT",null,1169.6099999999999,null,1169.6099999999999,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[25312,null,"See CPT",null,1341.15,null,1341.15,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[25315,null,"See CPT",null,1432.92,null,1432.92,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25316,null,"See CPT",null,1699.83,null,1699.83,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25320,null,"See CPT",null,1855.78,null,1855.78,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[25332,null,"See CPT",null,1575.07,null,1575.07,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25335,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X"]
[25337,null,"See CPT",null,1662.65,null,1662.65,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25350,null,"See CPT",null,1263.78,null,1263.78,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25355,null,"See CPT",null,1426.32,null,1426.32,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25360,null,"See CPT",null,1230.79,null,1230.79,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25365,null,"See CPT",null,1701.03,null,1701.03,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25370,null,"See CPT",null,1877.37,null,1877.37,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25375,null,"See CPT",null,1766.41,null,1766.41,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25390,null,"See CPT",null,1432.92,null,1432.92,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25391,null,"See CPT",null,1841.39,null,1841.39,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25392,null,"See CPT",null,1873.18,null,1873.18,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25393,null,"See CPT",null,2080.11,null,2080.11,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25394,null,"See CPT",null,1461.11,null,1461.11,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25400,null,"See CPT",null,1492.3,null,1492.3,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25405,null,"See CPT",null,1916.96,null,1916.96,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25415,null,"See CPT",null,1791.6,null,1791.6,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25420,null,"See CPT",null,2149.08,null,2149.08,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25425,null,"See CPT",null,1783.81,null,1783.81,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25426,null,"See CPT",null,2068.71,null,2068.71,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25430,null,"See CPT",null,1369.94,null,1369.94,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25431,null,"See CPT",null,1467.11,null,1467.11,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25440,null,"See CPT",null,1433.52,null,1433.52,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25441,null,"See CPT",null,1738.22,null,1738.22,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25442,null,"See CPT",null,1509.1,null,1509.1,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25443,null,"See CPT",null,1465.91,null,1465.91,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25444,null,"See CPT",null,1532.49,null,1532.49,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25445,null,"See CPT",null,1345.95,null,1345.95,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25446,null,"See CPT",null,2162.88,null,2162.88,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25447,null,"See CPT",null,1556.48,null,1556.48,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25449,null,"See CPT",null,1911.56,null,1911.56,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25450,null,"See CPT",null,1160.6099999999999,null,1160.6099999999999,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[25455,null,"See CPT",null,1366.94,null,1366.94,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[25490,null,"See CPT",null,1343.55,null,1343.55,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25491,null,"See CPT",null,1378.94,null,1378.94,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25492,null,"See CPT",null,1683.64,null,1683.64,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25500,null,"See CPT",null,560.21,null,505.63,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25505,null,"See CPT",null,983.07,null,885.3,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25515,null,"See CPT",null,1260.18,null,1260.18,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25520,null,"See CPT",null,1106.6300000000001,null,1040.05,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25525,null,"See CPT",null,1479.11,null,1479.11,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[25526,null,"See CPT",null,1779.61,null,1779.61,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[25530,null,"See CPT",null,523.03,null,478.64,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25535,null,"See CPT",null,956.08,null,878.71,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25545,null,"See CPT",null,1178.01,null,1178.01,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25560,null,"See CPT",null,571.01,null,508.03,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25565,null,"See CPT",null,999.27,null,887.7,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25574,null,"See CPT",null,1267.98,null,1267.98,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[25575,null,"See CPT",null,1685.44,null,1685.44,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25600,null,"See CPT",null,667.58,null,638.19000000000005,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25605,null,"See CPT",null,1037.6500000000001,null,975.87,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25606,null,"See CPT",null,1262.58,null,1262.58,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25607,null,"See CPT",null,1390.94,null,1390.94,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25608,null,"See CPT",null,1549.88,null,1549.88,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25609,null,"See CPT",null,1960.75,null,1960.75,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25622,null,"See CPT",null,605.20000000000005,null,556.61,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25624,null,"See CPT",null,954.28,null,860.11,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25628,null,"See CPT",null,1347.15,null,1347.15,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25630,null,"See CPT",null,598,null,554.22,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25635,null,"See CPT",null,905.1,null,817.53,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25645,null,"See CPT",null,1074.8399999999999,null,1074.8399999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25650,null,"See CPT",null,644.79,null,595.6,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25651,null,"See CPT",null,934.49,null,934.49,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25652,null,"See CPT",null,1173.21,null,1173.21,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25660,null,"See CPT",null,863.11,null,863.11,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25670,null,"See CPT",null,1140.82,null,1140.82,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25671,null,"See CPT",null,1015.46,null,1015.46,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25675,null,"See CPT",null,884.11,null,793.54,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25676,null,"See CPT",null,1187,null,1187,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25680,null,"See CPT",null,1011.86,null,1011.86,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25685,null,"See CPT",null,1371.74,null,1371.74,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25690,null,"See CPT",null,940.49,null,940.49,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25695,null,"See CPT",null,1188.2,null,1188.2,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25800,null,"See CPT",null,1364.55,null,1364.55,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25805,null,"See CPT",null,1576.87,null,1576.87,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25810,null,"See CPT",null,1617.06,null,1617.06,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25820,null,"See CPT",null,1223.5899999999999,null,1223.5899999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25825,null,"See CPT",null,1491.1,null,1491.1,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25830,null,"See CPT",null,1936.75,null,1936.75,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25900,null,"See CPT",null,1340.55,null,1340.55,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25905,null,"See CPT",null,1309.96,null,1309.96,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25907,null,"See CPT",null,1154.02,null,1154.02,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25909,null,"See CPT",null,1279.3699999999999,null,1279.3699999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25915,null,"See CPT",null,2143.69,null,2143.69,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25920,null,"See CPT",null,1368.14,null,1368.14,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25922,null,"See CPT",null,1216.99,null,1216.99,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25924,null,"See CPT",null,1336.95,null,1336.95,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25927,null,"See CPT",null,1624.26,null,1624.26,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25929,null,"See CPT",null,1125.22,null,1125.22,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25931,null,"See CPT",null,1507.3,null,1507.3,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25999,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,0,1,1,null,"N"]
[26010,null,"See CPT",null,659.18,null,266.91000000000003,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[26011,null,"See CPT",null,910.5,null,347.88,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[26020,null,"See CPT",null,1050.25,null,1050.25,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26025,null,"See CPT",null,792.94,null,792.94,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26030,null,"See CPT",null,926.69,null,926.69,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26034,null,"See CPT",null,1043.6500000000001,null,1043.6500000000001,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26035,null,"See CPT",null,1608.66,null,1608.66,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26037,null,"See CPT",null,1052.05,null,1052.05,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26040,null,"See CPT",null,606.4,null,606.4,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26045,null,"See CPT",null,896.1,null,896.1,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26055,null,"See CPT",null,1128.82,null,558.41,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26060,null,"See CPT",null,488.84,null,488.84,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26070,null,"See CPT",null,616.59,null,616.59,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26075,null,"See CPT",null,645.98,null,645.98,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26080,null,"See CPT",null,762.35,null,762.35,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26100,null,"See CPT",null,649.58000000000004,null,649.58000000000004,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26105,null,"See CPT",null,653.78,null,653.78,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26110,null,"See CPT",null,622.59,null,622.59,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26111,null,"See CPT",null,782.14,null,782.14,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26113,null,"See CPT",null,1029.26,null,1029.26,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26115,null,"See CPT",null,1047.8499999999999,null,630.99,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26116,null,"See CPT",null,989.07,null,989.07,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26117,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X"]
[26118,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X"]
[26121,null,"See CPT",null,1128.82,null,1128.82,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26123,null,"See CPT",null,1572.68,null,1572.68,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26125,null,"See CPT",null,484.04,null,484.04,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[26130,null,"See CPT",null,890.7,null,890.7,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26135,null,"See CPT",null,1044.25,null,1044.25,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26140,null,"See CPT",null,962.68,null,962.68,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26145,null,"See CPT",null,975.87,null,975.87,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26160,null,"See CPT",null,1176.81,null,604,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26170,null,"See CPT",null,776.74,null,776.74,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26180,null,"See CPT",null,856.51,null,856.51,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26185,null,"See CPT",null,1058.6500000000001,null,1058.6500000000001,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26200,null,"See CPT",null,854.12,null,854.12,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26205,null,"See CPT",null,1136.02,null,1136.02,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26210,null,"See CPT",null,852.32,null,852.32,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26215,null,"See CPT",null,1068.24,null,1068.24,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26230,null,"See CPT",null,942.89,null,942.89,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26235,null,"See CPT",null,931.49,null,931.49,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26236,null,"See CPT",null,837.32,null,837.32,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26250,null,"See CPT",null,1969.14,null,1969.14,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26260,null,"See CPT",null,1479.71,null,1479.71,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26262,null,"See CPT",null,1182.21,null,1182.21,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26320,null,"See CPT",null,665.18,null,665.18,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26340,null,"See CPT",null,694.57,null,694.57,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26341,null,"See CPT",null,223.73,null,147.55000000000001,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[26350,null,"See CPT",null,1423.93,null,1423.93,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26352,null,"See CPT",null,1576.27,null,1576.27,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26356,null,"See CPT",null,1499.5,null,1499.5,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26357,null,"See CPT",null,1672.84,null,1672.84,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26358,null,"See CPT",null,1839.59,null,1839.59,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26370,null,"See CPT",null,1486.3,null,1486.3,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26372,null,"See CPT",null,1728.02,null,1728.02,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26373,null,"See CPT",null,1665.04,null,1665.04,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26390,null,"See CPT",null,1651.25,null,1651.25,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26392,null,"See CPT",null,1883.97,null,1883.97,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26410,null,"See CPT",null,1149.22,null,1149.22,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26412,null,"See CPT",null,1360.35,null,1360.35,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26415,null,"See CPT",null,1606.26,null,1606.26,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26416,null,"See CPT",null,1735.22,null,1735.22,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26418,null,"See CPT",null,1198.4000000000001,null,1198.4000000000001,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26420,null,"See CPT",null,1409.53,null,1409.53,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26426,null,"See CPT",null,953.08,null,953.08,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26428,null,"See CPT",null,1510.3,null,1510.3,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26432,null,"See CPT",null,1041.25,null,1041.25,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26433,null,"See CPT",null,1091.6400000000001,null,1091.6400000000001,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26434,null,"See CPT",null,1322.56,null,1322.56,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26437,null,"See CPT",null,1269.18,null,1269.18,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26440,null,"See CPT",null,1241.5899999999999,null,1241.5899999999999,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26442,null,"See CPT",null,1874.38,null,1874.38,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26445,null,"See CPT",null,1156.4100000000001,null,1156.4100000000001,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26449,null,"See CPT",null,1321.96,null,1321.96,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26450,null,"See CPT",null,888.9,null,888.9,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26455,null,"See CPT",null,882.91,null,882.91,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26460,null,"See CPT",null,866.11,null,866.11,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26471,null,"See CPT",null,1256.58,null,1256.58,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26474,null,"See CPT",null,1243.3900000000001,null,1243.3900000000001,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26476,null,"See CPT",null,1228.99,null,1228.99,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26477,null,"See CPT",null,1200.8,null,1200.8,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[26478,null,"See CPT",null,1251.78,null,1251.78,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26479,null,"See CPT",null,1286.57,null,1286.57,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26480,null,"See CPT",null,1494.1,null,1494.1,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26483,null,"See CPT",null,1649.45,null,1649.45,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26485,null,"See CPT",null,1585.27,null,1585.27,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26489,null,"See CPT",null,1817.39,null,1817.39,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26490,null,"See CPT",null,1583.47,null,1583.47,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26492,null,"See CPT",null,1748.42,null,1748.42,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26494,null,"See CPT",null,1590.07,null,1590.07,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26496,null,"See CPT",null,1707.03,null,1707.03,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26497,null,"See CPT",null,1704.63,null,1704.63,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26498,null,"See CPT",null,2201.87,null,2201.87,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26499,null,"See CPT",null,1643.45,null,1643.45,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26500,null,"See CPT",null,1308.76,null,1308.76,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26502,null,"See CPT",null,1431.72,null,1431.72,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26508,null,"See CPT",null,1288.97,null,1288.97,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26510,null,"See CPT",null,1220.5899999999999,null,1220.5899999999999,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26516,null,"See CPT",null,1408.93,null,1408.93,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26517,null,"See CPT",null,1633.86,null,1633.86,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26518,null,"See CPT",null,1653.65,null,1653.65,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26520,null,"See CPT",null,1300.97,null,1300.97,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26525,null,"See CPT",null,1308.1600000000001,null,1308.1600000000001,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[26530,null,"See CPT",null,1024.46,null,1024.46,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26531,null,"See CPT",null,1189.4000000000001,null,1189.4000000000001,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26535,null,"See CPT",null,831.92,null,831.92,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26536,null,"See CPT",null,1426.32,null,1426.32,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26540,null,"See CPT",null,1327.96,null,1327.96,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[26541,null,"See CPT",null,1578.07,null,1578.07,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26542,null,"See CPT",null,1370.54,null,1370.54,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26545,null,"See CPT",null,1394.54,null,1394.54,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26546,null,"See CPT",null,1959.55,null,1959.55,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26548,null,"See CPT",null,1512.1,null,1512.1,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26550,null,"See CPT",null,3057.78,null,3057.78,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26551,null,"See CPT",null,6024.39,null,6024.39,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26553,null,"See CPT",null,5984.2,null,5984.2,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26554,null,"See CPT",null,6955.88,null,6955.88,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26555,null,"See CPT",null,2580.34,null,2580.34,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26556,null,"See CPT",null,6228.92,null,6228.92,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26560,null,"See CPT",null,1211,null,1211,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26561,null,"See CPT",null,1844.39,null,1844.39,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26562,null,"See CPT",null,2570.14,null,2570.14,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26565,null,"See CPT",null,1348.35,null,1348.35,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26567,null,"See CPT",null,1364.55,null,1364.55,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26568,null,"See CPT",null,1755.01,null,1755.01,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26580,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X"]
[26587,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X"]
[26590,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X"]
[26591,null,"See CPT",null,939.89,null,939.89,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26593,null,"See CPT",null,1229.5899999999999,null,1229.5899999999999,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26596,null,"See CPT",null,1539.09,null,1539.09,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26600,null,"See CPT",null,593.20000000000005,null,564.41,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26605,null,"See CPT",null,646.58000000000004,null,580.61,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26607,null,"See CPT",null,965.68,null,965.68,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26608,null,"See CPT",null,918.89,null,918.89,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26615,null,"See CPT",null,1088.6400000000001,null,1088.6400000000001,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26641,null,"See CPT",null,815.73,null,739.55,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26645,null,"See CPT",null,839.12,null,759.95,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26650,null,"See CPT",null,919.49,null,919.49,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26665,null,"See CPT",null,1184.01,null,1184.01,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[26670,null,"See CPT",null,681.37,null,605.20000000000005,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26675,null,"See CPT",null,894.3,null,812.13,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26676,null,"See CPT",null,974.08,null,974.08,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26685,null,"See CPT",null,1092.24,null,1092.24,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[26686,null,"See CPT",null,1168.4100000000001,null,1168.4100000000001,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26700,null,"See CPT",null,659.78,null,605.20000000000005,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26705,null,"See CPT",null,849.32,null,765.34,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26706,null,"See CPT",null,854.12,null,854.12,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26715,null,"See CPT",null,1085.04,null,1085.04,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26720,null,"See CPT",null,397.67,null,373.08,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26725,null,"See CPT",null,666.98,null,590.20000000000005,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26727,null,"See CPT",null,906.3,null,906.3,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26735,null,"See CPT",null,1124.03,null,1124.03,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26740,null,"See CPT",null,459.45,null,433.66,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26742,null,"See CPT",null,723.96,null,645.98,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26746,null,"See CPT",null,1390.34,null,1390.34,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26750,null,"See CPT",null,370.08,null,374.88,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26755,null,"See CPT",null,623.19000000000005,null,530.22,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26756,null,"See CPT",null,813.93,null,813.93,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26765,null,"See CPT",null,958.48,null,958.48,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26770,null,"See CPT",null,563.80999999999995,null,510.43,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26775,null,"See CPT",null,770.74,null,688.57,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26776,null,"See CPT",null,860.71,null,860.71,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26785,null,"See CPT",null,1037.6500000000001,null,1037.6500000000001,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26820,null,"See CPT",null,1567.88,null,1567.88,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26841,null,"See CPT",null,1471.31,null,1471.31,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[26842,null,"See CPT",null,1572.08,null,1572.08,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26843,null,"See CPT",null,1480.31,null,1480.31,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26844,null,"See CPT",null,1623.66,null,1623.66,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26850,null,"See CPT",null,1393.34,null,1393.34,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26852,null,"See CPT",null,1576.27,null,1576.27,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26860,null,"See CPT",null,1172.01,null,1172.01,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26861,null,"See CPT",null,183.54,null,183.54,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[26862,null,"See CPT",null,1454.52,null,1454.52,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26863,null,"See CPT",null,409.06,null,409.06,null,0,0,0,0,0,0,0,2,0,0,null,"R"]
[26910,null,"See CPT",null,1439.52,null,1439.52,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26951,null,"See CPT",null,1339.35,null,1339.35,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26952,null,"See CPT",null,1298.57,null,1298.57,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26989,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,1,1,1,null,"N"]
[26990,null,"See CPT",null,1276.3699999999999,null,1276.3699999999999,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26991,null,"See CPT",null,1332.76,null,984.27,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26992,null,"See CPT",null,1876.77,null,1876.77,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[27000,null,"See CPT",null,734.76,null,734.76,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27001,null,"See CPT",null,1011.26,null,1011.26,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27003,null,"See CPT",null,1125.22,null,1125.22,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27005,null,"See CPT",null,1340.55,null,1340.55,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27006,null,"See CPT",null,1335.15,null,1335.15,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27025,null,"See CPT",null,1721.43,null,1721.43,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[27027,null,"See CPT",null,1633.26,null,1633.26,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27030,null,"See CPT",null,1727.42,null,1727.42,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27033,null,"See CPT",null,1792.8,null,1792.8,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27035,null,"See CPT",null,2107.6999999999998,null,2107.6999999999998,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27036,null,"See CPT",null,1885.17,null,1885.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27040,null,"See CPT",null,639.99,null,367.68,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27041,null,"See CPT",null,1312.36,null,1312.36,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27043,null,"See CPT",null,864.31,null,864.31,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27045,null,"See CPT",null,1347.75,null,1347.75,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27047,null,"See CPT",null,930.89,null,672.98,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27048,null,"See CPT",null,1131.22,null,1131.22,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27049,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[27050,null,"See CPT",null,771.34,null,771.34,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[27052,null,"See CPT",null,1089.24,null,1089.24,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27054,null,"See CPT",null,1286.57,null,1286.57,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27057,null,"See CPT",null,1854.58,null,1854.58,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27059,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[27060,null,"See CPT",null,880.51,null,880.51,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27062,null,"See CPT",null,855.91,null,855.91,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27065,null,"See CPT",null,985.47,null,985.47,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27066,null,"See CPT",null,1517.49,null,1517.49,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27067,null,"See CPT",null,1915.76,null,1915.76,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27070,null,"See CPT",null,1645.85,null,1645.85,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27071,null,"See CPT",null,1809,null,1809,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27075,null,"See CPT",null,3787.14,null,3787.14,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27076,null,"See CPT",null,4565.68,null,4565.68,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27077,null,"See CPT",null,5086.3,null,5086.3,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27078,null,"See CPT",null,3734.95,null,3734.95,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27080,null,"See CPT",null,944.69,null,944.69,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[27086,null,"See CPT",null,593.20000000000005,null,318.49,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27087,null,"See CPT",null,1137.82,null,1137.82,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27090,null,"See CPT",null,1537.89,null,1537.89,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27091,null,"See CPT",null,2910.23,null,2910.23,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27093,null,"See CPT",null,438.45,null,122.36,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[27095,null,"See CPT",null,582.41,null,147.55000000000001,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[27096,null,"See CPT",null,310.7,null,151.75,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27097,null,"See CPT",null,1275.17,null,1275.17,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27098,null,"See CPT",null,1299.77,null,1299.77,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27100,null,"See CPT",null,1546.28,null,1546.28,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27105,null,"See CPT",null,1617.66,null,1617.66,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27110,null,"See CPT",null,1797,null,1797,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27111,null,"See CPT",null,1676.44,null,1676.44,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27120,null,"See CPT",null,2385.4,null,2385.4,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27122,null,"See CPT",null,2032.72,null,2032.72,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27125,null,"See CPT",null,2081.91,null,2081.91,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27130,null,"See CPT",null,2350.62,null,2350.62,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27132,null,"See CPT",null,3050.58,null,3050.58,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27134,null,"See CPT",null,3460.25,null,3460.25,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27137,null,"See CPT",null,2673.91,null,2673.91,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27138,null,"See CPT",null,2775.87,null,2775.87,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27140,null,"See CPT",null,1659.65,null,1659.65,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27146,null,"See CPT",null,2350.02,null,2350.02,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27147,null,"See CPT",null,2678.71,null,2678.71,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27151,null,"See CPT",null,2890.44,null,2890.44,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27156,null,"See CPT",null,3110.56,null,3110.56,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27158,null,"See CPT",null,2563.5500000000002,null,2563.5500000000002,null,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R"]
[27161,null,"See CPT",null,2244.4499999999998,null,2244.4499999999998,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27165,null,"See CPT",null,2519.7600000000002,null,2519.7600000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27170,null,"See CPT",null,2144.88,null,2144.88,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27175,null,"See CPT",null,1239.79,null,1239.79,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[27176,null,"See CPT",null,1709.43,null,1709.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27177,null,"See CPT",null,2058.5100000000002,null,2058.5100000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27178,null,"See CPT",null,1709.43,null,1709.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27179,null,"See CPT",null,1809,null,1809,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[27181,null,"See CPT",null,2066.91,null,2066.91,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[27185,null,"See CPT",null,1340.55,null,1340.55,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[27187,null,"See CPT",null,1841.99,null,1841.99,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27197,null,"See CPT",null,249.52,null,249.52,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[27198,null,"See CPT",null,580.01,null,580.01,null,0,0,0,0,0,2,0,0,2,0,null,"R"]
[27200,null,"See CPT",null,367.68,null,372.48,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[27202,null,"See CPT",null,983.67,null,983.67,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[27215,null,"See CPT",null,1115.6300000000001,null,1115.6300000000001,null,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27216,null,"See CPT",null,1645.85,null,1645.85,null,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27217,null,"See CPT",null,1548.08,null,1548.08,null,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27218,null,"See CPT",null,2117.29,null,2117.29,null,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27220,null,"See CPT",null,786.34,null,774.94,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27222,null,"See CPT",null,1810.8,null,1810.8,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27226,null,"See CPT",null,1948.15,null,1948.15,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27227,null,"See CPT",null,3015.19,null,3015.19,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27228,null,"See CPT",null,3420.06,null,3420.06,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27230,null,"See CPT",null,926.69,null,908.7,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27232,null,"See CPT",null,1332.16,null,1332.16,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27235,null,"See CPT",null,1676.44,null,1676.44,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27236,null,"See CPT",null,2195.27,null,2195.27,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27238,null,"See CPT",null,887.1,null,887.1,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27240,null,"See CPT",null,1760.41,null,1760.41,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27244,null,"See CPT",null,2255.85,null,2255.85,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27245,null,"See CPT",null,2253.4499999999998,null,2253.4499999999998,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27246,null,"See CPT",null,742.55,null,734.76,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27248,null,"See CPT",null,1376.54,null,1376.54,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27250,null,"See CPT",null,318.49,null,318.49,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[27252,null,"See CPT",null,1384.94,null,1384.94,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27253,null,"See CPT",null,1734.62,null,1734.62,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27254,null,"See CPT",null,2334.42,null,2334.42,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27256,null,"See CPT",null,589,null,437.25,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27257,null,"See CPT",null,665.18,null,665.18,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27258,null,"See CPT",null,2048.92,null,2048.92,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27259,null,"See CPT",null,2825.66,null,2825.66,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27265,null,"See CPT",null,794.14,null,794.14,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27266,null,"See CPT",null,1092.24,null,1092.24,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27267,null,"See CPT",null,838.52,null,838.52,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27268,null,"See CPT",null,1023.26,null,1023.26,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27269,null,"See CPT",null,2269.64,null,2269.64,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27275,null,"See CPT",null,346.08,null,346.08,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[27278,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"X"]
[27279,null,"See CPT",null,1471.91,null,1471.91,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27280,null,"See CPT",null,2477.17,null,2477.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27282,null,"See CPT",null,1597.87,null,1597.87,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27284,null,"See CPT",null,2921.63,null,2921.63,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27286,null,"See CPT",null,3000.2,null,3000.2,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27290,null,"See CPT",null,2972.01,null,2972.01,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27295,null,"See CPT",null,2303.83,null,2303.83,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27299,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,2,1,1,null,"N",null,"Y-UR"]
[27301,null,"See CPT",null,1268.58,null,949.48,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27303,null,"See CPT",null,1197.8,null,1197.8,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27305,null,"See CPT",null,909.9,null,909.9,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27306,null,"See CPT",null,650.78,null,650.78,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27307,null,"See CPT",null,768.94,null,768.94,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[27310,null,"See CPT",null,1366.34,null,1366.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27323,null,"See CPT",null,520.03,null,326.89,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27324,null,"See CPT",null,771.34,null,771.34,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27325,null,"See CPT",null,1062.25,null,1062.25,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[27326,null,"See CPT",null,986.67,null,986.67,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27327,null,"See CPT",null,947.68,null,591.4,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27328,null,"See CPT",null,1155.21,null,1155.21,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27329,null,"See CPT",null,1904.37,null,1904.37,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27330,null,"See CPT",null,801.93,null,801.93,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27331,null,"See CPT",null,900.3,null,900.3,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27332,null,"See CPT",null,1211,null,1211,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27333,null,"See CPT",null,1109.03,null,1109.03,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27334,null,"See CPT",null,1284.17,null,1284.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27335,null,"See CPT",null,1427.52,null,1427.52,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27337,null,"See CPT",null,776.74,null,776.74,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27339,null,"See CPT",null,1390.94,null,1390.94,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27340,null,"See CPT",null,714.36,null,714.36,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27345,null,"See CPT",null,918.29,null,918.29,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27347,null,"See CPT",null,993.87,null,993.87,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27350,null,"See CPT",null,1225.99,null,1225.99,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27355,null,"See CPT",null,1139.6199999999999,null,1139.6199999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27356,null,"See CPT",null,1380.74,null,1380.74,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27357,null,"See CPT",null,1523.49,null,1523.49,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27358,null,"See CPT",null,491.24,null,491.24,null,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-UR"]
[27360,null,"See CPT",null,1684.84,null,1684.84,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27364,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[27365,null,"See CPT",null,3733.16,null,3733.16,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27369,null,"See CPT",null,350.28,null,72.58,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[27372,null,"See CPT",null,1106.6300000000001,null,748.55,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27380,null,"See CPT",null,1172.01,null,1172.01,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27381,null,"See CPT",null,1530.69,null,1530.69,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27385,null,"See CPT",null,1146.82,null,1146.82,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27386,null,"See CPT",null,1598.47,null,1598.47,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27390,null,"See CPT",null,852.92,null,852.92,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27391,null,"See CPT",null,1088.6400000000001,null,1088.6400000000001,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR"]
[27392,null,"See CPT",null,1332.76,null,1332.76,null,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR"]
[27393,null,"See CPT",null,942.89,null,942.89,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27394,null,"See CPT",null,1225.99,null,1225.99,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[27395,null,"See CPT",null,1639.25,null,1639.25,null,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR"]
[27396,null,"See CPT",null,1159.4100000000001,null,1159.4100000000001,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27397,null,"See CPT",null,1701.03,null,1701.03,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27400,null,"See CPT",null,1300.3699999999999,null,1300.3699999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27403,null,"See CPT",null,1208.5999999999999,null,1208.5999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27405,null,"See CPT",null,1264.98,null,1264.98,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27407,null,"See CPT",null,1485.1,null,1485.1,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27409,null,"See CPT",null,1790.4,null,1790.4,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27412,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,"Y-UR"]
[27415,null,"See CPT",null,2526.36,null,2526.36,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27416,null,"See CPT",null,1810.8,null,1810.8,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[27418,null,"See CPT",null,1528.29,null,1528.29,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27420,null,"See CPT",null,1398.13,null,1398.13,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27422,null,"See CPT",null,1382.54,null,1382.54,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27424,null,"See CPT",null,1395.73,null,1395.73,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27425,null,"See CPT",null,861.91,null,861.91,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27427,null,"See CPT",null,1321.36,null,1321.36,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27428,null,"See CPT",null,2071.11,null,2071.11,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27429,null,"See CPT",null,2333.8200000000002,null,2333.8200000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27430,null,"See CPT",null,1384.34,null,1384.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27435,null,"See CPT",null,1505.5,null,1505.5,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27437,null,"See CPT",null,1236.79,null,1236.79,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27438,null,"See CPT",null,1560.08,null,1560.08,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27440,null,"See CPT",null,1483.31,null,1483.31,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27441,null,"See CPT",null,1530.09,null,1530.09,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27442,null,"See CPT",null,1609.86,null,1609.86,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27443,null,"See CPT",null,1516.89,null,1516.89,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27445,null,"See CPT",null,2303.23,null,2303.23,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27446,null,"See CPT",null,2108.3000000000002,null,2108.3000000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27447,null,"See CPT",null,2347.02,null,2347.02,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27448,null,"See CPT",null,1537.29,null,1537.29,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27450,null,"See CPT",null,1864.78,null,1864.78,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27454,null,"See CPT",null,2376.41,null,2376.41,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27455,null,"See CPT",null,1779.61,null,1779.61,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27457,null,"See CPT",null,1741.22,null,1741.22,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27465,null,"See CPT",null,2290.64,null,2290.64,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27466,null,"See CPT",null,2182.0700000000002,null,2182.0700000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27468,null,"See CPT",null,2460.38,null,2460.38,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27470,null,"See CPT",null,2176.67,null,2176.67,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27472,null,"See CPT",null,2324.8200000000002,null,2324.8200000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27475,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,"Y-UR"]
[27477,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,"Y-UR"]
[27479,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,"Y-UR"]
[27485,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"X",null,"Y-UR"]
[27486,null,"See CPT",null,2573.14,null,2573.14,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27487,null,"See CPT",null,3198.13,null,3198.13,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27488,null,"See CPT",null,2209.06,null,2209.06,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27495,null,"See CPT",null,2080.71,null,2080.71,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27496,null,"See CPT",null,1036.45,null,1036.45,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27497,null,"See CPT",null,1087.44,null,1087.44,null,90,0.1,0.69,0.21,0,2,1,0,2,0,null,"R"]
[27498,null,"See CPT",null,1231.3900000000001,null,1231.3900000000001,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27499,null,"See CPT",null,1311.76,null,1311.76,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27500,null,"See CPT",null,992.07,null,905.7,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27501,null,"See CPT",null,952.48,null,938.09,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27502,null,"See CPT",null,1392.14,null,1392.14,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27503,null,"See CPT",null,1485.1,null,1485.1,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27506,null,"See CPT",null,2460.98,null,2460.98,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27507,null,"See CPT",null,1777.81,null,1777.81,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27508,null,"See CPT",null,1001.07,null,945.28,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27509,null,"See CPT",null,1269.18,null,1269.18,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27510,null,"See CPT",null,1268.58,null,1268.58,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27511,null,"See CPT",null,1825.79,null,1825.79,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27513,null,"See CPT",null,2254.0500000000002,null,2254.0500000000002,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27514,null,"See CPT",null,1771.21,null,1771.21,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27516,null,"See CPT",null,996.27,null,927.89,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27517,null,"See CPT",null,1293.17,null,1293.17,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27519,null,"See CPT",null,1636.25,null,1636.25,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27520,null,"See CPT",null,637.59,null,586.6,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27524,null,"See CPT",null,1402.33,null,1402.33,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27530,null,"See CPT",null,604.6,null,566.21,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27532,null,"See CPT",null,1176.81,null,1092.8399999999999,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27535,null,"See CPT",null,1647.65,null,1647.65,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27536,null,"See CPT",null,2186.87,null,2186.87,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27538,null,"See CPT",null,930.89,null,862.51,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27540,null,"See CPT",null,1512.1,null,1512.1,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27550,null,"See CPT",null,977.67,null,893.1,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27552,null,"See CPT",null,1193.5999999999999,null,1193.5999999999999,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27556,null,"See CPT",null,1611.06,null,1611.06,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27557,null,"See CPT",null,1912.16,null,1912.16,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27558,null,"See CPT",null,2170.6799999999998,null,2170.6799999999998,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27560,null,"See CPT",null,724.56,null,657.98,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27562,null,"See CPT",null,931.49,null,931.49,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27566,null,"See CPT",null,1653.65,null,1653.65,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27570,null,"See CPT",null,290.3,null,290.3,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27580,null,"See CPT",null,2718.29,null,2718.29,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27590,null,"See CPT",null,1405.33,null,1405.33,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27591,null,"See CPT",null,1779.61,null,1779.61,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27592,null,"See CPT",null,1208.5999999999999,null,1208.5999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27594,null,"See CPT",null,926.09,null,926.09,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27596,null,"See CPT",null,1288.3699999999999,null,1288.3699999999999,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27598,null,"See CPT",null,1254.18,null,1254.18,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27599,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,2,1,1,null,"N",null,"Y-UR"]
[27600,null,"See CPT",null,734.76,null,734.76,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27601,null,"See CPT",null,822.33,null,822.33,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27602,null,"See CPT",null,860.11,null,860.11,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27603,null,"See CPT",null,987.27,null,726.96,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27604,null,"See CPT",null,846.92,null,603.4,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27605,null,"See CPT",null,623.19000000000005,null,340.69,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27606,null,"See CPT",null,499.03,null,499.03,null,10,0.1,0.8,0.1,0,2,1,1,1,0,null,"R"]
[27607,null,"See CPT",null,1113.23,null,1113.23,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27610,null,"See CPT",null,1202,null,1202,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27612,null,"See CPT",null,1069.44,null,1069.44,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27613,null,"See CPT",null,481.04,null,301.7,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27614,null,"See CPT",null,1112.03,null,777.34,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27615,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"X"]
[27616,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"X"]
[27618,null,"See CPT",null,921.29,null,574.01,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27619,null,"See CPT",null,876.31,null,876.31,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27620,null,"See CPT",null,841.52,null,841.52,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27625,null,"See CPT",null,1068.8399999999999,null,1068.8399999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27626,null,"See CPT",null,1154.02,null,1154.02,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27630,null,"See CPT",null,1019.66,null,671.78,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27632,null,"See CPT",null,756.35,null,756.35,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27634,null,"See CPT",null,1240.99,null,1240.99,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27635,null,"See CPT",null,1082.6400000000001,null,1082.6400000000001,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27637,null,"See CPT",null,1392.14,null,1392.14,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27638,null,"See CPT",null,1377.74,null,1377.74,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27640,null,"See CPT",null,1540.29,null,1540.29,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27641,null,"See CPT",null,1211.5999999999999,null,1211.5999999999999,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27645,null,"See CPT",null,3223.93,null,3223.93,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27646,null,"See CPT",null,2807.66,null,2807.66,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27647,null,"See CPT",null,1818.59,null,1818.59,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27648,null,"See CPT",null,403.07,null,92.97,null,0,0,0,0,0,2,1,0,0,0,null,"R"]
[27650,null,"See CPT",null,1228.3900000000001,null,1228.3900000000001,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27652,null,"See CPT",null,1247.58,null,1247.58,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27654,null,"See CPT",null,1333.96,null,1333.96,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27656,null,"See CPT",null,999.27,null,642.39,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27658,null,"See CPT",null,693.97,null,693.97,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[27659,null,"See CPT",null,883.51,null,883.51,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[27664,null,"See CPT",null,682.57,null,682.57,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[27665,null,"See CPT",null,797.73,null,797.73,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[27675,null,"See CPT",null,926.09,null,926.09,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27676,null,"See CPT",null,1136.6199999999999,null,1136.6199999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27680,null,"See CPT",null,789.34,null,789.34,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[27681,null,"See CPT",null,950.68,null,950.68,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27685,null,"See CPT",null,1239.79,null,873.91,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27686,null,"See CPT",null,993.87,null,993.87,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27687,null,"See CPT",null,851.12,null,851.12,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27690,null,"See CPT",null,1191.8,null,1191.8,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27691,null,"See CPT",null,1384.34,null,1384.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27692,null,"See CPT",null,182.94,null,182.94,null,0,0,0,0,0,0,0,2,1,0,null,"R"]
[27695,null,"See CPT",null,911.7,null,911.7,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27696,null,"See CPT",null,1020.86,null,1020.86,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27698,null,"See CPT",null,1184.6099999999999,null,1184.6099999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27700,null,"See CPT",null,1326.76,null,1326.76,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27702,null,"See CPT",null,1774.81,null,1774.81,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27703,null,"See CPT",null,2043.52,null,2043.52,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27704,null,"See CPT",null,1059.25,null,1059.25,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27705,null,"See CPT",null,1390.34,null,1390.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27707,null,"See CPT",null,767.74,null,767.74,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27709,null,"See CPT",null,2105.9,null,2105.9,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27712,null,"See CPT",null,2035.12,null,2035.12,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27715,null,"See CPT",null,1978.74,null,1978.74,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27720,null,"See CPT",null,1617.66,null,1617.66,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27722,null,"See CPT",null,1660.85,null,1660.85,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27724,null,"See CPT",null,2295.4299999999998,null,2295.4299999999998,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27725,null,"See CPT",null,2245.0500000000002,null,2245.0500000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27726,null,"See CPT",null,1761.61,null,1761.61,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27727,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[27730,null,"See CPT",null,1104.83,null,1104.83,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[27732,null,"See CPT",null,860.11,null,860.11,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[27734,null,"See CPT",null,1230.79,null,1230.79,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[27740,null,"See CPT",null,1321.96,null,1321.96,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[27742,null,"See CPT",null,1449.12,null,1449.12,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27745,null,"See CPT",null,1385.54,null,1385.54,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27750,null,"See CPT",null,678.37,null,627.99,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27752,null,"See CPT",null,1023.26,null,929.09,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27756,null,"See CPT",null,1086.8399999999999,null,1086.8399999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27758,null,"See CPT",null,1662.65,null,1662.65,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27759,null,"See CPT",null,1840.19,null,1840.19,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27760,null,"See CPT",null,651.98,null,599.20000000000005,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27762,null,"See CPT",null,939.89,null,842.12,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27766,null,"See CPT",null,1134.22,null,1134.22,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27767,null,"See CPT",null,568.01,null,566.80999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27768,null,"See CPT",null,858.31,null,858.31,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27769,null,"See CPT",null,1351.35,null,1351.35,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27780,null,"See CPT",null,605.79999999999995,null,556.01,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27781,null,"See CPT",null,848.12,null,776.74,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27784,null,"See CPT",null,1335.75,null,1335.75,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27786,null,"See CPT",null,612.4,null,559.01,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27788,null,"See CPT",null,821.73,null,738.35,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27792,null,"See CPT",null,1206.2,null,1206.2,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27808,null,"See CPT",null,658.58,null,596.79999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27810,null,"See CPT",null,914.1,null,818.13,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27814,null,"See CPT",null,1422.13,null,1422.13,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27816,null,"See CPT",null,648.98,null,573.41,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27818,null,"See CPT",null,947.08,null,838.52,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27822,null,"See CPT",null,1630.86,null,1630.86,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27823,null,"See CPT",null,1831.79,null,1831.79,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27824,null,"See CPT",null,613,null,591.4,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27825,null,"See CPT",null,1038.25,null,929.09,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27826,null,"See CPT",null,1594.87,null,1594.87,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27827,null,"See CPT",null,2082.5100000000002,null,2082.5100000000002,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27828,null,"See CPT",null,2454.38,null,2454.38,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27829,null,"See CPT",null,1325.56,null,1325.56,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27830,null,"See CPT",null,755.75,null,695.17,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27831,null,"See CPT",null,782.14,null,782.14,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27832,null,"See CPT",null,1415.53,null,1415.53,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27840,null,"See CPT",null,740.15,null,740.15,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27842,null,"See CPT",null,930.29,null,930.29,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27846,null,"See CPT",null,1352.55,null,1352.55,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27848,null,"See CPT",null,1463.51,null,1463.51,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27860,null,"See CPT",null,304.7,null,304.7,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27870,null,"See CPT",null,1860.58,null,1860.58,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27871,null,"See CPT",null,1287.17,null,1287.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27880,null,"See CPT",null,1611.06,null,1611.06,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27881,null,"See CPT",null,1522.89,null,1522.89,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27882,null,"See CPT",null,1064.6500000000001,null,1064.6500000000001,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,"Y-UR"]
[27884,null,"See CPT",null,1054.45,null,1054.45,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27886,null,"See CPT",null,1178.6099999999999,null,1178.6099999999999,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27888,null,"See CPT",null,1021.46,null,1021.46,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27889,null,"See CPT",null,1157.01,null,1157.01,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27892,null,"See CPT",null,989.07,null,989.07,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27893,null,"See CPT",null,1152.82,null,1152.82,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27894,null,"See CPT",null,1487.5,null,1487.5,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27899,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,0,1,1,null,"N"]
[28001,null,"See CPT",null,320.89,null,173.94,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[28002,null,"See CPT",null,460.65,null,255.51,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[28003,null,"See CPT",null,700.57,null,467.84,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[28005,null,"See CPT",null,1061.05,null,1061.05,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28008,null,"See CPT",null,804.33,null,551.22,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28010,null,"See CPT",null,442.65,null,392.87,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28011,null,"See CPT",null,593.79999999999995,null,524.23,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28020,null,"See CPT",null,1021.46,null,684.37,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[28022,null,"See CPT",null,917.69,null,613.6,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28024,null,"See CPT",null,871.51,null,578.80999999999995,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28035,null,"See CPT",null,994.47,null,671.18,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28039,null,"See CPT",null,894.9,null,629.79,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28041,null,"See CPT",null,838.52,null,838.52,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28043,null,"See CPT",null,722.16,null,489.44,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28045,null,"See CPT",null,902.1,null,648.38,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28046,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X"]
[28047,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[28050,null,"See CPT",null,783.94,null,523.03,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28052,null,"See CPT",null,734.16,null,479.84,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28054,null,"See CPT",null,692.17,null,439.65,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28055,null,"See CPT",null,725.16,null,725.16,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28060,null,"See CPT",null,975.27,null,674.78,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28062,null,"See CPT",null,1083.8399999999999,null,753.35,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28070,null,"See CPT",null,954.88,null,641.19000000000005,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28072,null,"See CPT",null,926.09,null,610,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28080,null,"See CPT",null,1009.46,null,715.56,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28086,null,"See CPT",null,987.87,null,656.18,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28088,null,"See CPT",null,878.11,null,553.62,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28090,null,"See CPT",null,879.31,null,579.41,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28092,null,"See CPT",null,800.13,null,514.03,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28100,null,"See CPT",null,1152.82,null,782.14,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28102,null,"See CPT",null,1146.22,null,1146.22,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28103,null,"See CPT",null,720.96,null,720.96,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28104,null,"See CPT",null,989.07,null,663.38,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[28106,null,"See CPT",null,791.74,null,791.74,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[28107,null,"See CPT",null,953.08,null,645.98,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[28108,null,"See CPT",null,818.73,null,542.22,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28110,null,"See CPT",null,874.51,null,551.82000000000005,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28111,null,"See CPT",null,891.9,null,593.79999999999995,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28112,null,"See CPT",null,908.7,null,586.6,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28113,null,"See CPT",null,1101.23,null,801.93,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[28114,null,"See CPT",null,1997.33,null,1561.28,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28116,null,"See CPT",null,1438.92,null,1082.04,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28118,null,"See CPT",null,1138.42,null,790.54,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28119,null,"See CPT",null,990.27,null,682.57,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28120,null,"See CPT",null,1257.78,null,924.89,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28122,null,"See CPT",null,1112.03,null,820.53,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28124,null,"See CPT",null,899.7,null,627.99,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28126,null,"See CPT",null,738.95,null,470.84,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28130,null,"See CPT",null,1151.6199999999999,null,1151.6199999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28140,null,"See CPT",null,1058.6500000000001,null,785.74,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[28150,null,"See CPT",null,788.74,null,523.63,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28153,null,"See CPT",null,764.75,null,497.23,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28160,null,"See CPT",null,771.34,null,502.03,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28171,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X"]
[28173,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"X"]
[28175,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"X"]
[28190,null,"See CPT",null,455.25,null,247.12,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[28192,null,"See CPT",null,863.11,null,580.01,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28193,null,"See CPT",null,977.07,null,681.97,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28200,null,"See CPT",null,931.49,null,613,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[28202,null,"See CPT",null,1119.23,null,797.13,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[28208,null,"See CPT",null,915.29,null,603.4,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[28210,null,"See CPT",null,1113.83,null,791.74,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[28220,null,"See CPT",null,849.32,null,572.80999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28222,null,"See CPT",null,1011.26,null,691.57,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28225,null,"See CPT",null,780.94,null,497.83,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28226,null,"See CPT",null,1168.4100000000001,null,755.15,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28230,null,"See CPT",null,814.53,null,533.82000000000005,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28232,null,"See CPT",null,712.56,null,454.05,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28234,null,"See CPT",null,776.74,null,509.83,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28238,null,"See CPT",null,1257.18,null,909.3,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28240,null,"See CPT",null,834.92,null,550.02,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28250,null,"See CPT",null,1106.03,null,770.14,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28260,null,"See CPT",null,1366.94,null,1005.86,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28261,null,"See CPT",null,2000.93,null,1560.08,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28262,null,"See CPT",null,2552.15,null,2039.32,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28264,null,"See CPT",null,1625.46,null,1241.5899999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28270,null,"See CPT",null,917.09,null,627.39,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28272,null,"See CPT",null,721.56,null,471.44,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28280,null,"See CPT",null,949.48,null,644.79,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28285,null,"See CPT",null,1017.26,null,726.36,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28286,null,"See CPT",null,834.32,null,557.80999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28288,null,"See CPT",null,1138.42,null,819.33,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28289,null,"See CPT",null,1296.17,null,863.11,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28291,null,"See CPT",null,1291.97,null,894.9,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28292,null,"See CPT",null,1317.16,null,909.9,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28295,null,"See CPT",null,1977.54,null,1123.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28296,null,"See CPT",null,1669.24,null,958.48,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28297,null,"See CPT",null,1927.16,null,1119.83,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28298,null,"See CPT",null,1575.07,null,947.68,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28299,null,"See CPT",null,1908.56,null,1109.03,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28300,null,"See CPT",null,1208.5999999999999,null,1208.5999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28302,null,"See CPT",null,1335.15,null,1335.15,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28304,null,"See CPT",null,1550.48,null,1140.22,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28305,null,"See CPT",null,1251.18,null,1251.18,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28306,null,"See CPT",null,1149.22,null,761.75,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28307,null,"See CPT",null,1480.91,null,972.28,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28308,null,"See CPT",null,1078.44,null,728.76,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28309,null,"See CPT",null,1673.44,null,1673.44,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28310,null,"See CPT",null,1029.26,null,680.17,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28312,null,"See CPT",null,1029.26,null,648.38,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[28313,null,"See CPT",null,995.07,null,677.77,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28315,null,"See CPT",null,899.1,null,610,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28320,null,"See CPT",null,1146.22,null,1146.22,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28322,null,"See CPT",null,1475.51,null,1077.24,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[28340,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X"]
[28341,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X"]
[28344,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X"]
[28345,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"X"]
[28360,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X"]
[28400,null,"See CPT",null,482.24,null,446.85,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28405,null,"See CPT",null,869.71,null,776.14,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28406,null,"See CPT",null,1119.23,null,1119.23,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28415,null,"See CPT",null,2079.5100000000002,null,2079.5100000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28420,null,"See CPT",null,2402.8000000000002,null,2402.8000000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28430,null,"See CPT",null,467.24,null,408.46,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28435,null,"See CPT",null,717.36,null,632.79,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28436,null,"See CPT",null,948.28,null,948.28,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28445,null,"See CPT",null,1940.35,null,1940.35,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28446,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X"]
[28450,null,"See CPT",null,411.46,null,371.28,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28455,null,"See CPT",null,490.04,null,436.65,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28456,null,"See CPT",null,715.56,null,715.56,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28465,null,"See CPT",null,1202.5999999999999,null,1202.5999999999999,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28470,null,"See CPT",null,424.66,null,399.47,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28475,null,"See CPT",null,501.43,null,439.65,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28476,null,"See CPT",null,742.55,null,742.55,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28485,null,"See CPT",null,1062.25,null,1062.25,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[28490,null,"See CPT",null,277.11,null,242.92,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28495,null,"See CPT",null,349.68,null,289.10000000000002,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28496,null,"See CPT",null,968.68,null,526.62,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28505,null,"See CPT",null,1224.19,null,927.89,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28510,null,"See CPT",null,236.32,null,235.72,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28515,null,"See CPT",null,320.89,null,278.91000000000003,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28525,null,"See CPT",null,1076.04,null,767.14,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28530,null,"See CPT",null,227.92,null,197.93,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28531,null,"See CPT",null,627.99,null,343.09,null,90,0.1,0.69,0.21,0,2,1,1,2,0,null,"R"]
[28540,null,"See CPT",null,379.67,null,339.49,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28545,null,"See CPT",null,603.4,null,526.02,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28546,null,"See CPT",null,1124.6300000000001,null,677.77,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28555,null,"See CPT",null,1618.26,null,1234.99,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28570,null,"See CPT",null,462.45,null,385.67,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28575,null,"See CPT",null,734.16,null,654.98,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28576,null,"See CPT",null,738.95,null,738.95,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28585,null,"See CPT",null,1683.64,null,1317.16,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28600,null,"See CPT",null,362.28,null,309.5,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28605,null,"See CPT",null,666.98,null,592.6,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28606,null,"See CPT",null,740.15,null,740.15,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28615,null,"See CPT",null,1552.88,null,1552.88,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[28630,null,"See CPT",null,294.5,null,206.33,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[28635,null,"See CPT",null,325.69,null,245.32,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[28636,null,"See CPT",null,672.98,null,419.26,null,10,0.1,0.8,0.1,0,2,0,1,2,0,null,"R"]
[28645,null,"See CPT",null,1225.99,null,911.1,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[28660,null,"See CPT",null,240.52,null,176.94,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[28665,null,"See CPT",null,287.3,null,237.52,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[28666,null,"See CPT",null,328.69,null,328.69,null,10,0.1,0.8,0.1,0,2,0,1,2,0,null,"R"]
[28675,null,"See CPT",null,1089.24,null,779.14,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28705,null,"See CPT",null,2240.25,null,2240.25,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28715,null,"See CPT",null,1743.02,null,1743.02,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28725,null,"See CPT",null,1447.32,null,1447.32,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28730,null,"See CPT",null,1348.35,null,1348.35,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28735,null,"See CPT",null,1436.52,null,1436.52,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28737,null,"See CPT",null,1281.17,null,1281.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28740,null,"See CPT",null,1547.48,null,1147.42,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28750,null,"See CPT",null,1461.71,null,1073.04,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[28755,null,"See CPT",null,951.28,null,627.39,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28760,null,"See CPT",null,1445.52,null,1065.24,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28800,null,"See CPT",null,975.27,null,975.27,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28805,null,"See CPT",null,1291.3699999999999,null,1291.3699999999999,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[28810,null,"See CPT",null,780.34,null,780.34,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28820,null,"See CPT",null,554.22,null,322.08999999999997,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[28825,null,"See CPT",null,545.22,null,313.7,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[28890,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X"]
[28899,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[29000,null,"See CPT",null,690.97,null,365.88,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29010,null,"See CPT",null,535.62,null,297.5,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29015,null,"See CPT",null,571.61,null,333.49,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29035,null,"See CPT",null,505.63,null,268.11,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29040,null,"See CPT",null,574.01,null,321.49,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29044,null,"See CPT",null,563.80999999999995,null,310.7,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29046,null,"See CPT",null,614.79999999999995,null,348.48,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29049,null,"See CPT",null,191.94,null,129.56,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29055,null,"See CPT",null,435.45,null,255.51,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29058,null,"See CPT",null,235.12,null,172.74,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29065,null,"See CPT",null,186.54,null,126.56,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29075,null,"See CPT",null,168.54,null,116.36,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29085,null,"See CPT",null,184.74,null,125.96,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29086,null,"See CPT",null,148.75,null,92.97,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29105,null,"See CPT",null,158.35,null,74.98,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29125,null,"See CPT",null,128.96,null,75.569999999999993,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29126,null,"See CPT",null,150.55000000000001,null,91.77,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29130,null,"See CPT",null,79.17,null,52.78,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29131,null,"See CPT",null,103.17,null,63.58,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29200,null,"See CPT",null,59.98,null,32.99,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[29240,null,"See CPT",null,55.78,null,32.39,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29260,null,"See CPT",null,53.98,null,34.19,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29280,null,"See CPT",null,55.78,null,36.590000000000003,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29305,null,"See CPT",null,481.04,null,293.89999999999998,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29325,null,"See CPT",null,530.22,null,328.69,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29345,null,"See CPT",null,256.70999999999998,null,182.94,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29355,null,"See CPT",null,268.70999999999998,null,195.53,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29358,null,"See CPT",null,311.3,null,190.14,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29365,null,"See CPT",null,238.12,null,162.55000000000001,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29405,null,"See CPT",null,153.55000000000001,null,109.16,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29425,null,"See CPT",null,143.94999999999999,null,100.77,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29435,null,"See CPT",null,236.92,null,160.15,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29440,null,"See CPT",null,81.569999999999993,null,50.98,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29445,null,"See CPT",null,240.52,null,180.54,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29450,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,1,0,0,null,"X",null,"Y-CM"]
[29505,null,"See CPT",null,172.74,null,97.17,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29515,null,"See CPT",null,137.94999999999999,null,92.37,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29520,null,"See CPT",null,65.38,null,32.99,null,0,0,0,0,0,2,1,0,0,0,null,"R"]
[29530,null,"See CPT",null,55.18,null,32.39,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29540,null,"See CPT",null,52.18,null,31.19,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29550,null,"See CPT",null,35.99,null,19.79,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29580,null,"See CPT",null,120.56,null,46.78,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29581,null,"See CPT",null,167.94,null,48.58,null,0,0,0,0,0,2,1,0,0,0,null,"R"]
[29584,null,"See CPT",null,153.55000000000001,null,28.19,null,0,0,0,0,0,2,1,0,0,0,null,"R"]
[29750,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,0,0,0,null,"X",null,"Y-CM"]
[29819,null,"See CPT",null,1098.23,null,1098.23,null,90,0.1,0.69,0.21,0,3,1,1,1,0,29805,"R",null,"Y-UR"]
[29835,null,"See CPT",null,956.08,null,956.08,null,90,0.1,0.69,0.21,0,3,1,2,1,0,29830,"R",null,"Y-UR"]
[29845,null,"See CPT",null,1100.03,null,1100.03,null,90,0.1,0.69,0.21,0,3,1,2,1,0,29840,"R",null,"Y-UR"]
[29866,null,"See CPT",null,1950.55,null,1950.55,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[29870,null,"See CPT",null,1047.8499999999999,null,772.54,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[29882,null,"See CPT",null,1281.17,null,1281.17,null,90,0.1,0.69,0.21,0,3,1,1,0,0,29870,"R",null,"Y-UR"]
[29893,null,"See CPT",null,1260.18,null,825.32,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[29901,null,"See CPT",null,1020.86,null,1020.86,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[30100,null,"See CPT",null,268.11,null,127.16,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[30200,null,"See CPT",null,210.53,null,111.56,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[30410,null,"See CPT",null,2654.12,null,2654.12,null,90,0.1,0.76,0.14000000000000001,0,2,0,2,0,0,null,"R"]
[30545,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.76,0.14000000000000001,0,2,0,2,0,0,null,"X"]
[30560,null,"See CPT",null,618.39,null,287.3,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[30906,null,"See CPT",null,712.56,null,239.32,null,0,0,0,0,0,2,2,1,0,0,null,"R"]
[31051,null,"See CPT",null,1309.3599999999999,null,1309.3599999999999,null,90,0.1,0.76,0.14000000000000001,0,2,1,1,0,0,null,"R"]
[31086,null,"See CPT",null,2203.67,null,2203.67,null,90,0.1,0.76,0.14000000000000001,0,2,1,2,0,0,null,"R"]
[31238,null,"See CPT",null,469.64,null,306.5,null,0,0,0,0,0,3,1,0,0,0,31231,"R"]
[31267,null,"See CPT",null,481.64,null,481.64,null,0,0,0,0,0,3,1,1,0,0,31231,"R"]
[31293,null,"See CPT",null,1970.34,null,1970.34,null,10,0.1,0.8,0.1,0,3,1,0,0,0,31231,"R"]
[31300,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X"]
[31500,null,"See CPT",null,250.12,null,250.12,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[31510,null,"See CPT",null,407.86,null,222.53,null,0,0,0,0,0,3,0,0,0,0,31505,"R"]
[31531,null,"See CPT",null,383.87,null,383.87,null,0,0,0,0,0,3,0,0,0,0,31526,"R"]
[31551,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.76,0.14000000000000001,0,2,0,0,1,0,null,"X"]
[31576,null,"See CPT",null,514.03,null,219.53,null,0,0,0,0,0,3,0,1,0,0,31575,"R"]
[31599,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[31615,null,"See CPT",null,323.29000000000002,null,212.33,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[31633,null,"See CPT",null,147.55000000000001,null,111.56,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[31641,null,"See CPT",null,452.25,null,452.25,null,0,0,0,0,0,3,0,1,0,0,31622,"R",null,"Y-CM"]
[31646,null,"See CPT",null,254.32,null,254.32,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[31725,null,"See CPT",null,140.94999999999999,null,140.94999999999999,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[31775,null,"See CPT",null,2471.1799999999998,null,2471.1799999999998,null,90,0.1,0.76,0.14000000000000001,0,2,0,2,0,0,null,"R"]
[32100,null,"See CPT",null,1445.52,null,1445.52,null,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R"]
[32200,null,"See CPT",null,2037.52,null,2037.52,null,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R"]
[32408,null,"See CPT",null,1609.86,null,270.51,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[32504,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X"]
[32552,null,"See CPT",null,336.49,null,284.91000000000003,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[32555,null,"See CPT",null,592,null,194.34,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[32650,null,"See CPT",null,1198.4000000000001,null,1198.4000000000001,null,90,0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[32658,null,"See CPT",null,1277.57,null,1277.57,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[32672,null,"See CPT",null,2674.51,null,2674.51,null,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[32820,null,"See CPT",null,2369.81,null,2369.81,null,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[32960,null,"See CPT",null,235.12,null,162.55000000000001,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33031,null,"See CPT",null,4337.75,null,4337.75,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33203,null,"See CPT",null,1434.72,null,1434.72,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R"]
[33208,null,"See CPT",null,918.89,null,918.89,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,2,0,null,"R",null,"Y-CM"]
[33227,null,"See CPT",null,607,null,607,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33230,null,"See CPT",null,666.38,null,666.38,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33249,null,"See CPT",null,1618.26,null,1618.26,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,1,0,null,"R",null,"Y-CM"]
[33258,null,"See CPT",null,1151.6199999999999,null,1151.6199999999999,null,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-CM"]
[33271,null,"See CPT",null,809.13,null,809.13,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33287,null,"See CPT",null,691.57,null,691.57,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R"]
[33320,null,"See CPT",null,1892.37,null,1892.37,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33335,null,"See CPT",null,3271.31,null,3271.31,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33406,null,"See CPT",null,5049.12,null,5049.12,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33412,null,"See CPT",null,5474.37,null,5474.37,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33427,null,"See CPT",null,4274.7700000000004,null,4274.7700000000004,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33468,null,"See CPT",null,4287.37,null,4287.37,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33504,null,"See CPT",null,2597.73,null,2597.73,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33511,null,"See CPT",null,3727.16,null,3727.16,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[33534,null,"See CPT",null,3859.11,null,3859.11,null,90,0.09,0.82,0.09,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[33542,null,"See CPT",null,4590.2700000000004,null,4590.2700000000004,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33622,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[33647,null,"See CPT",null,3186.14,null,3186.14,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33694,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[33730,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[33767,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[33782,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[33813,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[33822,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[33881,null,"See CPT",null,2661.31,null,2661.31,null,90,0.09,0.84,7.0000000000000007E-2,0,2,2,2,2,0,null,"R"]
[33886,null,"See CPT",null,1671.04,null,1671.04,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R"]
[33915,null,"See CPT",null,2410,null,2410,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33940,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM"]
[33949,null,"See CPT",null,407.86,null,407.86,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[33957,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[33971,null,"See CPT",null,1258.3800000000001,null,1258.3800000000001,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33975,null,"See CPT",null,2264.25,null,2264.25,null,0,0,0,0,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[33991,null,"See CPT",null,785.74,null,785.74,null,0,0,0,0,0,2,0,2,0,0,null,"R"]
[33995,null,"See CPT",null,618.99,null,618.99,null,0,0,0,0,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[34471,null,"See CPT",null,1872.58,null,1872.58,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[34701,null,"See CPT",null,2141.89,null,2141.89,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[34713,null,"See CPT",null,211.73,null,211.73,null,0,0,0,0,0,0,1,2,2,0,null,"R",null,"Y-UR"]
[34812,null,"See CPT",null,354.48,null,354.48,null,0,0,0,0,0,0,1,2,2,0,null,"R",null,"Y-CM"]
[34844,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,2,2,0,null,"N"]
[34847,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,2,2,0,null,"N"]
[35092,null,"See CPT",null,4487.7,null,4487.7,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35131,null,"See CPT",null,2399.1999999999998,null,2399.1999999999998,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35201,null,"See CPT",null,1642.85,null,1642.85,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R"]
[35231,null,"See CPT",null,2244.4499999999998,null,2244.4499999999998,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R"]
[35301,null,"See CPT",null,1963.75,null,1963.75,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35321,null,"See CPT",null,1568.48,null,1568.48,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35501,null,"See CPT",null,2520.96,null,2520.96,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35510,null,"See CPT",null,2126.89,null,2126.89,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35538,null,"See CPT",null,4027.06,null,4027.06,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[35556,null,"See CPT",null,2414.79,null,2414.79,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35616,null,"See CPT",null,1906.76,null,1906.76,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35626,null,"See CPT",null,2771.08,null,2771.08,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35650,null,"See CPT",null,1769.41,null,1769.41,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35671,null,"See CPT",null,1975.14,null,1975.14,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35697,null,"See CPT",null,251.32,null,251.32,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-CM"]
[35820,null,"See CPT",null,3529.82,null,3529.82,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[36005,null,"See CPT",null,476.84,null,83.37,null,0,0,0,0,0,2,1,0,0,0,null,"R"]
[36012,null,"See CPT",null,1564.28,null,304.10000000000002,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[36225,null,"See CPT",null,2997.2,null,572.80999999999995,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[36228,null,"See CPT",null,2450.1799999999998,null,436.65,null,0,0,0,0,0,0,1,1,0,0,null,"R"]
[36400,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
[36425,null,"See CPT",null,70.78,null,70.78,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[36473,null,"See CPT",null,2278.04,null,317.29000000000002,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[36482,null,"See CPT",null,3159.15,null,313.7,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[36557,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"X"]
[36561,null,"See CPT",null,1818.59,null,595,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[36583,null,"See CPT",null,2148.48,null,593.79999999999995,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[36597,null,"See CPT",null,205.13,null,106.16,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[36660,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X",null,"Y-CM"]
[36820,null,"See CPT",null,1272.18,null,1272.18,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[36860,null,"See CPT",null,433.66,null,193.74,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[36906,null,"See CPT",null,10179.81,null,893.7,null,0,0,0,0,0,2,0,1,1,0,null,"R",null,"Y-CM"]
[37185,null,"See CPT",null,878.11,null,282.51,null,0,0,0,0,0,0,2,1,2,0,null,"R"]
[37188,null,"See CPT",null,2712.9,null,491.24,null,0,0,0,0,0,0,1,1,2,0,null,"R"]
[37214,null,"See CPT",null,211.73,null,211.73,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[37225,null,"See CPT",null,16508.3,null,1035.25,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[37237,null,"See CPT",null,2419.59,null,364.08,null,0,0,0,0,0,0,1,0,0,0,null,"R"]
[37246,null,"See CPT",null,3397.87,null,605.20000000000005,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[37607,null,"See CPT",null,665.18,null,665.18,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,1,0,null,"R"]
[37650,null,"See CPT",null,806.73,null,806.73,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[37766,null,"See CPT",null,907.5,null,585.4,null,10,0.1,0.8,0.1,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[38101,null,"See CPT",null,2091.5,null,2091.5,null,90,0.11,0.73,0.16,0,2,0,2,1,0,null,"R"]
[38214,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[38221,null,"See CPT",null,308.89999999999998,null,127.76,null,0,0,0,0,0,2,1,0,0,0,null,"R"]
[38243,null,"See CPT",null,226.72,null,226.72,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[38530,null,"See CPT",null,1040.6500000000001,null,1040.6500000000001,null,90,0.11,0.73,0.16,0,2,1,2,1,0,null,"R"]
[38700,null,"See CPT",null,1485.7,null,1485.7,null,90,0.11,0.73,0.16,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[38780,null,"See CPT",null,1911.56,null,1911.56,null,90,0.11,0.73,0.16,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[39401,null,"See CPT",null,545.22,null,545.22,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[39501,null,"See CPT",null,1538.49,null,1538.49,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R"]
[40652,null,"See CPT",null,981.87,null,677.77,null,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R"]
[40701,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,2,2,0,0,null,"X"]
[40804,null,"See CPT",null,361.08,null,214.73,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[40831,null,"See CPT",null,557.21,null,374.88,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[41007,null,"See CPT",null,620.19000000000005,null,412.66,null,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R"]
[41105,null,"See CPT",null,357.48,null,206.33,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[41145,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[41510,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"X"]
[41825,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[41828,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"X"]
[42000,null,"See CPT",null,305.89999999999998,null,205.73,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[42225,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,0,0,null,"X"]
[42305,null,"See CPT",null,807.93,null,807.93,null,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R"]
[42405,null,"See CPT",null,574.01,null,422.26,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[42507,null,"See CPT",null,927.89,null,927.89,null,90,0.09,0.81,0.1,0,2,2,2,0,0,null,"R"]
[42665,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"X"]
[42820,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"X"]
[42845,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[42860,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"X"]
[42970,null,"See CPT",null,768.94,null,768.94,null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R"]
[43112,null,"See CPT",null,6100.57,null,6100.57,null,90,0.09,0.81,0.1,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[43123,null,"See CPT",null,7889.17,null,7889.17,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43198,null,"See CPT",null,398.27,null,176.94,null,0,0,0,0,0,3,0,1,0,0,43197,"R",null,"Y-CM"]
[43210,null,"See CPT",null,768.94,null,768.94,null,0,0,0,0,0,3,0,1,0,0,43235,"R",null,"Y-CM"]
[43216,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,3,0,1,0,0,43200,"X"]
[43236,null,"See CPT",null,762.35,null,250.72,null,0,0,0,0,0,3,0,1,0,0,43235,"R"]
[43243,null,"See CPT",null,426.46,null,426.46,null,0,0,0,0,0,3,0,1,0,0,43235,"R",null,"Y-CM"]
[43255,null,"See CPT",null,1187,null,360.48,null,0,0,0,0,0,3,0,1,0,0,43235,"R"]
[43264,null,"See CPT",null,653.17999999999995,null,653.17999999999995,null,0,0,0,0,0,3,0,1,0,0,43260,"R",null,"Y-CM"]
[43281,null,"See CPT",null,2748.88,null,2748.88,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[49593,null,"See CPT",null,1023.86,null,1023.86,null,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[43310,null,"See CPT",null,2621.13,null,2621.13,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43335,null,"See CPT",null,2352.42,null,2352.42,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43338,null,"See CPT",null,199.13,null,199.13,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[43400,null,"See CPT",null,2736.29,null,2736.29,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43500,null,"See CPT",null,1425.12,null,1425.12,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[43611,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[43645,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[43752,null,"See CPT",null,71.38,null,71.38,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[43774,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[43845,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[43848,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[43886,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X"]
[44100,null,"See CPT",null,191.34,null,191.34,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[44126,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[44145,null,"See CPT",null,2963.61,null,2963.61,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[44187,null,"See CPT",null,1979.34,null,1979.34,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[44207,null,"See CPT",null,3244.92,null,3244.92,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[44316,null,"See CPT",null,2546.75,null,2546.75,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[44361,null,"See CPT",null,286.10000000000002,null,286.10000000000002,null,0,0,0,0,0,3,0,1,0,0,44360,"R"]
[44365,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,3,0,0,0,0,44360,"X"]
[44388,null,"See CPT",null,595,null,280.70999999999998,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[44392,null,"See CPT",null,731.16,null,358.08,null,0,0,0,0,0,3,0,1,0,0,44388,"R",null,"Y-CM"]
[44603,null,"See CPT",null,2897.03,null,2897.03,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[44700,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[44800,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X"]
[45020,null,"See CPT",null,1046.05,null,1046.05,null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R"]
[45114,null,"See CPT",null,3258.11,null,3258.11,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[45120,null,"See CPT",null,2882.04,null,2882.04,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[45303,null,"See CPT",null,1805.4,null,155.94999999999999,null,0,0,0,0,0,3,0,1,0,0,45300,"R",null,"Y-CM"]
[45320,null,"See CPT",null,418.06,null,188.94,null,0,0,0,0,0,3,0,1,0,0,45300,"R",null,"Y-CM"]
[45341,null,"See CPT",null,224.93,null,224.93,null,0,0,0,0,0,3,0,1,0,0,45330,"R",null,"Y-CM"]
[45378,53,"See CPT",null,319.08999999999997,null,166.74,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[45392,null,"See CPT",null,546.41999999999996,null,546.41999999999996,null,0,0,0,0,0,3,0,1,0,0,45378,"R",null,"Y-CM"]
[45540,null,"See CPT",null,1902.57,null,1902.57,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[45562,null,"See CPT",null,2119.69,null,2119.69,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[45905,null,"See CPT",null,316.08999999999997,null,316.08999999999997,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[46080,null,"See CPT",null,541.02,null,288.5,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[46255,null,"See CPT",null,976.47,null,657.38,null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R"]
[46500,null,"See CPT",null,595,null,346.68,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[46608,null,"See CPT",null,550.62,null,152.94999999999999,null,0,0,0,0,0,3,0,1,0,0,46600,"R",null,"Y-CM"]
[46715,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,0,0,null,"X"]
[46760,null,"See CPT",null,2027.32,null,2027.32,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[46924,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X"]
[46942,null,"See CPT",null,482.24,null,239.92,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[47122,null,"See CPT",null,6105.96,null,6105.96,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[47142,null,"See CPT",null,8428.99,null,8428.99,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[47371,null,"See CPT",null,2270.2399999999998,null,2270.2399999999998,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[47531,null,"See CPT",null,799.53,null,125.96,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[47538,null,"See CPT",null,7081.84,null,412.66,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[47556,null,"See CPT",null,659.18,null,659.18,null,0,0,0,0,0,3,0,1,0,0,47552,"R"]
[47605,null,"See CPT",null,2036.32,null,2036.32,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[47620,null,"See CPT",null,2471.1799999999998,null,2471.1799999999998,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[47802,null,"See CPT",null,2747.68,null,2747.68,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[48000,null,"See CPT",null,3374.47,null,3374.47,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[48153,null,"See CPT",null,5559.55,null,5559.55,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[48520,null,"See CPT",null,1982.94,null,1982.94,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[49002,null,"See CPT",null,1876.77,null,1876.77,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[49185,null,"See CPT",null,2385.4,null,211.73,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[49320,null,"See CPT",null,601,null,601,null,10,0.1,0.8,0.1,0,2,0,2,0,0,null,"R"]
[49323,null,"See CPT",null,1164.21,null,1164.21,null,90,0.1,0.8,0.1,0,3,0,2,2,0,49320,"R",null,"Y-CM"]
[49412,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,1,0,null,"X"]
[49426,null,"See CPT",null,1220.5899999999999,null,1220.5899999999999,null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[49452,null,"See CPT",null,1453.92,null,240.52,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[49500,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,1,2,1,0,null,"X"]
[49600,null,"See CPT",null,1336.95,null,1336.95,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[49622,null,"See CPT",null,1637.45,null,1637.45,null,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[49905,null,"See CPT",null,624.99,null,624.99,null,0,0,0,0,0,0,0,2,2,0,null,"R"]
[50010,null,"See CPT",null,1290.77,null,1290.77,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R"]
[50220,null,"See CPT",null,1907.36,null,1907.36,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R"]
[50234,null,"See CPT",null,2351.2199999999998,null,2351.2199999999998,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R"]
[50329,null,"See CPT",null,317.89,null,317.89,null,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[50384,null,"See CPT",null,1605.66,null,400.07,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[50432,null,"See CPT",null,1705.83,null,362.88,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[50520,null,"See CPT",null,2095.6999999999998,null,2095.6999999999998,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[50546,null,"See CPT",null,2179.0700000000002,null,2179.0700000000002,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R"]
[50557,null,"See CPT",null,772.54,null,618.39,null,0,0,0,0,0,3,1,0,0,0,50551,"R"]
[50620,null,"See CPT",null,1639.85,null,1639.85,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[50660,null,"See CPT",null,2070.5100000000002,null,2070.5100000000002,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[50722,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"X"]
[50770,null,"See CPT",null,2088.5,null,2088.5,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[50845,null,"See CPT",null,2281.04,null,2281.04,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[50951,null,"See CPT",null,697.57,null,550.02,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[51020,null,"See CPT",null,869.11,null,869.11,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R"]
[51045,null,"See CPT",null,915.29,null,915.29,null,90,0.08,0.83,0.09,0,2,0,2,0,0,null,"R"]
[51570,null,"See CPT",null,2658.91,null,2658.91,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R"]
[51585,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.08,0.83,0.09,0,2,2,2,1,0,null,"X"]
[51725,null,"See CPT",null,432.46,null,432.46,null,0,0,0,0,1,2,0,0,0,0,null,"R"]
[51728,null,"See CPT",null,693.37,null,693.37,null,0,0,0,0,1,2,0,0,0,0,null,"R"]
[51736,26,"See CPT",null,14.4,null,14.4,null,0,0,0,0,1,2,0,0,0,0,null,"R"]
[51784,"TC","See CPT",null,53.98,null,53.98,null,0,0,0,0,1,2,0,1,0,0,null,"R"]
[51820,null,"See CPT",null,1971.54,null,1971.54,null,90,0.08,0.83,0.09,0,2,2,2,1,0,null,"R",null,"Y-CM"]
[51845,null,"See CPT",null,1067.04,null,1067.04,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[52007,null,"See CPT",null,852.32,null,299.3,null,0,0,0,0,0,3,1,1,0,0,52000,"R",null,"Y-CM"]
[52214,null,"See CPT",null,1421.53,null,311.89999999999998,null,0,0,0,0,0,3,0,1,0,0,52000,"R"]
[52275,null,"See CPT",null,1015.46,null,445.05,null,0,0,0,0,0,3,0,1,0,0,52000,"R"]
[52301,null,"See CPT",null,519.42999999999995,null,519.42999999999995,null,0,0,0,0,0,3,2,0,0,0,52000,"R",null,"Y-CM"]
[52341,null,"See CPT",null,509.23,null,509.23,null,0,0,0,0,0,3,1,1,0,0,52000,"R"]
[52352,null,"See CPT",null,633.39,null,633.39,null,0,0,0,0,0,3,1,1,0,0,52351,"R",null,"Y-CM"]
[52630,null,"See CPT",null,749.15,null,749.15,null,90,0.08,0.83,0.09,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[52648,null,"See CPT",null,3043.39,null,1266.18,null,90,0.08,0.83,0.09,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[53235,null,"See CPT",null,1162.4100000000001,null,1162.4100000000001,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[53415,null,"See CPT",null,2047.72,null,2047.72,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[53447,null,"See CPT",null,1470.71,null,1470.71,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[53450,null,"See CPT",null,754.55,null,754.55,null,90,0.08,0.83,0.09,0,2,0,1,0,0,null,"R"]
[53600,null,"See CPT",null,164.35,null,113.96,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[53665,null,"See CPT",null,67.78,null,67.78,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[54056,null,"See CPT",null,275.91000000000003,null,211.13,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[54111,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X"]
[54135,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.8,0.1,0,2,2,2,0,0,null,"X",null,"Y-CM"]
[54230,null,"See CPT",null,199.73,null,145.75,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[54324,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X"]
[54332,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X"]
[54405,null,"See CPT",null,1471.91,null,1471.91,null,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[54417,null,"See CPT",null,1638.05,null,1638.05,null,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[54505,null,"See CPT",null,385.07,null,385.07,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[54650,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.8,0.1,0,2,1,2,0,0,null,"X"]
[54861,null,"See CPT",null,1044.8499999999999,null,1044.8499999999999,null,90,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[54901,null,"See CPT",null,1923.56,null,1923.56,null,90,0.1,0.8,0.1,0,2,2,0,0,0,null,"R",null,"Y-CM"]
[55520,null,"See CPT",null,843.32,null,843.32,null,90,0.1,0.8,0.1,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[55540,null,"See CPT",null,1015.46,null,1015.46,null,90,0.1,0.8,0.1,0,2,1,1,1,0,null,"R"]
[55700,null,"See CPT",null,452.25,null,234.52,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[55862,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X"]
[55899,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[56441,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"X"]
[56634,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.12,0.74,0.14000000000000001,0,2,0,2,2,0,null,"X"]
[56700,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,2,1,0,null,"X"]
[57106,null,"See CPT",null,1001.67,null,1001.67,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[57110,null,"See CPT",null,1655.45,null,1655.45,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[57250,null,"See CPT",null,1134.22,null,1134.22,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[57268,null,"See CPT",null,940.49,null,940.49,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[57295,null,"See CPT",null,928.49,null,928.49,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R"]
[57311,null,"See CPT",null,1029.26,null,1029.26,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[57452,null,"See CPT",null,237.52,null,166.74,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[57456,null,"See CPT",null,285.5,null,183.54,null,0,0,0,0,0,3,0,1,0,0,57452,"R",null,"Y-CM"]
[57555,null,"See CPT",null,1141.42,null,1141.42,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[58110,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[58146,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"X"]
[58275,null,"See CPT",null,1814.99,null,1814.99,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[58340,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
[58410,null,"See CPT",null,1495.9,null,1495.9,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[58553,null,"See CPT",null,2040.52,null,2040.52,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[58561,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,3,0,0,2,0,58555,"X"]
[58611,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,2,0,0,null,"X"]
[58661,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,3,1,2,2,0,49320,"X"]
[58679,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,2,1,1,null,"N"]
[58825,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"X"]
[58957,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.12,0.74,0.14000000000000001,0,2,2,2,1,0,null,"X"]
[59000,null,"See CPT",null,218.93,null,145.15,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[59020,"TC","See CPT",null,67.78,null,67.78,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[59130,null,"See CPT",null,1717.83,null,1717.83,null,90,0.17,0.6,0.23,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[59409,null,"See CPT",null,1427.52,null,1427.52,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[59414,null,"See CPT",null,160.75,null,160.75,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[59525,null,"See CPT",null,854.12,null,854.12,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[59841,null,"See CPT",null,785.74,null,678.97,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[59899,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,2,1,1,null,"N"]
[60225,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.82,0.09,0,2,0,2,1,0,null,"X"]
[60512,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,2,1,0,null,"X"]
[60605,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.82,0.09,0,2,0,2,1,0,null,"X"]
[61107,null,"See CPT",null,553.02,null,553.02,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[61140,null,"See CPT",null,2323.63,null,2323.63,null,90,0.11,0.76,0.13,0,2,0,2,0,0,null,"R"]
[61250,null,"See CPT",null,1591.27,null,1591.27,null,90,0.11,0.76,0.13,0,2,1,2,1,0,null,"R"]
[61340,null,"See CPT",null,2617.5300000000002,null,2617.5300000000002,null,90,0.11,0.76,0.13,0,2,1,2,1,0,null,"R"]
[61460,null,"See CPT",null,3808.13,null,3808.13,null,90,0.11,0.76,0.13,0,2,0,2,2,0,null,"R"]
[61522,null,"See CPT",null,3952.08,null,3952.08,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[61540,null,"See CPT",null,3930.49,null,3930.49,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[61550,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"X"]
[61575,null,"See CPT",null,4511.7,null,4511.7,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[61581,null,"See CPT",null,5014.93,null,5014.93,null,90,0.11,0.76,0.13,0,2,1,1,2,2,null,"R",null,"Y-CM"]
[61606,null,"See CPT",null,5266.24,null,5266.24,null,90,0.11,0.76,0.13,0,2,0,2,1,2,null,"R",null,"Y-CM"]
[61613,null,"See CPT",null,5935.02,null,5935.02,null,90,0.11,0.76,0.13,0,2,1,2,1,2,null,"R",null,"Y-CM"]
[61626,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
[61686,null,"See CPT",null,8028.32,null,8028.32,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[61720,null,"See CPT",null,2317.0300000000002,null,2317.0300000000002,null,90,0.11,0.76,0.13,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[61770,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.11,0.76,0.13,0,2,0,1,1,0,null,"X"]
[61860,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.11,0.76,0.13,0,2,0,2,0,0,null,"X"]
[61867,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.11,0.76,0.13,0,2,1,2,1,0,null,"X"]
[61892,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.11,0.76,0.13,0,2,1,1,0,0,null,"X"]
[62143,null,"See CPT",null,1909.16,null,1909.16,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[62162,null,"See CPT",null,3424.86,null,3424.86,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[62230,null,"See CPT",null,1540.29,null,1540.29,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[62272,null,"See CPT",null,345.48,null,163.75,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[62290,null,"See CPT",null,648.38,null,283.11,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[62325,null,"See CPT",null,472.64,null,199.73,null,0,0,0,0,0,2,9,1,0,0,null,"R",null,"Y-UR"]
[62355,null,"See CPT",null,512.83000000000004,null,512.83000000000004,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[62362,null,"See CPT",null,710.16,null,710.16,null,10,0.1,0.8,0.1,0,2,0,0,1,0,null,"R",null,"Y-UR"]
[63015,null,"See CPT",null,2697.9,null,2697.9,null,90,0.11,0.76,0.13,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[63042,null,"See CPT",null,2368.61,null,2368.61,null,90,0.11,0.76,0.13,0,2,1,2,2,0,null,"R",null,"Y-UR"]
[63056,null,"See CPT",null,2708.1,null,2708.1,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63077,null,"See CPT",null,2667.31,null,2667.31,null,90,0.11,0.76,0.13,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[63172,null,"See CPT",null,2571.34,null,2571.34,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63267,null,"See CPT",null,2504.17,null,2504.17,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63276,null,"See CPT",null,3245.52,null,3245.52,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63280,null,"See CPT",null,3836.92,null,3836.92,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63303,null,"See CPT",null,4177.01,null,4177.01,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63610,null,"See CPT",null,1035.25,null,1035.25,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[63702,null,"See CPT",null,2619.9299999999998,null,2619.9299999999998,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[63744,null,"See CPT",null,1260.78,null,1260.78,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[64430,null,"See CPT",null,184.74,null,99.57,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[64462,null,"See CPT",null,131.96,null,86.37,null,0,0,0,0,0,0,1,1,0,0,null,"R",null,"Y-CM"]
[64487,null,"See CPT",null,405.46,null,112.76,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[64490,null,"See CPT",null,364.08,null,192.54,null,0,0,0,0,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[64555,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,"Y-CM"]
[64590,null,"See CPT",null,825.32,null,538.02,null,10,0.1,0.8,0.1,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[64610,null,"See CPT",null,1437.12,null,870.91,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[64624,null,"See CPT",null,"Not Covered",null,"Not Covered",null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"X"]
[64643,null,"See CPT",null,172.74,null,125.96,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[64712,null,"See CPT",null,1106.03,null,1106.03,null,90,0.11,0.76,0.13,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[64722,null,"See CPT",null,693.37,null,693.37,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[64732,null,"See CPT",null,850.52,null,850.52,null,90,0.11,0.76,0.13,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[64760,null,"See CPT",null,956.08,null,956.08,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[64786,null,"See CPT",null,1819.19,null,1819.19,null,90,0.11,0.76,0.13,0,2,1,2,0,0,null,"R"]
[64822,null,"See CPT",null,1303.3699999999999,null,1303.3699999999999,null,90,0.11,0.76,0.13,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[64837,null,"See CPT",null,649.58000000000004,null,649.58000000000004,null,0,0,0,0,0,0,0,2,0,0,null,"R"]
[64872,null,"See CPT",null,206.33,null,206.33,null,0,0,0,0,0,0,0,2,1,0,null,"R"]
[64898,null,"See CPT",null,2503.5700000000002,null,2503.5700000000002,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[64905,null,"See CPT",null,1835.99,null,1835.99,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[65093,null,"See CPT",null,1388.54,null,1388.54,null,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[65220,null,"See CPT",null,113.36,null,74.98,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[65260,null,"See CPT",null,1819.79,null,1819.79,null,90,0.1,0.7,0.2,0,2,1,2,0,0,null,"R"]
[65420,null,"See CPT",null,1019.06,null,710.76,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[65710,null,"See CPT",null,2112.5,null,2112.5,null,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R"]
[65775,null,"See CPT",null,1069.44,null,1069.44,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[65860,null,"See CPT",null,574.61,null,458.25,null,90,0.1,0.7,0.2,0,2,1,0,0,0,null,"R"]
[65930,null,"See CPT",null,1190,null,1190,null,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[66130,null,"See CPT",null,1317.76,null,1042.45,null,90,0.1,0.7,0.2,0,2,1,0,0,0,null,"R"]
[66505,null,"See CPT",null,806.73,null,806.73,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[66625,null,"See CPT",null,797.73,null,797.73,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[66770,null,"See CPT",null,990.27,null,893.7,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[66852,null,"See CPT",null,1549.28,null,1549.28,null,90,0.1,0.7,0.2,0,2,1,0,1,0,null,"R"]
[66987,null,"See CPT",null,"By Report ",null,"By Report ",null,90,0.1,0.7,0.2,0,2,1,0,1,1,null,"N",null,"Y-CM"]
[67028,null,"See CPT",null,210.53,null,167.94,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[67108,null,"See CPT",null,2184.4699999999998,null,2184.4699999999998,null,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R"]
[67115,null,"See CPT",null,927.89,null,927.89,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[67299,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,0,1,1,null,"N"]
[67314,null,"See CPT",null,845.12,null,845.12,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[67399,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,2,1,1,null,"N"]
[67445,null,"See CPT",null,2838.25,null,2838.25,null,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R"]
[67700,null,"See CPT",null,541.02,null,217.13,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[67810,null,"See CPT",null,349.68,null,123.56,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[67902,null,"See CPT",null,1341.15,null,1341.15,null,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[67906,null,"See CPT",null,932.09,null,932.09,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[67950,null,"See CPT",null,1098.23,null,855.91,null,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[68040,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,1,0,0,null,"X"]
[68320,null,"See CPT",null,1401.13,null,1004.07,null,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[68360,null,"See CPT",null,1021.46,null,762.35,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[68530,null,"See CPT",null,818.13,null,467.24,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[68750,null,"See CPT",null,1603.87,null,1603.87,null,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R"]
[68899,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,0,1,1,null,"N"]
[69020,null,"See CPT",null,443.25,null,272.31,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[69155,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,0,2,1,0,null,"X"]
[69420,null,"See CPT",null,364.08,null,227.92,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[69554,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,1,0,null,"X"]
[69603,null,"See CPT",null,2408.1999999999998,null,2408.1999999999998,null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[69643,null,"See CPT",null,2282.84,null,2282.84,null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[69662,null,"See CPT",null,2152.6799999999998,null,2152.6799999999998,null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R"]
[69717,null,"See CPT",null,1041.8499999999999,null,1041.8499999999999,null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[69745,null,"See CPT",null,2299.0300000000002,null,2299.0300000000002,null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,0,0,null,"R"]
[69950,null,"See CPT",null,3209.53,null,3209.53,null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[69970,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,1,0,null,"X"]
[70120,null,"See CPT",null,73.180000000000007,null,73.180000000000007,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[70130,null,"See CPT",null,118.16,null,118.16,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[70160,null,"See CPT",null,71.98,null,71.98,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70200,null,"See CPT",null,91.77,null,91.77,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70240,26,"See CPT",null,16.79,null,16.79,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70300,null,"See CPT",null,24.59,null,24.59,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70330,null,"See CPT",null,101.37,null,101.37,null,0,0,0,0,1,0,2,0,0,0,null,"R"]
[70332,null,"See CPT",null,157.75,null,157.75,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[70370,"TC","See CPT",null,174.54,null,174.54,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70371,"TC","See CPT",null,132.56,null,132.56,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70450,"TC","See CPT",null,133.76,null,133.76,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[70481,null,"See CPT",null,353.88,null,353.88,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70488,null,"See CPT",null,359.88,null,359.88,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70491,"TC","See CPT",null,241.12,null,241.12,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70540,"TC","See CPT",null,328.69,null,328.69,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70542,"TC","See CPT",null,388.07,null,388.07,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70547,26,"See CPT",null,103.17,null,103.17,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70549,26,"See CPT",null,154.15,null,154.15,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70554,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,4,3,0,0,0,null,"X"]
[70557,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[71046,"TC","See CPT",null,44.99,null,44.99,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[71048,26,"See CPT",null,26.39,null,26.39,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[71111,26,"See CPT",null,28.19,null,28.19,null,0,0,0,0,1,0,2,0,0,0,null,"R"]
[71120,26,"See CPT",null,17.39,null,17.39,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[71275,null,"See CPT",null,550.62,null,550.62,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[71550,"TC","See CPT",null,541.02,null,541.02,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[71552,26,"See CPT",null,194.34,null,194.34,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72050,26,"See CPT",null,23.39,null,23.39,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72074,26,"See CPT",null,21.59,null,21.59,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72082,null,"See CPT",null,134.96,null,134.96,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72083,26,"See CPT",null,31.19,null,31.19,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72114,"TC","See CPT",null,91.17,null,91.17,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72128,26,"See CPT",null,85.77,null,85.77,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72129,26,"See CPT",null,104.97,null,104.97,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72132,null,"See CPT",null,329.89,null,329.89,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72146,null,"See CPT",null,371.88,null,371.88,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[72156,null,"See CPT",null,626.79,null,626.79,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[72158,null,"See CPT",null,625.59,null,625.59,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[72191,26,"See CPT",null,153.55000000000001,null,153.55000000000001,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72192,26,"See CPT",null,93.57,null,93.57,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72198,null,"See CPT",null,665.18,null,665.18,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72200,null,"See CPT",null,63.58,null,63.58,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72220,"TC","See CPT",null,46.78,null,46.78,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72270,"TC","See CPT",null,170.94,null,170.94,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72295,"TC","See CPT",null,140.35,null,140.35,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR"]
[73040,null,"See CPT",null,252.52,null,252.52,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73080,null,"See CPT",null,62.98,null,62.98,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73090,"TC","See CPT",null,41.99,null,41.99,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73115,"TC","See CPT",null,209.93,null,209.93,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73120,"TC","See CPT",null,45.58,null,45.58,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73140,26,"See CPT",null,12,null,12,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73206,26,"See CPT",null,153.55000000000001,null,153.55000000000001,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[73222,null,"See CPT",null,617.19000000000005,null,617.19000000000005,null,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR"]
[73225,"TC","See CPT",null,524.83000000000004,null,524.83000000000004,null,0,0,0,0,1,4,0,9,0,0,null,"R"]
[73521,"TC","See CPT",null,59.38,null,59.38,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[73523,26,"See CPT",null,27.59,null,27.59,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[73560,26,"See CPT",null,15,null,15,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73564,26,"See CPT",null,20.39,null,20.39,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73580,"TC","See CPT",null,155.94999999999999,null,155.94999999999999,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73610,"TC","See CPT",null,54.58,null,54.58,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73620,26,"See CPT",null,13.2,null,13.2,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73700,26,"See CPT",null,85.77,null,85.77,null,0,0,0,0,1,4,3,0,0,0,null,"R"]
[73718,26,"See CPT",null,115.76,null,115.76,null,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR"]
[73721,null,"See CPT",null,397.07,null,397.07,null,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR"]
[74018,null,"See CPT",null,57.58,null,57.58,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74019,"TC","See CPT",null,50.38,null,50.38,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74022,26,"See CPT",null,27.59,null,27.59,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74174,26,"See CPT",null,187.74,null,187.74,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[74177,null,"See CPT",null,595,null,595,null,0,0,0,0,1,4,0,9,0,0,null,"R"]
[74183,null,"See CPT",null,663.38,null,663.38,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[74220,null,"See CPT",null,185.94,null,185.94,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74221,null,"See CPT",null,209.33,null,209.33,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74248,26,"See CPT",null,59.98,null,59.98,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74250,26,"See CPT",null,68.98,null,68.98,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74262,null,"See CPT",null,915.89,null,915.89,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[74283,null,"See CPT",null,484.04,null,484.04,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74300,"TC","See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[74330,"TC","See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[74363,26,"See CPT",null,74.38,null,74.38,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74415,null,"See CPT",null,290.3,null,290.3,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74440,null,"See CPT",null,187.14,null,187.14,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74450,"TC","See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[74455,"TC","See CPT",null,171.54,null,171.54,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74713,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[75557,"TC","See CPT",null,343.69,null,343.69,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[75563,null,"See CPT",null,830.72,null,830.72,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[75573,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,4,0,0,0,0,null,"X"]
[75605,"TC","See CPT",null,131.96,null,131.96,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75705,"TC","See CPT",null,262.70999999999998,null,262.70999999999998,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75716,"TC","See CPT",null,139.15,null,139.15,null,0,0,0,0,1,6,2,0,0,0,null,"R"]
[75726,"TC","See CPT",null,150.55000000000001,null,150.55000000000001,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75741,26,"See CPT",null,107.96,null,107.96,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75756,"TC","See CPT",null,215.33,null,215.33,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75805,"TC","See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[75809,26,"See CPT",null,40.79,null,40.79,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75825,26,"See CPT",null,94.77,null,94.77,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75840,26,"See CPT",null,97.77,null,97.77,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75870,null,"See CPT",null,293.3,null,293.3,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75885,null,"See CPT",null,256.70999999999998,null,256.70999999999998,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75889,"TC","See CPT",null,139.75,null,139.75,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75893,26,"See CPT",null,45.58,null,45.58,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75902,26,"See CPT",null,32.39,null,32.39,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[75958,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[75989,null,"See CPT",null,209.93,null,209.93,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76098,null,"See CPT",null,80.97,null,80.97,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[76120,26,"See CPT",null,34.79,null,34.79,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[76125,26,"See CPT",null,23.99,null,23.99,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76390,null,"See CPT",null,749.79,null,749.79,null,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-CM"]
[76496,26,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[76506,"TC","See CPT",null,159.55000000000001,null,159.55000000000001,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76511,"TC","See CPT",null,42.59,null,42.59,null,0,0,0,0,1,7,3,0,0,0,null,"R"]
[76514,26,"See CPT",null,14.4,null,14.4,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[76641,null,"See CPT",null,195.53,null,195.53,null,0,0,0,0,1,0,1,0,0,0,null,"R",null,"Y-CM"]
[76700,"TC","See CPT",null,152.35,null,152.35,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[76705,"TC","See CPT",null,115.76,null,115.76,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[76800,26,"See CPT",null,110.96,null,110.96,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76801,26,"See CPT",null,85.17,null,85.17,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76811,"TC","See CPT",null,170.94,null,170.94,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76814,"TC","See CPT",null,53.98,null,53.98,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76818,"TC","See CPT",null,133.76,null,133.76,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[76825,"TC","See CPT",null,355.68,null,355.68,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[76827,26,"See CPT",null,50.38,null,50.38,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76828,"TC","See CPT",null,43.79,null,43.79,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76872,null,"See CPT",null,386.87,null,386.87,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76873,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X",null,"Y-CM"]
[76883,null,"See CPT",null,132.56,null,132.56,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[76936,"TC","See CPT",null,326.29000000000002,null,326.29000000000002,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76942,26,"See CPT",null,54.58,null,54.58,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76965,26,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[76977,26,"See CPT",null,4.8,null,4.8,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76978,26,"See CPT",null,139.75,null,139.75,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[76989,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[76998,"TC","See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[77003,"TC","See CPT",null,149.35,null,149.35,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[77012,26,"See CPT",null,125.36,null,125.36,null,0,0,0,0,1,0,0,9,0,0,null,"R"]
[77022,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[77048,null,"See CPT",null,659.18,null,659.18,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[77061,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,9,0,0,null,"X",null,"Y-CM"]
[77065,null,"See CPT",null,239.32,null,239.32,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77072,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[77073,"TC","See CPT",null,62.38,null,62.38,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[77077,"TC","See CPT",null,59.38,null,59.38,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[77080,26,"See CPT",null,17.39,null,17.39,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77086,26,"See CPT",null,14.4,null,14.4,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[77263,null,"See CPT",null,307.7,null,307.7,null,0,0,0,0,2,0,0,0,0,0,null,"R",null,"Y-CM"]
[77295,26,"See CPT",null,413.26,null,413.26,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77299,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[77316,"TC","See CPT",null,335.29,null,335.29,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77317,"TC","See CPT",null,442.05,null,442.05,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77333,26,"See CPT",null,71.98,null,71.98,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77334,26,"See CPT",null,110.96,null,110.96,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77399,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[77412,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,3,0,0,0,0,0,null,"N",null,"Y-CM"]
[77499,26,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[77522,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,3,0,0,0,0,0,null,"N",null,"Y-CM"]
[77620,"TC","See CPT",null,1075.44,null,1075.44,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77750,26,"See CPT",null,482.24,null,482.24,null,90,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77768,26,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[77771,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[77790,26,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X",null,"Y-CM"]
[78012,"TC","See CPT",null,139.75,null,139.75,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78016,"TC","See CPT",null,427.06,null,427.06,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78018,"TC","See CPT",null,476.24,null,476.24,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78075,26,"See CPT",null,63.58,null,63.58,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78099,"TC","See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[78111,26,"See CPT",null,15.59,null,15.59,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78121,"TC","See CPT",null,124.16,null,124.16,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78185,"TC","See CPT",null,268.70999999999998,null,268.70999999999998,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78195,26,"See CPT",null,100.17,null,100.17,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78215,26,"See CPT",null,40.79,null,40.79,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78227,null,"See CPT",null,766.54,null,766.54,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78258,null,"See CPT",null,379.07,null,379.07,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78262,null,"See CPT",null,434.86,null,434.86,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78278,null,"See CPT",null,612.4,null,612.4,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78282,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[78300,null,"See CPT",null,397.67,null,397.67,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78306,"TC","See CPT",null,445.65,null,445.65,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[78414,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[78429,"TC","See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-UR"]
[78433,"TC","See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-UR"]
[78434,26,"See CPT",null,52.18,null,52.18,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR"]
[78456,null,"See CPT",null,553.62,null,553.62,null,0,0,0,0,1,6,9,9,9,9,null,"R",null,"Y-CM"]
[78457,null,"See CPT",null,293.89999999999998,null,293.89999999999998,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[78468,null,"See CPT",null,351.48,null,351.48,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[78472,"TC","See CPT",null,320.29000000000002,null,320.29000000000002,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[78492,"TC","See CPT",null,3194.8,null,3194.8,null,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-UR"]
[78496,null,"See CPT",null,79.17,null,79.17,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR"]
[78582,null,"See CPT",null,582.41,null,582.41,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78597,null,"See CPT",null,352.08,null,352.08,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78605,"TC","See CPT",null,311.89999999999998,null,311.89999999999998,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78606,"TC","See CPT",null,526.62,null,526.62,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78609,26,"See CPT",null,130.16,null,130.16,null,0,0,0,0,1,9,9,9,9,9,null,"R",null,"Y-CM"]
[78645,"TC","See CPT",null,521.23,null,521.23,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78701,null,"See CPT",null,400.67,null,400.67,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78708,"TC","See CPT",null,232.12,null,232.12,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78740,"TC","See CPT",null,356.88,null,356.88,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78761,"TC","See CPT",null,316.69,null,316.69,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78803,26,"See CPT",null,90.57,null,90.57,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[78804,26,"See CPT",null,84.57,null,84.57,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78814,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[78830,null,"See CPT",null,836.12,null,836.12,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78999,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[79101,26,"See CPT",null,169.14,null,169.14,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[79440,26,"See CPT",null,142.15,null,142.15,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[79999,"TC","See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[80081,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[80155,null,"See CPT",null,54.58,null,54.58,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80163,null,"See CPT",null,18.79,null,18.79,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80178,null,"See CPT",null,9.35,null,9.35,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80192,null,"See CPT",null,23.7,null,23.7,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80200,null,"See CPT",null,22.82,null,22.82,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80305,null,"See CPT",null,17.829999999999998,null,17.829999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80307,null,"See CPT",null,87.93,null,87.93,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80337,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[80340,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[80347,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[80359,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[80371,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[80400,null,"See CPT",null,46.16,null,46.16,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80422,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[80436,null,"See CPT",null,128.99,null,128.99,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[81007,null,"See CPT",null,42.42,null,42.42,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[81025,null,"See CPT",null,12.18,null,12.18,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[81109,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81167,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81175,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81183,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81205,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81215,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81227,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81230,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81237,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81248,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81257,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81269,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81284,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81291,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81303,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81310,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81318,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81326,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81333,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81345,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81361,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81373,null,"See CPT",null,180.31,null,180.31,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[81401,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81411,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81413,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81430,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81437,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81455,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81479,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81507,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81518,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81538,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81541,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[82013,null,"See CPT",null,17.39,null,17.39,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82043,null,"See CPT",null,8.18,null,8.18,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82108,null,"See CPT",null,36.049999999999997,null,36.049999999999997,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82140,null,"See CPT",null,20.62,null,20.62,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82190,null,"See CPT",null,22.5,null,22.5,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82286,null,"See CPT",null,7.3,null,7.3,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82340,null,"See CPT",null,8.5299999999999994,null,8.5299999999999994,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82365,null,"See CPT",null,18.25,null,18.25,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82387,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[82441,null,"See CPT",null,8.5,null,8.5,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82525,null,"See CPT",null,17.559999999999999,null,17.559999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82575,null,"See CPT",null,13.39,null,13.39,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82638,null,"See CPT",null,17.329999999999998,null,17.329999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82677,null,"See CPT",null,34.21,null,34.21,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[82715,null,"See CPT",null,32.5,null,32.5,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82728,null,"See CPT",null,19.29,null,19.29,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82785,null,"See CPT",null,23.29,null,23.29,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82941,null,"See CPT",null,24.95,null,24.95,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82962,null,"See CPT",null,4.6399999999999997,null,4.6399999999999997,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83001,null,"See CPT",null,26.29,null,26.29,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[83020,null,"See CPT",null,18.21,null,18.21,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83068,null,"See CPT",null,13.4,null,13.4,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83491,null,"See CPT",null,25.33,null,25.33,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83500,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[83586,null,"See CPT",null,18.11,null,18.11,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83630,null,"See CPT",null,27.88,null,27.88,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83698,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[83722,null,"See CPT",null,48.38,null,48.38,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[83873,null,"See CPT",null,24.34,null,24.34,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83935,null,"See CPT",null,9.65,null,9.65,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84030,null,"See CPT",null,7.78,null,7.78,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[84060,null,"See CPT",null,10.81,null,10.81,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84132,null,"See CPT",null,6.74,null,6.74,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84135,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[84156,null,"See CPT",null,5.19,null,5.19,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84166,null,"See CPT",null,25.23,null,25.23,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84233,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[84252,null,"See CPT",null,28.64,null,28.64,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84377,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[84392,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[84449,null,"See CPT",null,25.47,null,25.47,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84466,null,"See CPT",null,18.059999999999999,null,18.059999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84520,null,"See CPT",null,5.59,null,5.59,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84578,null,"See CPT",null,6.33,null,6.33,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84704,null,"See CPT",null,21.64,null,21.64,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85007,null,"See CPT",null,5.38,null,5.38,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85046,null,"See CPT",null,7.88,null,7.88,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85055,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[85270,null,"See CPT",null,25.33,null,25.33,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85291,null,"See CPT",null,12.89,null,12.89,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85345,null,"See CPT",null,6.64,null,6.64,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85370,null,"See CPT",null,17.59,null,17.59,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85421,null,"See CPT",null,14.4,null,14.4,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85525,null,"See CPT",null,16.75,null,16.75,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85610,null,"See CPT",null,6.07,null,6.07,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85613,null,"See CPT",null,13.56,null,13.56,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86008,null,"See CPT",null,25.37,null,25.37,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86036,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[86140,null,"See CPT",null,7.33,null,7.33,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86147,null,"See CPT",null,36.01,null,36.01,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86215,null,"See CPT",null,18.75,null,18.75,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86256,26,"See CPT",null,31.79,null,31.79,null,0,0,0,0,6,0,0,0,0,0,null,"R"]
[86310,null,"See CPT",null,10.43,null,10.43,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86318,null,"See CPT",null,25.6,null,25.6,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86336,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[86344,null,"See CPT",null,14.7,null,14.7,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86382,null,"See CPT",null,23.93,null,23.93,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86403,null,"See CPT",null,16.329999999999998,null,16.329999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86510,null,"See CPT",null,15,null,15,null,0,0,0,0,3,0,0,0,0,0,null,"R"]
[86603,null,"See CPT",null,18.21,null,18.21,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86631,null,"See CPT",null,16.73,null,16.73,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86658,null,"See CPT",null,18.440000000000001,null,18.440000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86677,null,"See CPT",null,23.84,null,23.84,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86687,null,"See CPT",null,12.86,null,12.86,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86709,null,"See CPT",null,15.93,null,15.93,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86713,null,"See CPT",null,21.65,null,21.65,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86753,null,"See CPT",null,17.53,null,17.53,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86765,null,"See CPT",null,18.23,null,18.23,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86800,null,"See CPT",null,22.51,null,22.51,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86812,null,"See CPT",null,36.520000000000003,null,36.520000000000003,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86833,null,"See CPT",null,461.01,null,461.01,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86849,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
[86911,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[86922,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
[86975,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
[86999,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
[87081,null,"See CPT",null,9.3800000000000008,null,9.3800000000000008,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87106,null,"See CPT",null,14.6,null,14.6,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87153,null,"See CPT",null,163.22999999999999,null,163.22999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87164,26,"See CPT",null,34.79,null,34.79,null,0,0,0,0,6,0,0,0,0,0,null,"R"]
[87205,null,"See CPT",null,6.04,null,6.04,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87207,26,"See CPT",null,31.79,null,31.79,null,0,0,0,0,6,0,0,0,0,0,null,"R"]
[87254,null,"See CPT",null,27.68,null,27.68,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87276,null,"See CPT",null,22.74,null,22.74,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87320,null,"See CPT",null,21.23,null,21.23,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87336,null,"See CPT",null,22.64,null,22.64,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87400,null,"See CPT",null,19.989999999999998,null,19.989999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87426,null,"See CPT",null,49.99,null,49.99,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[87476,null,"See CPT",null,49.65,null,49.65,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87486,null,"See CPT",null,49.65,null,49.65,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87496,null,"See CPT",null,49.65,null,49.65,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87512,null,"See CPT",null,59.09,null,59.09,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87530,null,"See CPT",null,60.62,null,60.62,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87537,null,"See CPT",null,31.02,null,31.02,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87557,null,"See CPT",null,60.62,null,60.62,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87580,null,"See CPT",null,28.37,null,28.37,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87640,null,"See CPT",null,49.65,null,49.65,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87651,null,"See CPT",null,49.65,null,49.65,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87798,null,"See CPT",null,49.65,null,49.65,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87811,null,"See CPT",null,58.55,null,58.55,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[87912,null,"See CPT",null,364.29,null,364.29,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[88029,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[88104,26,"See CPT",null,49.18,null,49.18,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88112,null,"See CPT",null,129.56,null,129.56,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88130,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[88142,null,"See CPT",null,28.67,null,28.67,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88155,null,"See CPT",null,20.73,null,20.73,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88166,null,"See CPT",null,25.13,null,25.13,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88177,"TC","See CPT",null,16.190000000000001,null,16.190000000000001,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88189,null,"See CPT",null,150.55000000000001,null,150.55000000000001,null,0,0,0,0,2,0,0,0,0,0,null,"R",null,"Y-CM"]
[88248,null,"See CPT",null,245.04,null,245.04,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88269,null,"See CPT",null,245.73,null,245.73,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88300,null,"See CPT",null,31.19,null,31.19,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88302,null,"See CPT",null,63.58,null,63.58,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88305,26,"See CPT",null,66.58,null,66.58,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88314,"TC","See CPT",null,133.76,null,133.76,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88319,null,"See CPT",null,262.70999999999998,null,262.70999999999998,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88332,null,"See CPT",null,102.57,null,102.57,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88342,null,"See CPT",null,202.73,null,202.73,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88346,"TC","See CPT",null,223.13,null,223.13,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88356,26,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[88358,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[88362,null,"See CPT",null,434.26,null,434.26,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88366,26,"See CPT",null,109.76,null,109.76,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88369,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[88374,26,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[88387,26,"See CPT",null,47.38,null,47.38,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88399,"TC","See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[89051,null,"See CPT",null,7.92,null,7.92,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[89230,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
[89257,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[89300,null,"See CPT",null,13.92,null,13.92,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[89330,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[89398,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[90378,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[90461,null,"See CPT",null,16.190000000000001,null,16.190000000000001,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[90611,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
[90633,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[90644,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[90660,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
[90670,null,"See CPT",null,257.99,null,257.99,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
[90687,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[90702,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[90734,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM"]
[90759,null,"See CPT",null,73.819999999999993,null,73.819999999999993,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
[90836,null,"See CPT",null,167.34,null,148.15,null,0,0,0,0,0,0,0,9,0,0,null,"R",null,"Y-CM"]
[90839,null,"See CPT",null,269.91000000000003,null,235.72,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[90870,null,"See CPT",null,323.29000000000002,null,190.14,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[90899,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
[90954,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[90966,null,"See CPT",null,536.22,null,536.22,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[90997,null,"See CPT",null,158.94999999999999,null,158.94999999999999,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[91022,"TC","See CPT",null,198.53,null,198.53,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[91034,26,"See CPT",null,89.37,null,89.37,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[91035,26,"See CPT",null,146.35,null,146.35,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[91111,26,"See CPT",null,82.17,null,82.17,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[91113,null,"See CPT",null,1722.63,null,1722.63,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[91132,26,"See CPT",null,47.38,null,47.38,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[91299,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[91314,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[92025,"TC","See CPT",null,33.590000000000003,null,33.590000000000003,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92072,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,2,0,0,0,null,"X"]
[92082,"TC","See CPT",null,51.58,null,51.58,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92133,"TC","See CPT",null,29.39,null,29.39,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92145,null,"See CPT",null,24.59,null,24.59,null,0,0,0,0,1,7,2,0,0,0,null,"R",null,"Y-CM"]
[92235,"TC","See CPT",null,234.52,null,234.52,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92242,26,"See CPT",null,98.37,null,98.37,null,0,0,0,0,1,7,2,0,0,0,null,"R",null,"Y-CM"]
[92274,null,"See CPT",null,170.34,null,170.34,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92286,null,"See CPT",null,73.78,null,73.78,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92325,null,"See CPT",null,79.17,null,79.17,null,0,0,0,0,5,0,0,0,0,0,null,"R"]
[92341,null,"See CPT",null,74.38,null,41.39,null,0,0,0,0,9,9,9,9,9,9,null,"R"]
[92511,null,"See CPT",null,224.33,null,70.180000000000007,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[92517,null,"See CPT",null,145.75,null,77.37,null,0,0,0,0,0,0,2,0,0,0,null,"R",null,"Y-CM"]
[92534,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
[92540,null,"See CPT",null,200.33,null,200.33,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[92545,"TC","See CPT",null,7.2,null,7.2,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[92550,null,"See CPT",null,40.79,null,40.79,null,0,0,0,0,7,0,2,0,0,0,null,"R"]
[92558,null,"See CPT",null,17.39,null,15.59,null,0,0,0,0,9,9,9,9,9,9,null,"R"]
[92565,null,"See CPT",null,40.79,null,40.79,null,0,0,0,0,3,0,2,0,0,0,null,"R"]
[92588,null,"See CPT",null,61.78,null,61.78,null,0,0,0,0,1,0,2,0,0,0,null,"R"]
[92590,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
[92605,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B",null,"Y-CM"]
[92610,null,"See CPT",null,159.55000000000001,null,130.16,null,0,0,0,0,7,0,0,0,0,0,null,"R",null,"Y-CM"]
[92627,null,"See CPT",null,37.79,null,32.39,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[92925,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[92941,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[92950,null,"See CPT",null,605.20000000000005,null,326.89,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[92979,26,"See CPT",null,131.36000000000001,null,131.36000000000001,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[92990,null,"See CPT",null,1934.95,null,1934.95,null,0,0.09,0.84,7.0000000000000007E-2,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[93025,26,"See CPT",null,67.180000000000007,null,67.180000000000007,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93150,null,"See CPT",null,188.94,null,77.37,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[93243,null,"See CPT",null,433.66,null,433.66,null,0,0,0,0,3,6,0,0,0,0,null,"R",null,"Y-CM"]
[93260,26,"See CPT",null,74.38,null,74.38,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93278,26,"See CPT",null,22.79,null,22.79,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[93279,"TC","See CPT",null,70.78,null,70.78,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93284,26,"See CPT",null,109.16,null,109.16,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93286,"TC","See CPT",null,59.38,null,59.38,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93290,"TC","See CPT",null,62.98,null,62.98,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93292,26,"See CPT",null,37.19,null,37.19,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93304,null,"See CPT",null,297.5,null,297.5,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93307,"TC","See CPT",null,181.74,null,181.74,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[93315,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[93317,"TC","See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[93350,null,"See CPT",null,352.68,null,352.68,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[93351,null,"See CPT",null,441.45,null,441.45,null,0,0,0,0,1,6,0,9,9,9,null,"R"]
[93454,"TC","See CPT",null,1278.17,null,1278.17,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[93455,"TC","See CPT",null,1401.73,null,1401.73,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[93459,"TC","See CPT",null,1509.1,null,1509.1,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[93461,26,"See CPT",null,720.96,null,720.96,null,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93564,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[93569,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[93586,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[93590,null,"See CPT",null,1905.56,null,1905.56,null,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[93597,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[93598,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[93609,"TC","See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[93616,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[93619,26,"See CPT",null,673.58,null,673.58,null,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93620,26,"See CPT",null,1080.24,null,1080.24,null,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93640,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,2,0,0,0,0,null,"N",null,"Y-CM"]
[93641,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,2,0,0,0,0,null,"N",null,"Y-CM"]
[93660,26,"See CPT",null,164.35,null,164.35,null,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93660,"TC","See CPT",null,140.94999999999999,null,140.94999999999999,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[93770,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
[93797,null,"See CPT",null,32.39,null,16.190000000000001,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[93886,"TC","See CPT",null,443.85,null,443.85,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[93890,26,"See CPT",null,92.37,null,92.37,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[93922,26,"See CPT",null,20.99,null,20.99,null,0,0,0,0,1,6,2,0,0,0,null,"R"]
[93923,26,"See CPT",null,38.39,null,38.39,null,0,0,0,0,1,6,2,0,0,0,null,"R"]
[93930,"TC","See CPT",null,311.3,null,311.3,null,0,0,0,0,1,6,2,0,0,0,null,"R"]
[93971,"TC","See CPT",null,190.14,null,190.14,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[93979,"TC","See CPT",null,183.54,null,183.54,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[93981,26,"See CPT",null,37.79,null,37.79,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[94003,null,"See CPT",null,115.76,null,115.76,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[94012,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[94150,"TC","See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,1,9,9,9,9,9,null,"B"]
[94200,null,"See CPT",null,28.79,null,28.79,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[94619,null,"See CPT",null,123.56,null,123.56,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-ONC"]
[94621,26,"See CPT",null,121.76,null,121.76,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[94669,null,"See CPT",null,39.590000000000003,null,39.590000000000003,null,0,0,0,0,5,0,0,0,0,0,null,"R"]
[94690,null,"See CPT",null,93.57,null,93.57,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[94729,null,"See CPT",null,108.56,null,108.56,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[94772,26,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[94799,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[95027,null,"See CPT",null,9.6,null,9.6,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[95132,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
[95144,null,"See CPT",null,31.79,null,6,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[95170,null,"See CPT",null,20.99,null,5.4,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[95710,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
[95721,null,"See CPT",null,381.47,null,373.68,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[95783,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[95805,null,"See CPT",null,830.72,null,830.72,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[95806,null,"See CPT",null,178.74,null,178.74,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[95812,"TC","See CPT",null,571.61,null,571.61,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95813,"TC","See CPT",null,696.37,null,696.37,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95819,26,"See CPT",null,103.17,null,103.17,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95860,26,"See CPT",null,91.77,null,91.77,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95864,"TC","See CPT",null,248.32,null,248.32,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95866,26,"See CPT",null,114.56,null,114.56,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[95870,26,"See CPT",null,35.99,null,35.99,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95874,null,"See CPT",null,145.75,null,145.75,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95887,null,"See CPT",null,157.15,null,157.15,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[95905,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[95908,"TC","See CPT",null,91.17,null,91.17,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95912,"TC","See CPT",null,179.94,null,179.94,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95923,"TC","See CPT",null,151.75,null,151.75,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95925,26,"See CPT",null,50.38,null,50.38,null,0,0,0,0,1,0,2,0,0,0,null,"R"]
[95929,26,"See CPT",null,142.75,null,142.75,null,0,0,0,0,1,0,2,0,0,0,null,"R"]
[95937,null,"See CPT",null,198.53,null,198.53,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95939,"TC","See CPT",null,857.11,null,857.11,null,0,0,0,0,1,0,2,0,0,0,null,"R"]
[95955,26,"See CPT",null,95.97,null,95.97,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95961,null,"See CPT",null,619.59,null,619.59,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95967,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[95983,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[96001,null,"See CPT",null,199.73,null,199.73,null,0,0,0,0,7,0,2,0,0,0,null,"R"]
[96116,null,"See CPT",null,169.74,null,144.55000000000001,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-ONC"]
[96136,null,"See CPT",null,78.569999999999993,null,41.99,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-ONC"]
[96167,null,"See CPT",null,130.16,null,113.36,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[96171,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[96367,null,"See CPT",null,53.98,null,53.98,null,0,0,0,0,5,0,0,0,0,0,null,"R"]
[96401,null,"See CPT",null,137.35,null,137.35,null,0,0,0,0,5,0,0,0,0,0,null,"R"]
[96415,null,"See CPT",null,52.78,null,52.78,null,0,0,0,0,5,0,0,0,0,0,null,"R"]
[96523,null,"See CPT",null,47.98,null,47.98,null,0,0,0,0,5,0,0,0,0,0,null,"R"]
[96573,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[96932,null,"See CPT",null,245.92,null,245.92,null,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM"]
[97024,null,"See CPT",null,13.8,null,13.8,null,0,0,0,0,7,5,0,0,0,0,null,"R"]
[97032,null,"See CPT",null,26.39,null,26.39,null,0,0,0,0,7,5,0,0,0,0,null,"R"]
[97110,null,"See CPT",null,55.18,null,55.18,null,0,0,0,0,7,5,0,0,0,0,null,"R"]
[97153,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[97162,null,"See CPT",null,147.97,null,147.97,null,0,0,0,0,7,5,0,0,0,0,null,"F"]
[97537,null,"See CPT",null,59.38,null,59.38,null,0,0,0,0,7,5,0,0,0,0,null,"R"]
[97606,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,0,0,0,0,0,0,null,"B",null,"Y-CM"]
[97761,null,"See CPT",null,78.569999999999993,null,78.569999999999993,null,0,0,0,0,7,5,0,0,0,0,null,"R"]
[98927,null,"See CPT",null,109.16,null,83.97,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[98960,null,"See CPT",null,59.38,null,59.38,null,0,0,0,0,9,9,9,9,9,9,null,"R"]
[98966,null,"See CPT",null,23.99,null,20.99,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99027,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[99053,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
[99100,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
[99173,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
[99190,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
[99214,null,"See CPT",null,238.72,null,176.94,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99233,null,"See CPT",null,215.33,null,215.33,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99238,null,"See CPT",null,148.15,null,148.15,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99283,null,"See CPT",null,127.16,null,127.16,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99305,null,"See CPT",null,244.12,null,244.12,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99347,null,"See CPT",null,82.77,null,82.77,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99377,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
[99384,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[99402,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[99408,null,"See CPT",null,62.98,null,57.58,null,0,0,0,0,9,9,9,9,9,9,null,"R"]
[99417,null,"See CPT",null,56.38,null,54.58,null,0,0,0,0,9,9,9,9,9,9,null,"R"]
[99441,null,"See CPT",null,105.56,null,63.58,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99450,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[99462,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[99469,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[99484,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[99490,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[99505,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[99509,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0002A",null,"See CPT",null,40,null,40,null,0,0,0,0,0,0,0,0,0,0,null,"D",null,"Y-CM"]
["0009U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0014U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0023U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0054T",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["0082U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0090U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0093U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0101T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0106U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0116U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0122U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0133U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0144A",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0150U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0153U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0174T",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["0206U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0209U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0213T",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,1,0,0,0,null,"N",null,"Y-UR"]
["0219T",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-UR"]
["0227U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0233U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0235T",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["0253T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0271T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0291U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0298U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0315U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0335T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0352T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0358T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0389R",null,"See CPT",null,12.71,null,12.71,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["0392R",null,"See CPT",null,"State Rate",null,"State Rate",null,0,0,0,0,0,0,0,0,0,0,null,"S",null,"Y-CM"]
["0405A",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["0410T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0417T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0424U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0432U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0435U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0448T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
["0469T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0489T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0501F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["0513T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0519F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["0526T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
["0528T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,9,9,9,9,9,null,"X"]
["0545F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["0547T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0557F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["0566C",null,"See CPT",null,"Contracted",null,"Contracted",null,0,0,0,0,0,0,0,0,0,0,null,"C"]
["0576T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0581T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0590T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0593T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0635T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,3,0,0,0,null,"X"]
["0677T",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,2,0,1,0,0,null,"N",null,"Y-UR"]
["0686T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
["0689T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,4,0,0,0,0,null,"X"]
["0701T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,3,0,0,0,null,"X"]
["0710T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,4,9,9,9,9,9,null,"X"]
["0746T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0749T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0760T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0771T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0788T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0811T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0823T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,2,0,null,"X"]
["0830T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0842T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0850T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0862T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
["0865T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,4,0,0,0,0,null,"X"]
["0831V",null,"See CPT",null,8.99,null,8.99,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["0842V",null,"See CPT",null,10.55,null,10.55,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["0910V",null,"See CPT",null,50,null,50,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["1011F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1026M",null,"AP final report at request of insurer",null,30.4,null,30.4,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["1034F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1050F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1055M",null,"Occupational disease hx, detailed, non-i, occupati",null,223.21,null,223.21,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["1073M",null,"Activity prescription form, insurer requested",null,59.81,null,59.81,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["1077M",null,"Opioid req for subacute pain w/doc",null,69.03,null,69.03,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["1090F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1116F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1126F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1130M",null,"Ime - terminated examination",null,427.58,null,427.58,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["1146M",null,"IME Forensic exam ",null,427.58,null,427.58,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["1151F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1170F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1192M",null,"Impairment rating by a/p, complex",null,910.07,null,910.07,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["1198M",null,"Impairment rating, addendum report",null,137.91,null,137.91,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["1226M",null,"Ur contract:  prospective review - inpatient",null,"Contracted",null,"Contracted",null,0,0,0,0,0,0,0,0,0,0,null,"C"]
["1253M",null,"UR, spinal injection - full clinical review",null,"Contracted",null,"Contracted",null,0,0,0,0,0,0,0,0,0,0,null,"C"]
["1270M",null,"IME Taxi",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["1400W",null,"See CPT",null,46.4,null,46.4,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["1450F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1500F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["2000F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["2014F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["2025F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["2050F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3014F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3021F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3048F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3073F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3077F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3085F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3112F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3150F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3218F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3272F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3284F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3317F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3320F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3330F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3354F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3450F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3472F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3500F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3514F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3725F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3752F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3759F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4011F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4017F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4044F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4056F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4066F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4100F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4133F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4136F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4158F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4169F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4185F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4200F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4242F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4255F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4293F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4305F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4510F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4552F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4570A",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["5095V",null,"See CPT",null,1.25,null,1.25,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["5934M",null,"Outpatient Day Program - Lunch",null,"State Rate",null,"State Rate",null,0,0,0,0,0,0,0,0,0,0,null,"S"]
["6102F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["8881H",null,"See CPT",null,749.61,null,749.61,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC"]
["8884H",null,"See CPT",null,622.39,null,622.39,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC"]
["8914H",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-ONC"]
["8952H",null,"See CPT",null,808.78,null,808.78,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC"]
["9917M",null,"IND HYGIENIST CONSULTATION",null,388,null,388,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["A0080",null,"Noninterest escort in non er",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A0160",null,"Noner transport case worker",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A0394",null,"Als iv drug therapy supplies",null,58.76,null,58.76,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A0426",null,"Als 1",null,770.82,null,770.82,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A0429",null,"Bls-emergency",null,673.74,null,673.74,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A2002",null,"Mirragen adv wnd mat per sq",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A2016",null,"Permeaderm b, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A2022",null,"Innovabrn/innovamatx xl sqcm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A4207",null,"2 cc sterile syringe&needle",null,1.99,null,1.99,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4221",null,"Supp non-insulin inf cath/wk",null,27.83,null,27.83,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["A4236",null,"Silvr oxide batt glucose mon",null,2.84,null,2.84,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4248",null,"Chlorhexidine antisept",null,0.1,null,0.1,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4253",null,"Blood glucose/reagent strips",null,66.34,null,66.34,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4269",null,"Spermicide",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A4283",null,"Replacement breastpump cap",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A4312",null,"Cath w/o bag 2-way silicone",null,23.76,null,23.76,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4322",null,"Irrigation syringe",null,4.22,null,4.22,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4338",null,"Indwelling catheter latex",null,16.989999999999998,null,16.989999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4356",null,"Ext ureth clmp or compr dvc",null,53.71,null,53.71,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4364",null,"Adhesive, liquid or equal",null,3.78,null,3.78,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4378",null,"Drainable rubber pch w/o fp",null,42.58,null,42.58,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4388",null,"Drainable pch w ex wear barr",null,6.04,null,6.04,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4391",null,"Urinary pouch w ex wear barr",null,9.7799999999999994,null,9.7799999999999994,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4406",null,"Pectin based ostomy paste",null,7.93,null,7.93,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4413",null,"2 pc drainable ost pouch",null,7.63,null,7.63,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4425",null,"Ost pch drain for barrier fl",null,4.95,null,4.95,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4429",null,"Urine ost pouch w bltinconv",null,11.43,null,11.43,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4458",null,"Reusable enema bag",null,8.26,null,8.26,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4463",null,"Surgical dress holder reuse",null,18.43,null,18.43,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4550",null,"Surgical trays",null,110.84,null,110.84,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4555",null,"Ca tx e-stim electr/transduc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A4570",null,"Splint",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A4596",null,"Ces system monthly supp",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A4613",null,"Battery charger",null,41.3,null,41.3,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4630",null,"Repl bat t.e.n.s. own by pt",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A4639",null,"Infrared ht sys replcmnt pad",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A4642",null,"In111 satumomab",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["A4690",null,"Dialyzer, each",null,187.24,null,187.24,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["A4708",null,"Acetate conc sol per gallon",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A4730",null,"Fistula cannulation set, ea",null,19.920000000000002,null,19.920000000000002,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4772",null,"Blood glucose test strips",null,0.89,null,0.89,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4918",null,"Venous pressure clamp",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A5051",null,"Pouch clsd w barr attached",null,2.85,null,2.85,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A5073",null,"Urinary pouch on barr w/flng",null,4.34,null,4.34,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A5083",null,"Stoma absorptive cover",null,0.89,null,0.89,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A5504",null,"Diabetic shoe with wedge",null,44.91,null,44.91,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["A5507",null,"Modification diabetic shoe",null,44.91,null,44.91,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["A6023",null,"Collagen dressing >48 sq in",null,263.57,null,263.57,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6204",null,"Composite drsg >16<=48 sq in",null,8.6199999999999992,null,8.6199999999999992,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6216",null,"Non-sterile gauze<=16 sq in",null,0.05,null,0.05,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6223",null,"Gauze >16<=48 no w/sal w/o b",null,3.36,null,3.36,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6238",null,"Hydrocolld drg >16<=48 w/bdr",null,31.58,null,31.58,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6241",null,"Hydrocolloid drg filler dry",null,3.56,null,3.56,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6252",null,"Absorpt drg >16 <=48 w/o bdr",null,4.51,null,4.51,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6262",null,"Wound filler dry form / gram",null,1.99,null,1.99,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6443",null,"Conform band n/s w>=3\"<5\"/yd",null,0.39,null,0.39,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6450",null,"Lt compres band >=5\"/yd",null,2.4300000000000002,null,2.4300000000000002,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6503",null,"Compres burngarment facehood",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A6510",null,"Compres burn garment leotard",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A6528",null,"G com garment bra nighttime",null,639.45000000000005,null,639.45000000000005,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6539",null,"Gc stocking waistlngth 18-30",null,93.9,null,93.9,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A6554",null,"Grad com stocking bk 40+",null,76.489999999999995,null,76.489999999999995,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6557",null,"G com stcking thgh30-40 cust",null,297.69,null,297.69,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6573",null,"Grad com garmnt toe cap cust",null,239.34,null,239.34,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6576",null,"Custom grad com sleeve med",null,187.27,null,187.27,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6588",null,"Grad com wrap w straps arm",null,234,null,234,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6596",null,"G comp bandge conform gauze",null,0.17,null,0.17,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6603",null,"G com bandge low dn foamchnl",null,2.2599999999999998,null,2.2599999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A7001",null,"Nondisposable pump canister",null,39.840000000000003,null,39.840000000000003,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["A7018",null,"Water distilled w/nebulizer",null,0.48,null,0.48,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A7025",null,"Replace chest compress vest",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A7041",null,"Water seal drain container",null,102.75,null,102.75,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A7046",null,"Repl water chamber, pap dev",null,61.13,null,61.13,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A7509",null,"Heat & moisture exchange sys",null,1.95,null,1.95,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A7527",null,"Trach/laryn tube plug/stop",null,4.95,null,4.95,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A9268",null,"Programmer orally ingest cap",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A9276",null,"Disposable sensor, cgm sys",null,21.84,null,21.84,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["A9292",null,"Pres dig visual therapy fda",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC"]
["A9500",null,"Tc99m sestamibi",null,546.04999999999995,null,546.04999999999995,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["A9521",null,"Tc99m exametazime",null,2605.0500000000002,null,2605.0500000000002,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["A9531",null,"I131 max 100uci",null,32.67,null,32.67,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["A9543",null,"Y90 ibritumomab, rx",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["A9553",null,"Cr51 chromate",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["A9566",null,"Tc99m fanolesomab",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["A9573",null,"Inj, gadopiclenol, 1 ml",null,15.43,null,15.43,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A9585",null,"Gadobutrol injection",null,0.34,null,0.34,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["A9588",null,"Fluciclovine f-18",null,587.9,null,587.9,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["A9607",null,"Lutetium lu 177 vipivotide",null,231.2,null,231.2,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["A9697",null,"Inj, magtrace per study dose",null,"Facility Only",null,"By Report ",null,0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-ONC"]
["B4082",null,"Enteral ng tubing w/o stylet",null,17.670000000000002,null,17.670000000000002,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["B4104",null,"Additive for enteral formula",null,1.1599999999999999,null,1.1599999999999999,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["B4160",null,"Ef ped caloric dense>/=0.7kc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X",null,"Y-CM"]
["B4178",null,"Parenteral sol amino acid >",null,82.75,null,82.75,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["B5000",null,"Parenteral sol renal-amirosy",null,17.100000000000001,null,17.100000000000001,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["B9006","RR","Parenteral infus pump statio",null,574.41999999999996,null,574.41999999999996,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["C1715",null,"Brachytherapy needle",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C1719",null,"Brachytx, ns, non-hdrir-192",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["C1728",null,"Cath, brachytx seed adm",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C1752",null,"Cath,hemodialysis,short-term",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C1764",null,"Event recorder, cardiac",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C1771",null,"Rep dev, urinary, w/sling",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C1786",null,"Pmkr, single, rate-resp",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C1789",null,"Prosthesis, breast, imp",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C1830",null,"Power bone marrow bx needle",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C1833",null,"CARDIAC MONITOR SYS",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["C1878",null,"Matrl for vocal cord",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C1892",null,"Intro/sheath,fixed,peel-away",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C1899",null,"Lead, pmkr/aicd combination",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C2622",null,"Prosthesis, penile, non-inf",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C2636",null,"Brachy linear, non-str,p-103",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["C2643",null,"Brachytx, non-stranded,c-131",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["C5278",null,"Low cost skin substitute app",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["C7502",null,"Perc bx breast lesions mr",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR"]
["C7509",null,"Dx bronch w/ navigation",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR"]
["C7522",null,"R hrt angio w/flow resrv",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR"]
["C7534",null,"Fem/pop revasc w/arthr & us",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR"]
["C7542",null,"Ercp w/bx & pancreatoscopy",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C7554",null,"Cystureth blu li cyst fl img",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR"]
["C7901",null,"Hopd mntl hlt, 30-60 min",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-CM"]
["C8911",null,"Mra w/o fol w/cont, chest",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C8914",null,"Mra w/o fol w/cont, lwr ext",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C8931",null,"Mra, w/dye, spinal canal",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C8937",null,"Cad breast mri",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["C9061",null,"Injection, teprotumumab-trbw",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["C9143",null,"Cocaine hcl nasal (numbrino)",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["C9290",null,"Inj, bupivacaine liposome",null,46.38,null,46.38,null,0,0,0,0,0,0,0,0,0,0,null,"D"]
["C9358",null,"Surgimend, fetal",null,"Facility Only",null,"Facility Only",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C9484",null,"Injection, eteplirsen",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["C9507",null,"COVID-19 CONVALESCENT PLASMA",null,"Facility Only",null,800.3,null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["C9606",null,"Perc d-e cor revasc w ami s",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["C9751",null,"Microwave bronch, 3d, ebus",null,"Facility Only",null,8973.9500000000007,null,0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR"]
["C9760",null,"Non-blind interatrial shunt",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["C9774",null,"Revasc lithotr-ather tib/per",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["C9786",null,"Echo cad for hf preserved ef",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-ONC"]
["C9791",null,"Mri hyperpolarized xenon129",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-UR"]
["D0191",null,"Assessment of a patient",null,103.2,null,103.2,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["D0230",null,"Intraoral periapical ea add",null,33.6,null,33.6,null,0,0,0,0,1,0,0,0,0,0,null,"F"]
["D0274",null,"Bitewings four images",null,81.599999999999994,null,81.599999999999994,null,0,0,0,0,1,0,0,0,0,0,null,"F"]
["D0367",null,"Cone beam ct interp both jaw",null,400,null,400,null,0,0,0,0,1,0,0,0,0,0,null,"F"]
["D0374",null,"Tomo periapical image",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
["D0393",null,"Trtmnt simulation 3d image",null,368.8,null,368.8,null,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-CM"]
["D0431",null,"Diag tst detect mucos abnorm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["D0475",null,"Decalcification procedure",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
["D0502",null,"Other oral pathology procedu",null,200.8,null,200.8,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["D0602",null,"Caries risk assess mod risk",null,96.8,null,96.8,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D0703",null,"2d oral/facial photo image",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
["D1120",null,"Dental prophylaxis child",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["D1330",null,"Oral hygiene instruction",null,"Bundled",null,"Bundled",null,0,0,0,0,0,0,0,0,0,0,null,"B"]
["D1526",null,"Remove bilat space main, max",null,548,null,548,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D1707",null,"Janssen Covid-19 vaccine administration",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["D2160",null,"Amalgam three surfaces perma",null,290.39999999999998,null,290.39999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D2420",null,"Dental gold foil two surface",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["D2544",null,"Dental onlay metl 4/more sur",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["D2630",null,"Dental onlay porc 3/more sur",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["D2721",null,"Crown resin w/ base metal",null,1264,null,1264,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D2780",null,"Crown 3/4 cast hi noble met",null,1414.4,null,1414.4,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D2921",null,"Reattach tooth fragment",null,333.6,null,333.6,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D2951",null,"Tooth pin retention",null,101.6,null,101.6,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D2961",null,"Lab labial veneer resin",null,1279.2,null,1279.2,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D2999",null,"Dental unspec restorative pr",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["D3240",null,"Pulpal therapy posterior pri",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["D3351",null,"Apexification/recalc initial",null,468.8,null,468.8,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D3410",null,"Apicoectomy - anterior",null,940,null,940,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D3431",null,"Biological materials",null,703.2,null,703.2,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D3911",null,"Intraorifice barrier",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["D4212",null,"Gingivectomy/plasty rest",null,363.2,null,363.2,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D4266",null,"Guided tiss regen resorble",null,860.8,null,860.8,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D4286",null,"Remove non-resorb barrier",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["D4322",null,"Splint intra-coronal",null,620,null,620,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D4999",null,"Unspecified periodontal proc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["D5224",null,"Immed mand part dent metal",null,2197.6,null,2197.6,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D5284",null,"Rem unilat dent flex base",null,1464,null,1464,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["D5622",null,"Rep cast part frame max",null,364,null,364,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5710",null,"Dentures rebase cmplt maxil",null,753.6,null,753.6,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5761",null,"Denture reln part mand lab",null,586.4,null,586.4,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5865",null,"Overdenture complete mandib",null,2804.8,null,2804.8,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5914",null,"Auricular prosthesis",null,8594.4,null,8594.4,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D5919",null,"Facial prosthesis",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["D5934",null,"Mandibular flange prosthesis",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["D5954",null,"Superimposed prosthesis",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["D5991",null,"Vesiculobullous disease carr",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["D6040",null,"Odontics eposteal implant",null,8495.2000000000007,null,8495.2000000000007,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D6062",null,"Abutment supported mtl crown",null,1680,null,1680,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6074",null,"Abutment supported retainer",null,1636,null,1636,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6083",null,"Imp crown porc to noble allo",null,1878.4,null,1878.4,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-ONC"]
["D6087",null,"Implant crown noble alloys",null,1855.2,null,1855.2,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-ONC"]
["D6103",null,"Bone graft repair perimplant",null,860.8,null,860.8,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6106",null,"Tissue regen resorbable",null,"By Report",null,"By Report",null,0,0,0,0,0,9,9,9,9,9,null,"N",null,"Y-CM"]
["D6118",null,"Imp/abut int fixed dent man",null,4527.2,null,4527.2,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D6195",null,"Abut retain porc to titanium",null,1803.2,null,1803.2,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC"]
["D6243",null,"Pontic porcelain to titanium",null,1476,null,1476,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-ONC"]
["D6603",null,"Cst hgh nble mtl inlay >=3sr",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,9,9,9,9,9,null,"X"]
["D6610",null,"Onlay cst hgh nbl mtl 2 srfc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,9,9,9,9,9,null,"X"]
["D6613",null,"Onlay cst base mtl >=3 surfa",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,9,9,9,9,9,null,"X"]
["D6782",null,"Crown 3/4 cast noble metal",null,1361.6,null,1361.6,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6794",null,"Crown titanium",null,1364.8,null,1364.8,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7140",null,"Extraction erupted tooth/exr",null,252.8,null,252.8,null,0,0,0,0,0,9,9,9,9,9,null,"F"]
["D7251",null,"Coronectomy",null,583.20000000000005,null,583.20000000000005,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7288",null,"Brush biopsy",null,269.60000000000002,null,269.60000000000002,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D7296",null,"Corticotomy, 1-3 teeth",null,1220,null,1220,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7411",null,"Excision benign lesion>1.25c",null,820.8,null,820.8,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7414",null,"Excision malig lesion>1.25cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["D7520",null,"I&d abscess extraoral",null,644.79999999999995,null,644.79999999999995,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7540",null,"Removal of fb reaction",null,804,null,804,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7710",null,"Maxilla open reduct compound",null,5564.8,null,5564.8,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7771",null,"Alveolus clsd reduc stblz te",null,2381.6,null,2381.6,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7865",null,"Tmj reshaping components",null,9002.4,null,9002.4,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7876",null,"Tmj arthroscopy discectomy",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["D7911",null,"Dental suture wound to 5 cm",null,707.2,null,707.2,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D7945",null,"Bone cutting body mandible",null,9093.6,null,9093.6,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7971",null,"Excision pericoronal gingiva",null,351.2,null,351.2,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["D7980",null,"Surgical sialolithotomy",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["D7999",null,"Oral surgery procedure",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["D8090",null,"Compre dental tx adult",null,5649.6,null,5649.6,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D8701",null,"Repair fixed retainer max",null,348,null,348,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["D9130",null,"Temporomandibular joint dysf",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["D9311",null,"Consult w/med hlth care prof",null,218.4,null,218.4,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D9430",null,"Office visit during hours",null,103.2,null,103.2,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["D9938",null,"Fab removable appliance",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["D9942",null,"Repair/reline occlusal guard",null,301.60000000000002,null,301.60000000000002,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D9970",null,"Enamel microabrasion",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["D9973",null,"Extrnl bleaching per tooth",null,292,null,292,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D9991",null,"Case mgmt, appt barriers",null,108.8,null,108.8,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E0113","NU","Crutch underarm each wood",null,29.28,null,29.28,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0141","RR","Rigid wheeled walker adj/fix",null,16.46,null,16.46,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0144","NU","Enclosed walker w rear seat",null,355.05,null,355.05,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0156","RR","Walker seat attachment",null,3.06,null,3.06,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0158","NU","Walker leg extenders set of4",null,33.36,null,33.36,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0181","NU","Press pad alternating w/ pum",null,282.37,null,282.37,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0183","NU","Press underlay alter w/pump",null,282.37,null,282.37,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0190",null,"Positioning cushion",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E0197","RR","Air pressure pad for mattres",null,33.06,null,33.06,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0221",null,"Infrared heating pad system",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E0231","RR","Wound warming device",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["E0250","NU","Hosp bed fixed ht w/ mattres",null,953.8,null,953.8,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E0256","RR","Hospital bed var ht w/o matt",null,88.72,null,88.72,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E0272","NU","Mattress foam rubber",null,206.41,null,206.41,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0274","NU","Over-bed table",null,134.24,null,134.24,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0293","NU","Hosp bed var ht no sr no mat",null,789.06,null,789.06,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["E0296","RR","Hosp bed total elect w/ matt",null,166.88,null,166.88,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["E0305","NU","Rails bed side half length",null,176.81,null,176.81,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["E0316","RR","Bed safety enclosure",null,242.41,null,242.41,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0373","NU","Nonpowered pressure mattress",null,4929.25,null,4929.25,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0425",null,"Gas system stationary compre",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E0455","RR","Oxygen tent excl croup/ped t",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-PHL"]
["E0459","NU","Chest wrap",null,258.14999999999998,null,258.14999999999998,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["E0471","NU","Rad w/backup non inv intrfc",null,5611.02,null,5611.02,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E0481","RR","Intrpulmnry percuss vent sys",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["E0493",null,"Oral dv/app neuromus mouthpi",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E0555","NU","Humidifier for use w/ regula",null,5.16,null,5.16,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["E0585","RR","Nebulizer w/ compressor & he",null,39.299999999999997,null,39.299999999999997,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0601","NU","Cont airway pressure device",null,939.38,null,939.38,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E0619",null,"Apnea monitor w recorder",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E0621","NU","Patient lift sling or seat",null,121.3,null,121.3,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0629","RR","Seat lift mech, non-electric",null,39.92,null,39.92,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["E0640","NU","Fixed patient lift system",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["E0655","RR","Pneumatic appliance half arm",null,15.04,null,15.04,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0665","NU","Pneumatic appliance full arm",null,175.68,null,175.68,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0671","NU","Pressure pneum appl full leg",null,575.23,null,575.23,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0672","RR","Pressure pneum appl full arm",null,44.73,null,44.73,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0700","NU","Safety equipment",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["E0710","NU","Restraints any type",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["E0744",null,"Neuromuscular stim for scoli",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E0749","NU","Elec osteogen stim implanted",null,3847.87,null,3847.87,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC"]
["E0769",null,"Electric wound treatment dev",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E0780","NU","Mech amb infusion pump <8hrs",null,14.36,null,14.36,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0791","NU","Parenteral infusion pump sta",null,3952.61,null,3952.61,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0830","RR","Ambulatory traction device",null,57.69,null,57.69,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0890","NU","Traction frame attach pelvic",null,166.74,null,166.74,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0910","NU","Trapeze bar attached to bed",null,184.12,null,184.12,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0920","RR","Fracture frame attached to b",null,59.07,null,59.07,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0947","RR","Fracture frame attachmnts pe",null,86.58,null,86.58,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0956","NU","W/c lateral trunk/hip suppor",null,108.18,null,108.18,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0959","RR","Amputee adapter",null,5.94,null,5.94,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0969","RR","Wheelchair narrowing device",null,21.48,null,21.48,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0974","NU","W/ch access anti-rollback",null,101.67,null,101.67,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E0983","NU","Add pwr joystick",null,3461.35,null,3461.35,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E0986","NU","Man w/c push-rim powr system",null,6736.76,null,6736.76,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E0994","NU","Wheelchair arm rest",null,24.42,null,24.42,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E1006","NU","Pwr seat combo w/o shear",null,7705.68,null,7705.68,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E1014",null,"Reclining back add ped w/c",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E1028","NU","W/c manual swingaway",null,210.11,null,210.11,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E1039","NU","Transport chair pt wt >300lb",null,449.65,null,449.65,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E1070","RR","Wheelchair detachable foot r",null,151.69999999999999,null,151.69999999999999,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E1088","RR","Wheelchair lightweight det a",null,208.81,null,208.81,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E1090","NU","Wheelchair lightweight det a",null,2581.5100000000002,null,2581.5100000000002,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E1100","RR","Whchr s-recl fxd arm leg res",null,143.75,null,143.75,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E1161","RR","Manual adult wc w tiltinspac",null,327.67,null,327.67,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["E1195","RR","Wheelchair amputee heavy dut",null,173.97,null,173.97,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["E1221","NU","Wheelchair spec size w foot",null,572.55999999999995,null,572.55999999999995,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["E1229",null,"Pediatric wheelchair nos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E1236",null,"Folding ped wc adjustable",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E1280","NU","Whchr h-duty det arm leg res",null,1797.97,null,1797.97,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E1285","RR","Wheelchair heavy duty fixed",null,153.86000000000001,null,153.86000000000001,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E1297","NU","Wheelchair special seat dept",null,144.87,null,144.87,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E1357","RR","Battery charger, port conc",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-PHL"]
["E1406","RR","O2/water vapor enrich w/o he",null,186.44,null,186.44,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["E1580","RR","Unipuncture control system",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["E1634","NU","Peritoneal dialysis clamp",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["E1700","RR","Jaw motion rehab system",null,40.6,null,40.6,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E1816","RR","Sps ankle device",null,188.69,null,188.69,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E1821","NU","Replacement interface spsd",null,145.74,null,145.74,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E1905",null,"Vr cbt therapy",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E2201","RR","Man w/ch acc seat w>=20\"<24\"",null,45.6,null,45.6,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2206","RR","Man wc whl lock comp repl ea",null,5.25,null,5.25,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2215","NU","Pneumatic caster tire tube",null,13.07,null,13.07,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2227","RR","Gear reduction drive wheel",null,259.08999999999997,null,259.08999999999997,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2291",null,"Planar back for ped size wc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["E2312","NU","Mini-prop remote joystick",null,2792.77,null,2792.77,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2324","NU","Chin cup interface",null,52.3,null,52.3,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2324","RR","Chin cup interface",null,5.21,null,5.21,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2330","RR","Head control proximity switc",null,408.47,null,408.47,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2342","NU","W/c dpth 20-21 in seat frame",null,620.42999999999995,null,620.42999999999995,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2362","NU","Gr24 nonsealed leadacid",null,127.39,null,127.39,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2368","NU","Pwr wc drivewheel motor repl",null,570.84,null,570.84,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2372","NU","Gr27 non-sealed leadacid",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["E2377","RR","Expandable controller, initl",null,56.6,null,56.6,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2385","NU","Tube, pneumatic caster tire",null,55.78,null,55.78,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2386","RR","Foam filled drive wheel tire",null,15.56,null,15.56,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2392","RR","Solid caster tire, integrate",null,5.94,null,5.94,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2397","NU","Pwc acc, lith-based battery",null,572.44000000000005,null,572.44000000000005,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2506","RR","Sgd prerec msg > 40 min",null,320.31,null,320.31,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2602","NU","Gen w/c cushion wdth >=22 in",null,125.2,null,125.2,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2613","NU","Position back cush wd <22in",null,433.13,null,433.13,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2623","NU","Adj skin pro wc cus wd>=22in",null,487.58,null,487.58,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2630","NU","Monosuspension arm/hand supp",null,881.38,null,881.38,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["E2633","NU","Mobile arm support supinator",null,189.75,null,189.75,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["G0018",null,"Crisis psychotherapy add 30m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0030",null,"Pt scr tob & cess int",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0039",null,"Pt no ref, rn spec",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0050",null,"Pt w/ lmted life expec",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0063",null,"Cardiology ss",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0079",null,"Care manag h vst new pt 60 m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0086",null,"Care man home care plan 30 m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0089",null,"Adm subq drug 1st home visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0109",null,"Diab manage trn ind/group",null,29.39,null,29.39,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
["G0122",26,"Colon ca scrn; barium enema",null,85.77,null,85.77,null,0,0,0,0,1,9,9,9,9,9,null,"R",null,"Y-CM"]
["G0137",null,"Inten outpt svs,min 9 pr 7 d",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0146",null,"Nav srv peer sup add 30 pr m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0162",null,"Hhc rn e&m plan svs, 15 min",null,47.06,null,47.06,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["G0202",26,"Scr mammo bi incl cad",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0206",26,"Dx mammo incl cad uni",null,79.41,null,79.41,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["G0219","TC","Pet img wholbod melano nonco",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,9,9,9,9,9,null,"X"]
["G0255",null,"Current percep threshold tst",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,9,9,9,9,9,null,"X"]
["G0259",null,"Inject for sacroiliac joint",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["G0281",null,"Elec stim unattend for press",null,21.59,null,21.59,null,0,0,0,0,7,5,0,0,0,0,null,"R",null,"Y-CM"]
["G0295",null,"Electromagnetic therapy onc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0320",null,"Two-way audio and video hhs",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0341",null,"Percutaneous islet celltrans",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,1,0,null,"X"]
["G0380",null,"Lev 1 hosp type b ed visit",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["G0397",null,"Alcohol/subs interv >30 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0411",null,"Inter active grp psych parti",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["G0414",null,"Pelvic ring fx treat int fix",null,1849.78,null,1849.78,null,0,0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
["G0428",null,"Collagen meniscus implant",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0438",null,"Ppps, initial visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0454",null,"Md document visit by npp",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0468",null,"Fqhc visit, ippe or awv",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0482",null,"Drug test def 15-21 classes",null,281.22000000000003,null,281.22000000000003,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-ONC"]
["G0492",null,"Md/oth eval acut kid no esrd",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0512",null,"Cocm by rhc/fqhc 60 min mo",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,9,9,9,9,9,null,"X"]
["G0516",null,"Insert drug del implant, >=4",null,372.48,null,176.34,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-ONC"]
["G1004",null,"Cdsm ndsc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G1014",null,"Cdsm inveniqa",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2002",null,"Post-d/c h vst new pt 30 m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G2006",null,"Post-d/c h vst ext pt 20 m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G2022",null,"Benef refuses service, mod",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2069",null,"Med assist tx inject",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2087",null,"Off base opioid tx, 60 m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G2091",null,"Pt 66+ frailty and adv ill",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2107",null,"Pt 66+ frailty and adv ill",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2122",null,"Psy/dep/anx/apandicd noasse",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2143",null,"Fs odi 9-15mo > 22",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2150",null,"No mpm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2178",null,"Pt not elig low neuro ex",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2181",null,"Bmi not doc medrsn ptref",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2197",null,"Screen hlthy etoh use",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2202",null,"No rsn no brief couns",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G3002",null,"Brief chkin by md/qhp, 11-21",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G4001",null,"Diagnostic rad ss",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G4013",null,"Mentl/behav health ss",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G4020",null,"Ophthalmology ss",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G4032",null,"Rheumatology ss",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G4035",null,"Thoracic surgery ss",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G6009",null,"Radiation treatment delivery",null,337.09,null,337.09,null,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM"]
["G6013",null,"Radiation treatment delivery",null,446.85,null,446.85,null,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM"]
["G8416",null,"Pt inelig footwear evaluatio",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8419",null,"Calc bmi out nrm param nof/u",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8465",null,"High risk recurrence pro ca",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8482",null,"Flu immunize order/admin",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8559",null,"Pt ref doc oto eval",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8566",null,"Pt inelig ref oto eval",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8602",null,"No tpa init w/in 3 hrs",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8647",null,"Rafscrs ki scor >= 0",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8667",null,"Rafscrs ewh scor >= 0",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8694",null,"Lvef <40%",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8733",null,"Doc pos elder mal scrn plan",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8755",null,"Dias bp > or = 90",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8833",null,"Pt not disch home day#2 evar",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8843",null,"Doc reas no ahi or rdi",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8863",null,"No assess bone loss",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8866",null,"Doc pt reas no pneumococcal",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8913",null,"Pt doc no wrong event",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8916",null,"Pt w iv ab given on time",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8950",null,"Pre-htn or htn doc, f/u indc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8958",null,"Assess vol mgmt not doc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9008",null,"Mccd,phys coor-care ovrsght",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["G9016",null,"Demo-smoking cessation coun",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9061",null,"Onc prac cond noadd by guide",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9064",null,"Onc dx nsclc stg2 no progres",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9083",null,"Onc dx prostate unknwn nos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9086",null,"Onc dx colon t1-4 no dx prog",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9099",null,"Onc dx esophageal unknown",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9106",null,"Onc dx pancreatc p r1/r2 no",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9123",null,"Onc dx cml chronic phase",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9131",null,"Onc dx brst unknown nos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9156",null,"Evaluation for wheelchair",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9188",null,"Beta not given no reason",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9242",null,"Doc viral load >=200",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9274",null,"Bp out of nrml limits",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9281",null,"Pne scrn done doc not ind",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9293",null,"No pt category on report",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9310",null,"Unplnd hosp readm in 30d",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9317",null,"No doc comm risk calc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9353",null,"Medrsn >1 sinus ct w 90d dx",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9357",null,"Pp eval/edu perf",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9402",null,"Recd f/u w/in 30d disch",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9405",null,"Recd f/u w/in 7d dc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9412",null,"Admit w/in 180d req surg rev",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9424",null,"Site no lung or lung cx",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9456",null,"Doc med pt reas no hcc scrn",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9459",null,"Tob non-user",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9502",null,"Med reas no perf foot exam",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9507",null,"Doc reas on statin or contra",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9529",null,"Minor blunt trauma w/head ct",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9533",null,"Indic for head ct not valid",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9544",null,"No filt remov w/in 3mos plcm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9580",null,"Door to punc time <2hrs",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9608",null,"Intraop cyst eval not done",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9625",null,"Pt bl srg 30 day pst srg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9646",null,"Pt w/90d mrs 0-2",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9658",null,"Toc tool incl elem not used",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9687",null,"Hospice anytime msmt per",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9690",null,"Pt in hos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9698",null,"Sys rsn no presc bronchdil",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9708",null,"Bilat mast/hx bi /unilat mas",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9727",null,"Pt unable cmplt knee fs prom",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9734",null,"Refused to participate",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9754",null,"Incid pulm nodule",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9762",null,"Pt had >= 2-3 hpv vaccines",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9775",null,"Recd 2 anti-emet pre/intraop",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9779",null,"Pts breastfeeding",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9790",null,"Most rct bp >/= 140/90",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9807",null,"Pt no recd cerv cyto/hpv",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9822",null,"Endo abl proc yr prev ind dt",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9844",null,"Pt no recd anti-egfr ther",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9876",null,"2 em core ms mo 7-9 no wl",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9884",null,"2 em ongoing ms mo 19-21 wl",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9894",null,"Adr dep thrpy prescribed",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9901",null,"Pt 66+ snp or ltc pos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9911",null,"Node neg pre/post syst ther",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9923",null,"Safty cncrns scrn and neg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9938",null,"Pt 66+ snp or ltc pos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9959",null,"Systemic antimicro not presc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9976",null,"DOC HAT RSN NO MAC EXM PERF ",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G9996",null,"Doc pt pal or hospice",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H0007",null,"Alcohol and/or drug services",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["H0010",null,"Alcohol and/or drug services",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["H0017",null,"Alcohol and/or drug services",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["H0029",null,"Alcohol and/or drug preventi",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H0036",null,"Comm psy face-face per 15min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H0048",null,"Spec coll non-blood:a/d test",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["H1010",null,"Nonmed family planning ed",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H2016",null,"Comp comm supp svc, per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H2028",null,"Sex offend tx svc, 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H2035",null,"A/d tx program, per hour",null,"Facility Only",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-CM"]
["H2038",null,"Skill train and dev/diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0135",null,"Adalimumab injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0174",null,"Inj, lecanemab-irmb, 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0215",null,"Alefacept",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0224",null,"Inj. lumasiran, 0.5 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0278",null,"Amikacin sulfate injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0330",null,"Succinycholine chloride inj",null,0.6,null,0.6,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0380",null,"Inj metaraminol bitartrate",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0395",null,"Arbutamine hcl injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0476",null,"Baclofen intrathecal trial",null,37.44,null,37.44,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0565",null,"Inj, bezlotoxumab, 10 mg",null,39.86,null,39.86,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J0585",null,"Injection,onabotulinumtoxina",null,6.33,null,6.33,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J0593",null,"Inj., lanadelumab-flyo, 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0620",null,"Calcium glycer & lact/10 ml",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0670",null,"Inj mepivacaine hcl/10 ml",null,3.29,null,3.29,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0695",null,"Inj ceftolozane tazobactam",null,7.37,null,7.37,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0702",null,"Betamethasone acet&sod phosp",null,6.82,null,6.82,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0720",null,"Chloramphenicol sodium injec",null,40.270000000000003,null,40.270000000000003,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0741",null,"Inj, cabote rilpivir 2mg 3mg",null,22.6,null,22.6,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0799",null,"Hiv prep, fda approved, noc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0873",null,"Inj, daptomycin (xellia)",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["J0888",null,"Epoetin beta non esrd",null,1.62,null,1.62,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0945",null,"Brompheniramine maleate inj",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1097",null,"Phenylep ketorolac opth soln",null,116.25,null,116.25,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1120",null,"Acetazolamid sodium injectio",null,28.12,null,28.12,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1205",null,"Chlorothiazide sodium inj",null,121.35,null,121.35,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1265",null,"Dopamine injection",null,0.77,null,0.77,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1322",null,"Elosulfase alfa, injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1364",null,"Erythro lactobionate /500 mg",null,80.78,null,80.78,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1435",null,"Injection estrone per 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1443",null,"Inj ferric pyrophosphate cit",null,0.03,null,0.03,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J1457",null,"Gallium nitrate injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1460",null,"Gamma globulin 1 cc inj",null,50.73,null,50.73,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1572",null,"Flebogamma injection",null,56.12,null,56.12,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J1575",null,"Hyqvia 100mg immuneglobulin",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1627",null,"Inj, granisetron, xr, 0.1 mg",null,5.67,null,5.67,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1642",null,"Inj heparin sodium per 10 u",null,0.02,null,0.02,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1730",null,"Diazoxide injection",null,112.16,null,112.16,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1786",null,"Imuglucerase injection",null,44.02,null,44.02,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1812",null,"Inj. insulin (fiasp)",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC"]
["J1815",null,"Insulin injection",null,0.9,null,0.9,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1940",null,"Furosemide injection",null,0.56999999999999995,null,0.56999999999999995,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1944",null,"Aripirazole lauroxil 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2060",null,"Lorazepam injection",null,1.1200000000000001,null,1.1200000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2175",null,"Meperidine hydrochl /100 mg",null,7.3,null,7.3,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2260",null,"Inj milrinone lactate / 5 mg",null,1.56,null,1.56,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2311",null,"Inj, naloxone hcl (zimhi)",null,5.76,null,5.76,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J2329",null,"Inj ublituximab-xiiy, 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2354",null,"Octreotide inj, non-depot",null,1.19,null,1.19,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J2410",null,"Oxymorphone hcl injection",null,2.85,null,2.85,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2427",null,"Inj, invega hafyera/trinza",null,12.29,null,12.29,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["J2513",null,"Pentastarch 10% solution",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2560",null,"Phenobarbital sodium inj",null,31.43,null,31.43,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2690",null,"Procainamide hcl injection",null,146.32,null,146.32,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2730",null,"Pralidoxime chloride inj",null,86.7,null,86.7,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2786",null,"Injection, reslizumab, 1mg",null,10.17,null,10.17,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J2794",null,"Inj risperdal consta, 0.5 mg",null,12.15,null,12.15,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2860",null,"Injection, siltuximab",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2919",null,"Inj, methylpred sod succ 5mg",null,0.27,null,0.27,null,0,0,0,0,0,0,0,0,0,0,null,"D"]
["J3032",null,"Inj. eptinezumab-jjmr 1 mg",null,18.059999999999999,null,18.059999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["J3105",null,"Terbutaline sulfate inj",null,7.79,null,7.79,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J3250",null,"Trimethobenzamide hcl inj",null,47.84,null,47.84,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J3300",null,"Triamcinolone a inj prs-free",null,4.1900000000000004,null,4.1900000000000004,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J3357",null,"Ustekinumab sub cu inj, 1 mg",null,153.96,null,153.96,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J3365",null,"Urokinase 250,000 iu inj",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J3424",null,"Inj hydroxocobalamin iv 25mg",null,"Facility Only",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["J3465",null,"Injection, voriconazole",null,1.1599999999999999,null,1.1599999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J3591",null,"Esrd on dialysi drug/bio noc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7042",null,"5% dextrose/normal saline",null,1.59,null,1.59,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J7170",null,"Inj., emicizumab-kxwh 0.5 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7189",null,"Factor viia",null,2.4300000000000002,null,2.4300000000000002,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J7196",null,"Antithrombin recombinant",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["J7199",null,"Hemophilia clot factor noc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["J7295",null,"Eth estr and eton monthly",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7298",null,"Mirena, 52 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7320",null,"Genvisc 850, inj, 1mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM"]
["J7323",null,"Euflexxa inj per dose",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM"]
["J7345",null,"Aminolevulinic acid, 10% gel",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7501",null,"Azathioprine parenteral",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7515",null,"Cyclosporine oral 25 mg",null,0.84,null,0.84,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J7518",null,"Mycophenolic acid",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7614",null,"Levalbuterol non-comp unit",null,0.05,null,0.05,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J7622",null,"Beclomethasone comp unit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7637",null,"Dexamethasone comp con",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7645",null,"Ipratropium bromide comp",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7669",null,"Metaproterenol non-comp unit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7682",null,"Tobramycin non-comp unit",null,21.79,null,21.79,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J8515",null,"Cabergoline, oral 0.25mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J8565",null,"Gefitinib oral",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9017",null,"Arsenic trioxide injection",null,15.78,null,15.78,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9021",null,"Inj, aspara, rylaze, 0.1 mg",null,50.96,null,50.96,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9045",null,"Carboplatin injection",null,3.6,null,3.6,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9048",null,"Inj, bortezomib freseniuskab",null,2.68,null,2.68,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9063",null,"Inj, elahere, 1 mg",null,66.790000000000006,null,66.790000000000006,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["J9075",null,"Inj, cyclophosphamide, nos",null,"Facility Only",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"O"]
["J9155",null,"Degarelix injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9178",null,"Inj, epirubicin hcl, 2 mg",null,1.38,null,1.38,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9202",null,"Goserelin acetate implant",null,609.01,null,609.01,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9209",null,"Mesna injection",null,1.37,null,1.37,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9229",null,"Inj inotuzumab ozogam 0.1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9246",null,"Inj., evomela, 1 mg",null,16.489999999999998,null,16.489999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["J9259",null,"Paclitaxel (american regent)",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC"]
["J9272",null,"Inj, dostarlimab-gxly, 10 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9299",null,"Injection, nivolumab",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9311",null,"Inj rituximab, hyaluronidase",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9322",null,"Inj pemetrexed (bluepoint)",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC"]
["J9325",null,"Inj talimogene laherparepvec",null,66.59,null,66.59,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9354",null,"Inj, ado-trastuzumab emt 1mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9357",null,"Valrubicin injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM"]
["J9380",null,"Inj teclistamab cqyv 0.5 mg",null,31.4,null,31.4,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["K0005","RR","Ultralightweight wheelchair",null,256.01,null,256.01,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0008","RR","Cstm manual wheelchair/base",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["K0012","NU","Ltwt portbl power whlchr",null,4499.8,null,4499.8,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0018","RR","Detach adjust armrst upper",null,3.3,null,3.3,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["K0020","NU","Fixed adjust armrest pair",null,55.46,null,55.46,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["K0044","NU","Ftrst upr hanger brac rep ea",null,19.86,null,19.86,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["K0045","RR","Ftrst compl assembly repl ea",null,6.78,null,6.78,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["K0052","NU","Swingaway detach ftrest repl",null,100.84,null,100.84,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["K0073","NU","Caster pin lock each",null,46.95,null,46.95,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["K0552","NU","Sup/ext non-ins inf pump syr",null,2.95,null,2.95,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["K0607",null,"Repl batt for aed",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["K0744","NU","Absorp drg <= 16 suc pump",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
["K0807","NU","Pov group 2 hd 301-450 lbs",null,2716.6,null,2716.6,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0820","RR","Pwc gp 2 std port seat/back",null,406,null,406,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0825","RR","Pwc gp 2 hd cap chair",null,655.46,null,655.46,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0826","NU","Pwc gp 2 vhd seat/back",null,10337.469999999999,null,10337.469999999999,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0835","NU","Pwc gp2 std sing pow opt s/b",null,5788.14,null,5788.14,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0841","NU","Pwc gp2 std mult pow opt s/b",null,6295.74,null,6295.74,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0848","RR","Pwc gp 3 std seat/back",null,946.18,null,946.18,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0854","RR","Pwc gp 3 xhd seat/back",null,1725.76,null,1725.76,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0858","NU","Pwc gp3 hd sing pow opt s/b",null,12600.72,null,12600.72,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0861","NU","Pwc gp3 std mult pow opt s/b",null,10172.33,null,10172.33,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["K0869","NU","Pwc gp 4 std cap chair",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["K0877","RR","Pwc gp4 std sing pow opt s/b",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["K0886","RR","Pwc gp4 hd mult pow s/b",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["K1030",null,"Ext recharge bat replacement",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["L0130",null,"Flex thermoplastic collar mo",null,263.12,null,263.12,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L0200",null,"Cerv col supp adj bar & thor",null,883.86,null,883.86,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L0464",null,"Tlso 4mod sacro-scap pre",null,2074.0500000000002,null,2074.0500000000002,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L0490",null,"Tlso rigid plastic pre one",null,394.73,null,394.73,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L0621",null,"Sio flex pelvic/sacr pre ots",null,124.71,null,124.71,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L0628",null,"Lso flex no ri stays pre ots",null,95.96,null,95.96,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L0640",null,"Lso s/c shell/panel custom",null,1460.11,null,1460.11,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L0651",null,"Lso sag-co shell pnl pre ots",null,1314.07,null,1314.07,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L0984",null,"Protect body sock ea pre ots",null,91.4,null,91.4,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L1050",null,"Sternal pad",null,137,null,137,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L1110",null,"Ring flange plas/leather mol",null,399.54,null,399.54,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L1300",null,"Body jacket mold to patient",null,2258.09,null,2258.09,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L1499",null,"Spinal orthosis nos",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N","Y"]
["L1652",null,"Ho bi thighcuffs w sprdr bar",null,497.37,null,497.37,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L1810",null,"Ko elastic with joints",null,152.4,null,152.4,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L1833",null,"Ko adj jnt pos r sup pre ots",null,725.83,null,725.83,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L1900",null,"Afo sprng wir drsflx calf bd",null,397.6,null,397.6,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L1951",null,"Afo spiral prefabricated",null,1171.83,null,1171.83,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L2005",null,"Kafo sng/dbl mechanical act",null,5717.66,null,5717.66,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L2060",null,"Hkafo torsion ball bearing j",null,914.34,null,914.34,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L2114",null,"Afo tib fx semi-rigid",null,793.44,null,793.44,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L2134",null,"Kafo fem fx cast semi-rigid",null,1351.99,null,1351.99,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L2220",null,"Dorsi & plantar flex ass/res",null,129.36000000000001,null,129.36000000000001,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L2270",null,"Varus/valgus strap padded/li",null,95.72,null,95.72,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L2375",null,"Torsion ank & half solid sti",null,151.04,null,151.04,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L2500",null,"Thi/glut/ischia wgt bearing",null,452.76,null,452.76,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L2550",null,"Thigh/wght bear high roll cu",null,418.88,null,418.88,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L2650",null,"Pelv & thor control gluteal",null,213.89,null,213.89,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L2760",null,"Extension per extension per",null,82.96,null,82.96,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L2800",null,"Knee cap medial or lateral p",null,163.44,null,163.44,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3010",null,"Foot longitudinal arch suppo",null,243.17,null,243.17,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3070",null,"Arch suprt att to sho longit",null,44.32,null,44.32,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3204",null,"Hightop w/ supp/pronator inf",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["L3219",null,"Orthopedic mens shoes oxford",null,147.21,null,147.21,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3251",null,"Shoe molded to pt silicone s",null,762.7,null,762.7,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3260",null,"Ambulatory surgical boot eac",null,36.340000000000003,null,36.340000000000003,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3400",null,"Shoe metatarsal bar wedge ro",null,56.8,null,56.8,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3430",null,"Sho heel count plast reinfor",null,223.6,null,223.6,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3530",null,"Ortho shoe add half sole",null,44.32,null,44.32,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3595",null,"Ortho shoe add march bar",null,58.54,null,58.54,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3675",null,"So vest canvas/web pre ots",null,222.86,null,222.86,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3740",null,"Cuffs adj lock w/ active con",null,1403.51,null,1403.51,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L3891",null,"Torsion mechanism wrist/elbo",null,291.35000000000002,null,291.35000000000002,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L3919",null,"Ho w/o joints cf",null,343.93,null,343.93,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L3930",null,"Hfo nontorsion jnts pre ots",null,123.88,null,123.88,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L3935",null,"Fo nontorsion joint cf",null,280.52,null,280.52,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L3980",null,"Up ext fx orthos humeral nos",null,404.38,null,404.38,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L4002",null,"Replace strap, any orthosis",null,38.85,null,38.85,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L4205",null,"Ortho dvc repair per 15 min",null,71.36,null,71.36,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L4370",null,"Pneum full leg splnt pre ots",null,336.47,null,336.47,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L5050",null,"Ank symes mold sckt sach ft",null,3996.86,null,3996.86,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5280",null,"Hemipelvect canad sing axis",null,10066.040000000001,null,10066.040000000001,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5410",null,"Postop dsg bk ea add cast ch",null,762.21,null,762.21,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5450",null,"Postop app non-wgt bear dsg",null,654.19000000000005,null,654.19000000000005,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5585",null,"Prep ak ischial open end",null,4280.1000000000004,null,4280.1000000000004,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5613",null,"Ak 4 bar ling w/hydraul swig",null,3633.7,null,3633.7,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5632",null,"Symes type ptb brim design s",null,438.97,null,438.97,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5642",null,"Above knee leather socket",null,1224.8599999999999,null,1224.8599999999999,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5654",null,"Socket insert symes",null,574.45000000000005,null,574.45000000000005,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5676",null,"Bk knee joints single axis p",null,625.92999999999995,null,625.92999999999995,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5683",null,"Initial custom socket insert",null,1914.67,null,1914.67,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L5686",null,"Bk back check",null,94.52,null,94.52,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5702",null,"Replace socket hip",null,7877.96,null,7877.96,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L5712",null,"Knee-shin exo frict swg & st",null,819.9,null,819.9,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5785",null,"Exoskeletal bk ultralt mater",null,920.26,null,920.26,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5816",null,"Endo knee-shin polyc mch sta",null,1260.98,null,1260.98,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5855",null,"Mech hip extension assist",null,610.54999999999995,null,610.54999999999995,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L5960",null,"Endo hip ultra-light materia",null,1519.16,null,1519.16,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5970",null,"Foot external keel sach foot",null,363.7,null,363.7,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L5973",null,"Ank-foot sys dors-plant flex",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["L6000",null,"Part hand thumb rem",null,2626.77,null,2626.77,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L6026",null,"Part hand myo exclu term dev",null,6475.13,null,6475.13,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L6320",null,"Shoulder passive restor cap",null,2533.87,null,2533.87,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L6386",null,"Postop ea cast chg & realign",null,684.45,null,684.45,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L6590",null,"Shdr fair lead cable direct",null,4808.47,null,4808.47,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L6628",null,"Quick disconn hook adapter o",null,857.51,null,857.51,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L6641",null,"Excursion amplifier pulley t",null,254.63,null,254.63,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L6646",null,"Multipo locking shoulder jnt",null,4590.91,null,4590.91,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L6687",null,"Frame typ socket bel elbow/w",null,855.25,null,855.25,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L6690",null,"Frame typ sock interscap-tho",null,1359.39,null,1359.39,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L6707",null,"Term dev mech hook vol close",null,2085.1799999999998,null,2085.1799999999998,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L6715",null,"Term device, multi art digit",null,4595.47,null,4595.47,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L6895",null,"Custom glove for term device",null,919.26,null,919.26,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L6935",null,"Below elbow myoelectronic ct",null,13229.9,null,13229.9,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L7040",null,"Prehensile actuator",null,4465.9799999999996,null,4465.9799999999996,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L7180",null,"Electronic elbow sequential",null,54323.46,null,54323.46,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM"]
["L7403",null,"Add ue prost b/e acrylic",null,536.02,null,536.02,null,0,0,0,0,0,0,0,0,0,0,null,"F","Y"]
["L7499",null,"Upper extremity prosthes nos",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N","Y","Y-CM"]
["L8020",null,"Mastectomy form",null,357.22,null,357.22,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L8046",null,"Partial facial prosthesis",null,3943.06,null,3943.06,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L8330",null,"Truss add to std pad scrotal",null,73.19,null,73.19,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L8435",null,"Pros sock multi ply upper lm",null,41.57,null,41.57,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["L8509",null,"Trach-esoph voice pros md in",null,158.94999999999999,null,158.94999999999999,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC"]
["L8512",null,"Gel cap for trach voice pros",null,3.14,null,3.14,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC"]
["L8615",null,"Coch implant headset replace",null,656.48,null,656.48,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["L8618",null,"Coch implant tran cable repl",null,38.15,null,38.15,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["L8629",null,"Cid transmit coil and cable",null,260.62,null,260.62,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["L8681",null,"Pt prgrm for implt neurostim",null,1599.55,null,1599.55,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC"]
["L8693",null,"Aud osseo dev, abutment",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["L8702",null,"Pow ue rom dev ewhf uprt cus",null,83327.75,null,83327.75,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["M0222",null,"Bebteleovimab injection",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["M0241",null,"CASIRI AND IMDEV REPEAT HM",null,799.77,null,799.77,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["M1004",null,"Doc med rsn no srn tb",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1012",null,"Dc eoc doc med rec",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1038",null,"Pt dx lum sp reg fract",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1041",null,"Pt cr ft inf lm or pt id sl",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1059",null,"Pt no prm nurs hm res in pp",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1107",null,"Docu dx degen neuro",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1119",null,"Oc ni pt dc 1-2 vis",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1128",null,"Oc ni pt 1-2 vis",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1145",null,"Mfn drug add-on, per dose",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["M1148",null,"Pt self dschg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1167",null,"No neck fs prom incap",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1170",null,"No neck fs prom incap",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1182",null,"No neck fs prom incap",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1189",null,"No neck fs prom incap",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1198",null,"No neck fs prom incap",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1209",null,"No neck fs prom incap",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1221",null,"Dre w/o rtnopthy",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1224",null,"Iop dec <20% from base",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1240",null,"Pt no resp best int",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1243",null,"Pt othr thn true heard",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1255",null,"Pts w/ othr rsn vst,+prg tst",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1263",null,"Pts hosp dialysis dt",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1275",null,"Pts hosp exl",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1282",null,"Pt scrn tbco id as non user",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1294",null,"Bp scrn perf rec interval",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1297",null,"Bmi not doc medrsn ptref",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1313",null,"No tob scr/cess int",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1322",null,"Pts 7wk inj, scrn iop =<25",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1324",null,"Pts intravitreal/pci",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1336",null,"Pts eval ini xm 2 wks",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1348",null,"Pt pam incr 6 pt 6-12 mo",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1355",null,"Suicd based cln eval",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1367",null,"Qual care ent disorder mvp",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1370",null,"Rehab support msk care mvp",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["P9010",null,"Whole blood for transfusion",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["P9026",null,"Cryo fib comp path redu each",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["P9037",null,"Plate pheres leukoredu irrad",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["P9051",null,"Blood, l/r, cmv-neg",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["P9073",null,"Platelets pheresis path redu",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q0035",null,"Cardiokymography",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
["Q0114",null,"Fern test",null,13.78,null,13.78,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
["Q0167",null,"Dronabinol 2.5mg oral",null,0.73,null,0.73,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["Q0240",null,"CASIRIVI AND IMDEVI 600MG",null,0.01,null,0.01,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["Q0245",null,"Bamlanivimab and etesevima",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM"]
["Q0481",null,"Microprcsr cu elec vad, rep",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q0493",null,"Emr pwr cbl combo vad, rep",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q0506",null,"Lith-ion batt elec/pneum vad",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q0515",null,"Sermorelin acetate injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q2035",null,"Afluria vacc, 3 yrs & >, im",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q2049",null,"Imported lipodox inj",null,484.5,null,484.5,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["Q4001",null,"Cast sup body cast plaster",null,60.61,null,60.61,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["Q4004",null,"Cast sup shoulder cast fbrgl",null,150.66,null,150.66,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["Q4011",null,"Cast sup sht arm ped plaster",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4023",null,"Cast sup sht arm splnt ped p",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4032",null,"Cast sup lng leg ped fbrgls",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4043",null,"Cast sup lng leg splnt ped p",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4100",null,"Skin substitute, nos",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["Q4107",null,"Graftjacket",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["Q4122",null,"Dermacell, awm, porous sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4125",null,"Arthroflex",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4134",null,"Hmatrix",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4150",null,"Allowrap ds or dry 1 sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4155",null,"Neoxflo or clarixflo 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4167",null,"Truskin, per sq centimeter",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4180",null,"Revita, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4206",null,"Fluid flow or fluid gf 1 cc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4219",null,"Surgigraft dual per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4222",null,"Progenamatrix, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4241",null,"Polycyte, topical only 0.5cc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4247",null,"Amniotext patch, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4254",null,"Novafix dl per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4266",null,"Neostim per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4278",null,"Epieffect, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4285",null,"Nudyn dl or dl mesh pr sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4290",null,"Membrane wrap hydr per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4301",null,"Activate matrix, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4308",null,"Sanopellis, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["Q5010",null,"Hospice home care in hospice",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["Q5113",null,"Inj herzuma 10 mg",null,40.31,null,40.31,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["Q5125",null,"Inj, releuko 1 mcg",null,0.54,null,0.54,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["Q9003",null,"Va chaplain counsel group",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q9955",null,"Inj perflexane lip micros,ml",null,13.25,null,13.25,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["Q9969",null,"Non-heu tc-99m add-on/dose",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["R0075","UR","Transport port x-ray multipl",null,40.090000000000003,null,40.090000000000003,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["R0076",null,"Transport portable ekg",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["S0013",null,"Esketamine, nasal spray",null,11.58,null,11.58,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["S0034",null,"Injection, ofloxacin, 400 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0104",null,"Zidovudine, oral, 100 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0122",null,"Inj menotropins 75 iu",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0157",null,"Becaplermin gel 1%, 0.5 gm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0182",null,"Procarbazine, oral",null,104.08,null,104.08,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["S0197",null,"Prenatal vitamins 30 day",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0207",null,"Paramedicintercep nonhospals",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0271",null,"Home hospice case 30 days",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0310",null,"Hospitalist visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0400",null,"Global eswl kidney",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0515",null,"Scleral lens liquid bandage",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0613",null,"Ann breast exam",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S1016",null,"Non-pvc intravenous administ",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S1040",null,"Cranial remolding orthosis",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S2054",null,"Transplantation of multivisc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S2107",null,"Adoptive immunotherapy",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S2120",null,"Low density lipoprotein(ldl)",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S2230",null,"Implant semi-imp hear",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S2325",null,"Hip core decompression",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S2405",null,"Fetal surg sacrococ teratoma",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S3652",null,"Saliva test, hormone level;",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S3842",null,"Gene test hippel-lindau",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S3900",null,"Surface emg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S4011",null,"Ivf package",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S4020",null,"Ivf canc a aspir case rate",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S4040",null,"Monit store cryo embryo 30 d",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S4993",null,"Contraceptive pills for bc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S5102",null,"Adult day care per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S5130",null,"Homaker service nos per 15m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S5136",null,"Adult companioncare per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S5161",null,"Emer rspns sys serv permonth",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["S5520",null,"Hit picc insert kit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S5523",null,"Hip midline cath insert kit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8032",null,"Low dose ct lung screening",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["S8085",null,"Fluorine-18 fluorodeoxygluco",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8185",null,"Flutter device",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8301",null,"Infect control supplies nos",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["S8415",null,"Supplies for home delivery",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8420",null,"Custom gradient sleev/glov",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8421",null,"Ready gradient sleev/glov",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8422",null,"Custom grad sleeve med",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8423",null,"Custom grad sleeve heavy",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8424",null,"Ready gradient sleeve",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8425",null,"Custom grad glove med",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8426",null,"Custom grad glove heavy",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8427",null,"Ready gradient glove",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8428",null,"Ready gradient gauntlet",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8429",null,"Gradient pressure wrap",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8430",null,"Padding for comprssn bdg",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8431",null,"Compression bandage",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S8450",null,"Splint digit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8451",null,"Splint wrist or ankle",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8452",null,"Splint elbow",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8460",null,"Camisole post-mast",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8490",null,"100 insulin syringes",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8930",null,"Auricular electrostimulation",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8940",null,"Hippotherapy per session",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8948",null,"Low-level laser trmt 15 min",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["S8950",null,"Complex lymphedema therapy,",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8990",null,"Pt or manip for maint",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8999",null,"Resuscitation bag",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9001",null,"Home uterine monitor with or",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9002",null,"Intra-vag motion sens biofk",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["S9007",null,"Ultrafiltration monitor",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9024",null,"Paranasal sinus ultrasound",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9025",null,"Omnicardiogram/cardiointegra",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9034",null,"Eswl for gallstones",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9055",null,"Procuren or other growth fac",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9056",null,"Coma stimulation per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9061",null,"Medical supplies and equipme",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9083",null,"Urgent care center global",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9088",null,"Services provided in urgent",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9090",null,"Vertebral axial decompressio",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9097",null,"Home visit wound care",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9098",null,"Home phototherapy visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9110",null,"Telemonitoring/home per mnth",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9117",null,"Back school visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9122",null,"Home health aide or certifie",null,43,null,43,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["S9123",null,"Nursing care in home rn",null,86.43,null,86.43,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["S9124",null,"Nursing care, in the home; b",null,62.44,null,62.44,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["S9125",null,"Respite care, in the home, p",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9126",null,"Hospice care, in the home, p",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9127",null,"Social work visit, in the ho",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9128",null,"Speech therapy, in the home,",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9129",null,"Occupational therapy, in the",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9131",null,"Pt in the home per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9140",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9141",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9145",null,"Insulin pump initiation",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9150",null,"Evaluation by ocularist",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9152",null,"Speech therapy, re-eval",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9208",null,"Home mgmt preterm labor",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9209",null,"Home mgmt pprom",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9211",null,"Home mgmt gest hypertension",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9212",null,"Hm postpar hyper per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9213",null,"Hm preeclamp per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9214",null,"Hm gest dm per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9325",null,"Hit pain mgmt per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9326",null,"Hit cont pain per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9327",null,"Hit int pain per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9328",null,"Hit pain imp pump diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9329",null,"Hit chemo per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9330",null,"Hit cont chem diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9331",null,"Hit intermit chemo diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9335",null,"Ht hemodialysis diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9336",null,"Hit cont anticoag diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9338",null,"Hit immunotherapy diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9339",null,"Hit periton dialysis diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9340",null,"Hit enteral per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9341",null,"Hit enteral grav diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9342",null,"Hit enteral pump diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9343",null,"Hit enteral bolus nurs",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9345",null,"Hit anti-hemophil diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9346",null,"Hit alpha-1-proteinas diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9347",null,"Hit longterm infusion diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9348",null,"Hit sympathomim diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9349",null,"Hit tocolysis diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9351",null,"Hit cont antiemetic diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9353",null,"Hit cont insulin diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9355",null,"Hit chelation diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9357",null,"Hit enzyme replace diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9359",null,"Hit anti-tnf per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9361",null,"Hit diuretic infus diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9363",null,"Hit anti-spasmotic diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9364",null,"Hit tpn total diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9365",null,"Hit tpn 1 liter diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9366",null,"Hit tpn 2 liter diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9367",null,"Hit tpn 3 liter diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9368",null,"Hit tpn over 3l diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9370",null,"Ht inj antiemetic diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9372",null,"Ht inj anticoag diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9373",null,"Hit hydra total diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9374",null,"Hit hydra 1 liter diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9375",null,"Hit hydra 2 liter diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9376",null,"Hit hydra 3 liter diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9377",null,"Hit hydra over 3l diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9379",null,"Hit noc per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9381",null,"Hit high risk/escort",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9401",null,"Anticoag clinic per session",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9430",null,"Pharmacy comp/disp serv",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9432",null,"Med food non inborn err meta",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9433",null,"Medical food oral 100% nutr",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9434",null,"Mod solid food suppl",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9435",null,"Medical foods for inborn err",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9436",null,"Lamaze class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9437",null,"Childbirth refresher class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9438",null,"Cesarean birth class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9439",null,"Vbac class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9441",null,"Asthma education",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9442",null,"Birthing class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9443",null,"Lactation class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9444",null,"Parenting class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9445",null,"Pt education noc individ",null,46.23,null,46.23,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["S9446",null,"Pt education noc group",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9447",null,"Infant safety class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9449",null,"Weight mgmt class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9451",null,"Exercise class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9452",null,"Nutrition class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9453",null,"Smoking cessation class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9454",null,"Stress mgmt class",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9455",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9460",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9465",null,"Diabetic management program,",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9470",null,"Nutritional counseling, diet",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9472",null,"Cardiac rehabilitation progr",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9473",null,"Pulmonary rehabilitation pro",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9474",null,"Enterostomal therapy by a re",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9475",null,"Ambulatory setting substance",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9476",null,"Vestibular rehab per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9480",null,"Intensive outpatient psychia",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["S9482",null,"Family stabilization 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9484",null,"Crisis intervention per hour",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9485",null,"Crisis intervention mental h",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9490",null,"Hit corticosteroid/diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9494",null,"Hit antibiotic total diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9497",null,"Hit antibiotic q3h diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9500",null,"Hit antibiotic q24h diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9501",null,"Hit antibiotic q12h diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9502",null,"Hit antibiotic q8h diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9503",null,"Hit antibiotic q6h diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9504",null,"Hit antibiotic q4h diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9529",null,"Venipuncture home/snf",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9537",null,"Ht hem horm inj diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9538",null,"Hit blood products diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9542",null,"Ht inj noc per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9558",null,"Ht inj growth horm diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9559",null,"Hit inj interferon diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9560",null,"Ht inj hormone diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9562",null,"Ht inj palivizumab diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9563",null,"Ht inj immuno diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9590",null,"Ht irrigation diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9810",null,"Ht pharm per hour",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9900",null,"Christian sci pract visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9901",null,"Christian sci nurse visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9960",null,"Air ambulanc nonemerg fixed",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9961",null,"Air ambulan nonemerg rotary",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9970",null,"Health club membership yr",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9975",null,"Transplant related per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9976",null,"Lodging per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9977",null,"Meals per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9981",null,"Med record copy admin",null,29.93,null,29.93,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["S9982",null,"Med record copy per page",null,0.59,null,0.59,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["S9986",null,"Not medically necessary svc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9988",null,"Serv part of phase i trial",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9989",null,"Services outside us",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9990",null,"Services provided as part of",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9991",null,"Services provided as part of",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9992",null,"Transportation costs to and",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9994",null,"Lodging costs (e.g. hotel ch",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9996",null,"Meals for clinical trial par",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S9999",null,"Sales tax",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1000",null,"Private duty/independent nsg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1001",null,"Nursing assessment/evaluatn",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1002",null,"Rn services up to 15 minutes",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1003",null,"Lpn/lvn services up to 15min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1004",null,"Nsg aide service up to 15min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1005",null,"Respite care service 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1006",null,"Family/couple counseling",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1007",null,"Treatment plan development",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1009",null,"Child sitting services",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1010",null,"Meals when receive services",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1012",null,"Alcohol/substance abuse skil",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1013",null,"Sign lang/oral interpreter",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1014",null,"Telehealth transmit, per min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1015",null,"Clinic service",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["T1016",null,"Case management",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1017",null,"Targeted case management",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1018",null,"School-based iep ser bundled",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1019",null,"Personal care ser per 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1020",null,"Personal care ser per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1021",null,"Hh aide or cn aide per visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1022",null,"Contracted services per day",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1023",null,"Program intake assessment",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1024",null,"Team evaluation & management",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1025",null,"Ped compr care pkg, per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1026",null,"Ped compr care pkg, per hour",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1027",null,"Family training & counseling",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1028",null,"Home environment assessment",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1029",null,"Dwelling lead investigation",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1030",null,"Rn home care per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1031",null,"Lpn home care per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1032",null,"Sv doula brth wrk per 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1033",null,"Sv doula brth wrk per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1040",null,"Comm bh clinic svc per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1041",null,"Comm bh clinic svc per month",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1502",null,"Medication admin visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1503",null,"Med admin, not oral/inject",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1505",null,"Elec med comp dev, noc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T1999",null,"Noc retail items andsupplies",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2001",null,"N-et; patient attend/escort",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2002",null,"N-et; per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2003",null,"N-et; encounter/trip",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2004",null,"N-et; commerc carrier pass",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2005",null,"N-et; stretcher van",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2007",null,"Non-emer transport wait time",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2010",null,"Pasrr level i",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2011",null,"Pasrr level ii",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2012",null,"Habil ed waiver, per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2013",null,"Habil ed waiver per hour",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2014",null,"Habil prevoc waiver, per d",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2015",null,"Habil prevoc waiver per hr",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2016",null,"Habil res waiver per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2017",null,"Habil res waiver 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2018",null,"Habil sup empl waiver/diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2019",null,"Habil sup empl waiver 15min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2020",null,"Day habil waiver per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2021",null,"Day habil waiver per 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2022",null,"Case management, per month",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2023",null,"Targeted case mgmt per month",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2024",null,"Serv asmnt/care plan waiver",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2025",null,"Waiver service, nos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2026",null,"Special childcare waiver/d",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2027",null,"Spec childcare waiver 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2028",null,"Special supply, nos waiver",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2029",null,"Special med equip, noswaiver",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2030",null,"Assist living waiver/month",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2031",null,"Assist living waiver/diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2032",null,"Res care, nos waiver/month",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2033",null,"Res, nos waiver per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2034",null,"Crisis interven waiver/diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2035",null,"Utility services waiver",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2036",null,"Camp overnite waiver/session",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2037",null,"Camp day waiver/session",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2038",null,"Comm trans waiver/service",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2039",null,"Vehicle mod waiver/service",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2040",null,"Financial mgt waiver/15min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2041",null,"Support broker waiver/15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2042",null,"Hospice routine home care",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2043",null,"Hospice continuous home care",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2044",null,"Hospice respite care",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2045",null,"Hospice general care",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2046",null,"Hospice long term care, r&b",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2047",null,"Hab prevo waiver per 15",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2048",null,"Bh ltc res r&b, per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2049",null,"N-et; stretcher van, mileage",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2050",null,"Financial mgt waiver/diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2051",null,"Support broker waiver/diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T2101",null,"Breast milk proc/store/dist",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T4521",null,"Adult size brief/diaper sm",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4522",null,"Adult size brief/diaper med",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4523",null,"Adult size brief/diaper lg",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4524",null,"Adult size brief/diaper xl",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4525",null,"Adult size pull-on sm",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4526",null,"Adult size pull-on med",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4527",null,"Adult size pull-on lg",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4528",null,"Adult size pull-on xl",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4529",null,"Ped size brief/diaper sm/med",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T4530",null,"Ped size brief/diaper lg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T4531",null,"Ped size pull-on sm/med",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T4532",null,"Ped size pull-on lg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T4533",null,"Youth size brief/diaper",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4534",null,"Youth size pull-on",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4535",null,"Disposable liner/shield/pad",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4536",null,"Reusable pull-on any size",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4537",null,"Reusable underpad bed size",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4538",null,"Diaper serv reusable diaper",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T4539",null,"Reuse diaper/brief any size",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4540",null,"Reusable underpad chair size",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4541",null,"Large disposable underpad",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4542",null,"Small disposable underpad",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4543",null,"Adult disp brief/diap abv xl",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T4544",null,"Adlt disp und/pull on abv xl",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T4545",null,"Incon disposable penile wrap",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["T5001",null,"Position seat spec orth need",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["T5999",null,"Supply, nos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["U0001",null,"2019-ncov diagnostic p",null,50.83,null,50.83,null,0,0,0,0,0,0,0,0,0,0,null,"L",null,"Y-CM"]
["U0002",null,"Covid-19 lab test non-cdc",null,72.599999999999994,null,72.599999999999994,null,0,0,0,0,0,0,0,0,0,0,null,"L",null,"Y-CM"]
["V0028",null,"Travel, vocational services, claimant",null,"State Rate",null,"State Rate",null,0,0,0,0,0,0,0,0,0,0,null,"S"]
["V2020",null,"Vision svcs frames purchases",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2025",null,"Eyeglasses delux frames",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2100",null,"Lens spher single plano 4.00",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2101",null,"Single visn sphere 4.12-7.00",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2102",null,"Singl visn sphere 7.12-20.00",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2103",null,"Spherocylindr 4.00d/12-2.00d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2104",null,"Spherocylindr 4.00d/2.12-4d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2105",null,"Spherocylinder 4.00d/4.25-6d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2106",null,"Spherocylinder 4.00d/>6.00d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2107",null,"Spherocylinder 4.25d/12-2d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2108",null,"Spherocylinder 4.25d/2.12-4d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2109",null,"Spherocylinder 4.25d/4.25-6d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2110",null,"Spherocylinder 4.25d/over 6d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2111",null,"Spherocylindr 7.25d/.25-2.25",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2112",null,"Spherocylindr 7.25d/2.25-4d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2113",null,"Spherocylindr 7.25d/4.25-6d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2114",null,"Spherocylinder over 12.00d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2115",null,"Lens lenticular bifocal",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2118",null,"Lens aniseikonic single",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2121",null,"Lenticular lens, single",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2199",null,"Lens single vision not oth c",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2200",null,"Lens spher bifoc plano 4.00d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2201",null,"Lens sphere bifocal 4.12-7.0",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2202",null,"Lens sphere bifocal 7.12-20.",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2203",null,"Lens sphcyl bifocal 4.00d/.1",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2204",null,"Lens sphcy bifocal 4.00d/2.1",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2205",null,"Lens sphcy bifocal 4.00d/4.2",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2206",null,"Lens sphcy bifocal 4.00d/ove",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2207",null,"Lens sphcy bifocal 4.25-7d/.",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2208",null,"Lens sphcy bifocal 4.25-7/2.",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2209",null,"Lens sphcy bifocal 4.25-7/4.",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2210",null,"Lens sphcy bifocal 4.25-7/ov",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2211",null,"Lens sphcy bifo 7.25-12/.25-",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2212",null,"Lens sphcyl bifo 7.25-12/2.2",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2213",null,"Lens sphcyl bifo 7.25-12/4.2",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2214",null,"Lens sphcyl bifocal over 12.",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2215",null,"Lens lenticular bifocal",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2218",null,"Lens aniseikonic bifocal",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2219",null,"Lens bifocal seg width over",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2220",null,"Lens bifocal add over 3.25d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2221",null,"Lenticular lens, bifocal",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2299",null,"Lens bifocal speciality",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2300",null,"Lens sphere trifocal 4.00d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2301",null,"Lens sphere trifocal 4.12-7.",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2302",null,"Lens sphere trifocal 7.12-20",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2303",null,"Lens sphcy trifocal 4.0/.12-",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2304",null,"Lens sphcy trifocal 4.0/2.25",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2305",null,"Lens sphcy trifocal 4.0/4.25",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2306",null,"Lens sphcyl trifocal 4.00/>6",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2307",null,"Lens sphcy trifocal 4.25-7/.",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2308",null,"Lens sphc trifocal 4.25-7/2.",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2309",null,"Lens sphc trifocal 4.25-7/4.",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2310",null,"Lens sphc trifocal 4.25-7/>6",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2311",null,"Lens sphc trifo 7.25-12/.25-",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2312",null,"Lens sphc trifo 7.25-12/2.25",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2313",null,"Lens sphc trifo 7.25-12/4.25",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2314",null,"Lens sphcyl trifocal over 12",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2315",null,"Lens lenticular trifocal",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2318",null,"Lens aniseikonic trifocal",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2319",null,"Lens trifocal seg width > 28",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2320",null,"Lens trifocal add over 3.25d",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2321",null,"Lenticular lens, trifocal",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2399",null,"Lens trifocal speciality",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2410",null,"Lens variab asphericity sing",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2430",null,"Lens variable asphericity bi",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2499",null,"Variable asphericity lens",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2500",null,"Contact lens pmma spherical",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2501",null,"Cntct lens pmma-toric/prism",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2502",null,"Contact lens pmma bifocal",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2503",null,"Cntct lens pmma color vision",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2510",null,"Cntct gas permeable sphericl",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2511",null,"Cntct toric prism ballast",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2512",null,"Cntct lens gas permbl bifocl",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2513",null,"Contact lens extended wear",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2520",null,"Contact lens hydrophilic",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2521",null,"Cntct lens hydrophilic toric",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2522",null,"Cntct lens hydrophil bifocl",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2523",null,"Cntct lens hydrophil extend",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2524",null,"Cntct lens hydrophil photoch",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2525",null,"Cl, hydrophilic, dual focus",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V2526",null,"Cntct lens blue violet",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V2530",null,"Contact lens gas impermeable",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2531",null,"Contact lens gas permeable",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2599",null,"Contact lens/es other type",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2600",null,"Hand held low vision aids",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2610",null,"Single lens spectacle mount",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2615",null,"Telescop/othr compound lens",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2623",null,"Plastic eye prosth custom",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2624",null,"Polishing artifical eye",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2625",null,"Enlargemnt of eye prosthesis",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2626",null,"Reduction of eye prosthesis",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2627",null,"Scleral cover shell",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2628",null,"Fabrication & fitting",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2629",null,"Prosthetic eye other type",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2630",null,"Anter chamber intraocul lens",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2631",null,"Iris support intraoclr lens",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2632",null,"Post chmbr intraocular lens",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2700",null,"Balance lens",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2702",null,"Deluxe lens feature",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2710",null,"Glass/plastic slab off prism",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2715",null,"Prism lens/es",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2718",null,"Fresnell prism press-on lens",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2730",null,"Special base curve",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2744",null,"Tint photochromatic lens/es",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2745",null,"Tint, any color/solid/grad",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2750",null,"Anti-reflective coating",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2755",null,"Uv lens/es",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2756",null,"Eye glass case",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2760",null,"Scratch resistant coating",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2761",null,"Mirror coating",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2762",null,"Polarization, any lens",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2770",null,"Occluder lens/es",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2780",null,"Oversize lens/es",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2781",null,"Progressive lens per lens",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2782",null,"Lens, 1.54-1.65 p/1.60-1.79g",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2783",null,"Lens, >= 1.66 p/>=1.80 g",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2784",null,"Lens polycarb or equal",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2785",null,"Corneal tissue processing",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2786",null,"Occupational multifocal lens",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2787",null,"Astigmatism-correct function",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V2788",null,"Presbyopia-correct function",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V2790",null,"Amniotic membrane",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2797",null,"Vis item/svc in other code",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V2799",null,"Misc vision item or service",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5008",null,"Hearing screening",null,93.09,null,93.09,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5010",null,"Assessment for hearing aid",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["V5011",null,"Hearing aid fitting/checking",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["V5014",null,"Hearing aid repair/modifying",null,62.07,null,62.07,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5020",null,"Conformity evaluation",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["V5030",null,"Body-worn hearing aid air",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5040",null,"Body-worn hearing aid bone",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5050",null,"Hearing aid monaural in ear",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5060",null,"Behind ear hearing aid",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5070",null,"Glasses air conduction",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5080",null,"Glasses bone conduction",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5090",null,"Hearing aid dispensing fee",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5095",null,"Implant mid ear hearing pros",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5100",null,"Body-worn bilat hearing aid",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5110",null,"Hearing aid dispensing fee",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5120",null,"Body-worn binaur hearing aid",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5130",null,"In ear binaural hearing aid",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5140",null,"Behind ear binaur hearing ai",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5150",null,"Glasses binaural hearing aid",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5160",null,"Dispensing fee binaural",null,1762.64,null,1762.64,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5171",null,"Hearing aid monaural ite",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5172",null,"Hearing aid monaural itc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5181",null,"Hearing aid monaural bte",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5190",null,"Hearing aid monaural glasses",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5200",null,"Disp fee contralateral monau",null,1056.48,null,1056.48,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5211",null,"Hearing aid binaural ite/ite",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5212",null,"Hearing aid binaural ite/itc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5213",null,"Hearing aid binaural ite/bte",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5214",null,"Hearing aid binaural itc/itc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5215",null,"Hearing aid binaural itc/bte",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5221",null,"Hearing aid binaural bte/bte",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5230",null,"Hearing aid binaural glasses",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5240",null,"Disp fee contralateral binau",null,1056.48,null,1056.48,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5241",null,"Dispensing fee, monaural",null,881.32,null,881.32,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5242",null,"Hearing aid, monaural, cic",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5243",null,"Hearing aid, monaural, itc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5244",null,"Hearing aid, prog, mon, cic",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5245",null,"Hearing aid, prog, mon, itc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5246",null,"Hearing aid, prog, mon, ite",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5247",null,"Hearing aid, prog, mon, bte",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5248",null,"Hearing aid, binaural, cic",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5249",null,"Hearing aid, binaural, itc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5250",null,"Hearing aid, prog, bin, cic",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5251",null,"Hearing aid, prog, bin, itc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5252",null,"Hearing aid, prog, bin, ite",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5253",null,"Hearing aid, prog, bin, bte",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5254",null,"Hearing id, digit, mon, cic",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5255",null,"Hearing aid, digit, mon, itc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5256",null,"Hearing aid, digit, mon, ite",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5257",null,"Hearing aid, digit, mon, bte",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5258",null,"Hearing aid, digit, bin, cic",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5259",null,"Hearing aid, digit, bin, itc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5260",null,"Hearing aid, digit, bin, ite",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5261",null,"Hearing aid, digit, bin, bte",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["V5262",null,"Hearing aid, disp, monaural",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5263",null,"Hearing aid, disp, binaural",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5264",null,"Ear mold/insert",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL"]
["V5265",null,"Ear mold/insert, disp",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5266",null,"Battery for hearing device",null,1.0900000000000001,null,1.0900000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["V5267",null,"Hearing aid sup/access/dev",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL"]
["V5268",null,"Ald telephone amplifier",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5269",null,"Alerting device, any type",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5270",null,"Ald, tv amplifier, any type",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5271",null,"Ald, tv caption decoder",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5272",null,"Tdd",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5273",null,"Ald for cochlear implant",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5274",null,"Ald unspecified",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5275",null,"Ear impression",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5281",null,"Ald fm/dm system, monaural",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5282",null,"Ald fm/dm system binaural",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5283",null,"Ald neck, loop ind receiver",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5284",null,"Ald fm/dm ear level receiver",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5285",null,"Ald fm/dm aud input receiver",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5286",null,"Ald blu tooth fm/dm receiver",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5287",null,"Ald fm/dm receiver, nos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5288",null,"Ald fm/dm transmitter ald",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5289",null,"Ald fm/dm adapt/boot couplin",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5290",null,"Ald transmitter microphone",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5298",null,"Hearing aid noc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["V5299",null,"Hearing service",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["V5336",null,"Repair communication device",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V5362",null,"Speech screening",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V5363",null,"Language screening",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["V5364",null,"Dysphagia screening",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]

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["Updates and Corrections"]
["Posting date","Policy Area","Description"]
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["Posting date","Description","Updated Version"]
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["Posting date","Policy Area","Description"]
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["Posting date","Description","Updated Version"]

{"sheet":"Chapters Inclusion","index":4,"n_rows":20797,"n_cols":22,"rows_kept":4500,"cut":true,"hidden":true,"merged":[[0,0,0,8],[1,0,1,8],[4,3,4,4],[4,6,4,14]],"bounds":{"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0}}
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[null,null,null,"DOLLAR VALUE",null,null,"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 Chapters2","MARFS Chapters3","MARFS Chapters","MARFS Chapters"]
["See CPT",58.35,58.35,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,4,null,4]
["See CPT",77.290000000000006,77.290000000000006,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,4,null,4]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,4,null,4]
["See CPT",95.97,77.97,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",251.92,131.36000000000001,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",110.96,89.97,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",578.21,160.15,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",266.31,91.17,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",814.53,194.34,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",445.65,127.76,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT","By Report","By Report",0,0,0,0,0,2,0,0,0,0,null,"N",null,"Y-CM",2,29,null,4]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,29,null,4]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29,null,4]
["See CPT",1211.5999999999999,240.52,0,0,0,0,9,2,9,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,29,null,4]
["See CPT",220.73,94.77,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",240.52,200.93,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",403.07,344.29,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",479.24,197.33,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",651.38,314.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",289.10000000000002,199.13,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",497.83,339.49,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",321.49,220.73,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",245.32,180.54,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",494.24,330.49,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",112.16,49.78,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",51.58,26.99,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1010.06,1010.06,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1368.14,1368.14,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1241.5899999999999,1241.5899999999999,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",481.04,481.04,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",839.72,505.03,10,0.1,0.8,0.1,0,2,2,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",934.49,538.02,0,0,0,0,0,2,2,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1212.8,751.55,0,0,0,0,0,2,2,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",245.92,110.96,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",434.26,278.31,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",577.01,406.66,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",74.38,44.99,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",134.36000000000001,97.77,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",220.73,173.34,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",136.75,27.59,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",157.75,39.590000000000003,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",171.54,51.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",191.34,68.38,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",95.37,39.590000000000003,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",238.12,85.17,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",112.76,46.18,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",295.7,102.57,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",134.96,55.78,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",175.74,144.55000000000001,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",34.19,29.39,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",191.94,61.78,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",230.92,92.97,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",260.31,108.56,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",287.3,128.96,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",199.73,67.180000000000007,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",232.72,88.17,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",262.11,112.76,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",275.31,125.96,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",220.13,82.77,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",259.11,113.96,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",294.5,134.96,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",341.89,174.54,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",244.72,159.55000000000001,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",296.89999999999998,198.53,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",326.29000000000002,216.53,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",374.88,280.11,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",423.46,307.10000000000002,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",597.4,458.85,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",241.12,154.75,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",302.89999999999998,203.93,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",339.49,254.92,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",388.07,293.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",448.05,337.09,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",612.4,494.24,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",274.11,203.33,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",330.49,251.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",366.48,275.91000000000003,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",430.06,334.69,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",532.02,418.66,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",717.36,585.4,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",813.93,487.64,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",988.47,614.20000000000005,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",792.34,465.44,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1001.67,617.79,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",858.91,533.22,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1028.6600000000001,651.38,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",374.28,227.92,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",433.06,275.31,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",463.05,299.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",525.41999999999996,356.28,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",584.80999999999995,391.07,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",837.32,577.01,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",376.07,229.72,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",434.26,276.51,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",478.64,313.10000000000002,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",557.21,385.07,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",632.79,436.65,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",758.15,530.22,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",386.27,236.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",448.65,287.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",506.23,336.49,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",591.4,417.46,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",728.76,515.83000000000004,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",939.29,708.96,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",26.99,13.2,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",62.38,25.19,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",83.97,42.59,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",218.33,97.77,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",61.78,30.59,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",110.36,60.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",304.7,189.54,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",230.92,109.76,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",349.68,203.33,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",542.82000000000005,345.48,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",316.69,174.54,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",668.78,341.29,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",1180.4100000000001,832.52,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",1446.72,1074.24,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",108.56,54.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",131.96,82.77,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",379.07,208.73,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",417.46,239.32,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",115.76,52.18,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",152.94999999999999,94.17,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",202.73,131.96,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",270.51,185.34,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",298.10000000000002,202.13,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",1897.77,1897.77,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1042.45,1042.45,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1029.8599999999999,1029.8599999999999,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2,29,null,4]
["See CPT",187.74,112.76,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",206.33,131.36000000000001,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",262.70999999999998,185.94,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",177.54,80.37,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",214.13,105.56,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",248.32,131.36000000000001,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",330.49,168.54,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",380.87,206.33,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",430.66,256.70999999999998,0,0,0,0,0,2,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",210.53,99.57,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",218.33,103.17,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",266.31,133.16,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",320.89,166.74,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",405.46,226.12,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",272.91000000000003,272.91000000000003,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",307.10000000000002,307.10000000000002,0,0,0,0,0,2,0,2,0,0,null,"R",null,null,2,29,null,4]
["See CPT",566.21,347.88,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",332.89,262.11,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",499.03,281.31,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",575.80999999999995,353.88,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",632.79,379.07,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",732.36,443.25,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",812.13,515.83000000000004,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",909.9,598,10,0.1,0.8,0.1,0,2,0,0,1,0,null,"R",null,null,2,29,null,4]
["See CPT",500.23,268.70999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",586.6,362.28,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",724.56,394.67,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",777.34,505.03,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",938.09,583.01,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1025.06,644.79,10,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,null,2,29,null,4]
["See CPT",536.82000000000005,313.7,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",596.20000000000005,368.88,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",687.37,397.07,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",721.56,403.07,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",946.48,553.62,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1088.6400000000001,707.16,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1135.42,769.54,10,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,null,2,29,null,4]
["See CPT",642.99,368.28,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",749.15,454.65,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",217.13,129.56,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",669.38,427.06,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",801.33,472.64,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",236.32,148.75,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",730.56,443.85,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",884.71,553.62,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",312.5,226.72,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",794.14,509.23,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",930.89,613,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",342.49,245.92,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1461.11,1461.11,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1198.4000000000001,938.09,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1519.89,1208,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1326.76,1056.25,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1629.06,1313.56,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1428.72,1157.6099999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1732.82,1410.73,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1441.32,1233.79,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1871.38,1516.29,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",2021.93,1599.07,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R",null,null,2,29,null,4]
["See CPT",387.47,387.47,0,0,0,0,0,0,0,2,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1248.78,1248.78,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",639.99,396.47,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",128.36000000000001,80.37,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",731.76,469.64,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",212.93,160.15,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",492.44,227.32,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1103.03,851.72,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1617.06,1318.36,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",346.08,199.73,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1541.49,1309.3599999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",204.53,180.54,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1497.7,1276.97,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",277.11,246.52,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",1577.47,1271.58,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",386.27,238.72,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",1346.55,1107.83,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",177.54,160.75,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",1624.86,1399.33,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",175.14,160.75,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",1293.77,1166.01,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",212.33,192.54,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",266.31,248.32,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1471.31,1341.15,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",285.5,265.70999999999998,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",317.29000000000002,289.7,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",1572.68,1244.5899999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",261.51,137.35,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1448.52,1133.6199999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",241.72,124.16,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1745.42,1480.91,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",325.69,193.14,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1876.77,1569.08,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",382.67,245.32,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",289.7,151.75,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",45.58,29.99,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",574.01,350.28,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",151.15,79.17,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",298.10000000000002,168.54,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",59.38,44.39,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",632.79,398.87,0,0,0,0,0,2,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",176.34,99.57,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",1689.04,1341.15,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1647.05,1361.55,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1653.65,1366.34,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1462.31,1199,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",646.58000000000004,401.27,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",701.17,460.65,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",848.72,613,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",877.51,645.38,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1023.86,754.55,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",2678.71,1690.84,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",2089.1,1840.19,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1888.77,1888.77,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",2733.29,2733.29,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29,null,4]
["See CPT",2239.65,2239.65,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29,null,4]
["See CPT",2317.63,2317.63,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29,null,4]
["See CPT",1896.57,1557.68,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1721.43,1721.43,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R",null,null,2,29,null,4]
["See CPT",4159.6099999999997,4159.6099999999997,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R",null,null,2,29,null,4]
["See CPT",4133.82,4133.82,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R",null,null,2,29,null,4]
["See CPT",4117.63,4117.63,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R",null,null,2,29,null,4]
["See CPT",1585.27,1293.17,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",888.3,888.3,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,4]
["See CPT",1252.98,1252.98,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2,29,null,4]
["See CPT",702.37,463.65,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",948.28,634.59,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",385.07,385.07,0,0,0,0,0,0,1,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",686.77,686.77,0,0,0,0,0,2,0,2,1,0,null,"R",null,null,2,29,null,4]
["See CPT",1598.47,1238.5899999999999,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",1010.06,797.73,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",921.29,695.17,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",852.92,666.98,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,4]
["See CPT",434.26,248.92,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT",56.38,29.99,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,1,0,0,null,"X",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,1,0,0,null,"X",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,0,0,0,null,"X",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,0,0,0,null,"X",null,null,2,29,null,4]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT",1094.6400000000001,968.08,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1169.01,1029.8599999999999,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",872.11,747.95,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1172.01,1031.06,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1632.14,1632.14,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,29,null,29]
["See CPT",1403.36,1403.36,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,29,null,29]
["See CPT",1327.08,1327.08,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,29,null,29]
["See CPT",4545.6099999999997,4545.6099999999997,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,29,null,29]
["See CPT","By Report","By Report",0,0,0,0,0,2,1,0,0,0,null,"N",null,"Y-CM",2,29,null,29]
["See CPT",2149.08,2149.08,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1699.83,1699.83,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1621.26,1621.26,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1650.05,1650.05,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1717.23,1717.23,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1476.11,1476.11,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1622.46,1326.76,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1207.4000000000001,1207.4000000000001,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1665.04,1364.55,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1865.38,1865.38,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",3259.91,3259.91,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",4918.3599999999997,4918.3599999999997,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1962.55,1962.55,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,2,1,0,null,"N",null,"Y-CM",2,29,null,29]
["See CPT",103.77,119.96,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",80.37,80.37,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",22.19,22.19,0,0,0,0,5,0,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",30.59,30.59,0,0,0,0,5,0,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",190.14,190.14,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT",1166.01,1166.01,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1479.11,1479.11,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1293.17,1293.17,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1609.26,1609.26,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1817.39,1817.39,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2132.89,2132.89,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1644.65,1644.65,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1901.37,1901.37,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1303.3699999999999,1303.3699999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1716.03,1716.03,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1729.22,1729.22,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1886.97,1886.97,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2946.82,2946.82,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1184.6099999999999,1184.6099999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1667.44,1667.44,90,0.1,0.71,0.19,0,2,0,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1695.63,1695.63,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1866.58,1866.58,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2178.4699999999998,2178.4699999999998,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2159.2800000000002,2159.2800000000002,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report","By Report",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",149.35,82.17,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",162.55000000000001,103.77,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",294.5,203.93,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",368.88,239.92,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",352.08,352.08,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",146.94999999999999,146.94999999999999,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",128.36000000000001,103.77,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",12.6,3.6,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",317.89,182.94,10,0.1,0.8,0.1,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",650.78,515.23,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",844.52,671.18,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1192.4000000000001,978.27,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",217.73,130.16,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",253.72,156.55000000000001,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",166.14,69.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",188.94,131.36000000000001,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",282.51,162.55000000000001,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",338.29,204.53,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",365.88,226.12,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",392.27,241.12,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",444.45,282.51,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",284.31,177.54,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",315.49,194.94,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",357.48,224.33,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",395.87,253.12,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",461.25,308.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",533.82000000000005,371.28,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",267.51,161.94999999999999,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",340.69,218.93,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",388.67,251.92,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",458.25,314.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",519.42999999999995,364.68,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",663.98,494.84,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1286.57,644.79,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",783.34,343.09,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1211,578.21,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",750.95,317.89,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",149.94999999999999,90.57,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","By Report","By Report",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",189.54,75.569999999999993,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",48.58,37.79,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",885.3,584.21,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",308.89999999999998,135.55000000000001,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",941.69,290.89999999999998,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",728.16,145.75,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",939.29,275.31,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",717.36,137.35,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1445.52,320.29000000000002,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1123.43,159.55000000000001,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",279.51,122.96,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",612.4,409.06,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT",913.5,654.38,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",868.51,602.79999999999995,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",968.08,769.54,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1064.6500000000001,849.32,90,0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",283.70999999999998,283.70999999999998,0,0,0,0,0,0,0,1,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",455.25,175.74,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",324.49,88.17,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",488.24,177.54,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",359.28,88.77,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",695.77,149.94999999999999,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",571.01,75.569999999999993,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1202.5999999999999,224.33,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",929.69,112.16,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",291.5,291.5,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1461.11,1461.11,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2007.53,2007.53,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1142.02,1142.02,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1026.26,1026.26,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1193,1193,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1401.73,1401.73,90,0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1407.73,1407.73,90,0.1,0.71,0.19,0,2,1,0,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1554.08,1246.3800000000001,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT",2150.2800000000002,2150.2800000000002,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2850.85,2850.85,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",4945.3500000000004,4945.3500000000004,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",3234.72,3234.72,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",3947.88,3947.88,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",3670.78,3670.78,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1243.3900000000001,1243.3900000000001,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1314.16,1314.16,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1491.7,1491.7,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",512.83000000000004,260.31,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","By Report","By Report",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",1083.8399999999999,1083.8399999999999,10,0.1,0.8,0.1,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1088.04,380.27,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1157.01,466.04,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1057.45,632.19000000000005,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1846.78,1846.78,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",407.86,172.74,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",571.01,280.70999999999998,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",418.06,103.77,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",439.05,157.15,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",717.96,232.12,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",254.92,254.92,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",620.79,620.79,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",719.76,719.76,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",769.54,769.54,10,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",233.32,166.14,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",269.31,64.78,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",412.66,276.51,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",876.31,456.45,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",153.55000000000001,103.17,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",163.75,119.96,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",107.96,70.180000000000007,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",107.36,69.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",98.37,67.180000000000007,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",113.36,76.17,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT",48.58,26.99,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",69.58,40.19,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",100.77,64.78,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",155.94999999999999,82.77,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",103.17,67.180000000000007,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",169.14,94.17,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",121.16,82.77,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",186.54,106.76,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",122.36,74.98,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",481.04,302.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",437.85,311.89999999999998,10,0.1,0.8,0.1,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",427.66,427.66,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",985.47,985.47,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",981.27,981.27,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",907.5,907.5,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1648.25,1648.25,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",222.53,182.94,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",678.97,271.70999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1128.82,779.74,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1101.83,1101.83,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2090.3000000000002,2090.3000000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",836.72,836.72,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",816.93,643.59,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2146.6799999999998,2146.6799999999998,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3432.66,3432.66,0,0,0,0,3,0,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",151.75,151.75,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",115.16,115.16,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",255.51,255.51,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",187.14,187.14,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",269.31,269.31,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",222.53,222.53,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",4993.93,4993.93,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",5921.23,5921.23,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",7130.42,7130.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3738.55,3738.55,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3241.92,3241.92,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3746.35,3746.35,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3326.49,3326.49,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",5070.71,5070.71,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",726.96,328.09,0,0,0,0,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",498.43,498.43,0,0,0,0,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",899.1,899.1,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",901.5,901.5,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",748.55,748.55,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1149.82,922.49,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",942.89,942.89,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,29,null,29]
["See CPT",196.13,196.13,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1352.55,1352.55,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1240.3900000000001,1240.3900000000001,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1350.75,1350.75,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,29,null,29]
["See CPT",296.89999999999998,296.89999999999998,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",325.69,325.69,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",124.16,124.16,0,0,0,0,0,0,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",505.63,163.15,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",4451.12,4451.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",4799.6000000000004,4799.6000000000004,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",5003.53,5003.53,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",4885.97,4885.97,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",4947.1499999999996,4947.1499999999996,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",5176.2700000000004,5176.2700000000004,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",5160.68,5160.68,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",5447.98,5447.98,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",158.35,94.17,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",319.69,319.69,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",107.36,57.58,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT",259.11,259.11,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report","By Report",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",1372.94,1372.94,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",710.16,490.64,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",632.19000000000005,632.19000000000005,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1007.06,749.15,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",968.68,968.68,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1292.57,1292.57,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT",1483.91,1227.79,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1009.46,801.93,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1450.32,1163.6099999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",862.51,673.58,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",725.76,511.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",704.77,488.24,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2411.1999999999998,2074.71,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",872.11,675.97,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1596.07,1596.07,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2209.66,2209.66,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1830.59,1830.59,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2222.86,2222.86,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1844.98,1844.98,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2110.6999999999998,2110.6999999999998,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1605.06,1605.06,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1452.12,1452.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1137.82,1137.82,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",719.76,445.65,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1602.07,1286.57,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",3914.89,3163.35,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2690.1,2128.69,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",3071.58,2402.1999999999998,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2843.05,2205.46,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2658.91,2036.32,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2529.96,1882.77,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2883.24,2176.67,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1269.18,884.11,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2908.43,2330.8200000000002,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2908.43,2330.8200000000002,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report","By Report",90,0.1,0.69,0.21,0,0,0,0,0,0,null,"N",null,null,2,29,null,29]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,1,1,1,null,"N",null,null,2,29,null,29]
["See CPT",1175.6099999999999,666.98,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1628.46,1344.75,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",406.66,80.97,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1252.98,953.08,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1184.6099999999999,984.27,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1393.34,1393.34,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1569.68,1569.68,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4948.3500000000004,1233.19,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",7683.44,1428.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1389.14,1389.14,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1685.44,1685.44,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2006.93,2006.93,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2458.58,2458.58,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2522.16,2522.16,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2598.33,2598.33,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2849.05,2849.05,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2975.61,2975.61,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3128.56,3128.56,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3017.59,3017.59,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3316.89,3316.89,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3570.01,3570.01,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3955.68,3955.68,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4729.42,4729.42,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",5125.8900000000003,5125.8900000000003,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3844.12,3844.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4028.26,4028.26,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2779.47,2779.47,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3100.37,3100.37,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1368.74,1368.74,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3852.52,3852.52,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4187.8,4187.8,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4502.7,4502.7,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2910.23,2910.23,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2265.44,2265.44,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2618.73,2618.73,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2472.98,2472.98,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2639.72,2639.72,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1858.18,1858.18,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1864.18,1864.18,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1787.4,1787.4,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3101.57,1363.95,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1498.3,1132.42,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",3337.89,1404.13,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",7792,1458.71,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1378.94,1378.94,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1390.94,1067.04,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1931.96,1931.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1872.58,1872.58,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3096.17,3096.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1868.98,1868.98,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2288.84,1753.82,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1566.08,1566.08,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2906.03,2906.03,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1830.59,1463.51,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2471.7800000000002,2037.52,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2471.1799999999998,2471.1799999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2281.64,2281.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1906.16,1378.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1556.48,1556.48,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1103.6300000000001,1103.6300000000001,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",753.95,753.95,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",290.89999999999998,109.16,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",410.86,173.94,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",842.72,842.72,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1007.66,1007.66,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1339.95,1339.95,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1199.5999999999999,1199.5999999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",793.54,568.61,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1263.78,1263.78,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1422.73,1422.73,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1396.33,1396.33,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2025.52,2025.52,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2565.94,2565.94,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1514.5,1196,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1912.76,1912.76,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1929.56,1929.56,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2016.53,2016.53,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",849.92,615.99,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1031.6600000000001,753.95,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",983.07,983.07,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1985.94,1985.94,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2342.2199999999998,2342.2199999999998,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1357.95,1357.95,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1279.97,1279.97,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1416.13,1416.13,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1490.5,1490.5,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1849.78,1849.78,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",417.46,324.49,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",968.68,621.39,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1086.8399999999999,1086.8399999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1193.5999999999999,1193.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1662.65,1662.65,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1218.19,1023.86,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1157.01,1157.01,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1470.71,1470.71,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1298.57,1298.57,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1321.96,1321.96,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",3165.74,3165.74,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2585.14,2585.14,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",3726.56,3726.56,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1455.71,1159.4100000000001,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1470.71,1184.6099999999999,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1125.22,911.7,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1458.71,1211,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1406.53,875.11,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2080.11,1764.01,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",909.9,909.9,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3498.03,2005.13,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3721.76,2182.0700000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1473.71,1473.71,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2151.48,2151.48,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",270.51,55.78,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1830.59,1490.5,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1452.72,1452.72,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1347.15,1115.6300000000001,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",924.89,632.79,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",927.89,927.89,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",833.72,833.72,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",506.23,290.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",824.73,824.73,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1343.55,1343.55,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",818.73,574.01,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",980.67,980.67,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1754.42,1754.42,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1053.8499999999999,1053.8499999999999,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2080.11,2080.11,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2786.07,2786.07,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3045.18,3045.18,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2205.46,2205.46,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1120.43,1120.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1273.3800000000001,1273.3800000000001,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",921.89,921.89,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1011.86,1011.86,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2412.4,2412.4,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2183.27,2183.27,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",635.19000000000005,635.19000000000005,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",942.89,942.89,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",993.27,993.27,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1015.46,1015.46,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1832.99,1832.99,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","By Report ","By Report ",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"N",null,"Y-UR",2,29,null,29]
["See CPT","By Report ","By Report ",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"N",null,"Y-UR",2,29,null,29]
["See CPT",1213.4000000000001,1213.4000000000001,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1054.45,1054.45,0,0,0,0,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1272.78,1272.78,0,0,0,0,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1740.02,1740.02,0,0,0,0,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",291.5,287.89999999999998,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1016.06,1016.06,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,"Y-UR",2,29,null,29]
["See CPT",486.44,287.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",933.89,708.96,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",946.48,679.57,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",864.91,864.91,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1218.19,1218.19,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1351.95,1351.95,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1863.58,1863.58,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1791,1791,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1752.02,1752.02,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1750.22,1750.22,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1624.86,1624.86,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1428.12,1428.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",239.92,239.92,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1951.15,1951.15,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2093.3000000000002,2093.3000000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2093.3000000000002,2093.3000000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",250.12,250.12,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4436.12,4436.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4349.75,4349.75,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1046.05,1046.05,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3268.91,3268.91,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2777.67,2777.67,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2777.07,2777.07,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",644.79,644.79,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2964.81,2964.81,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3219.13,3219.13,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2904.83,2904.83,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",638.79,638.79,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",589,561.41,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1686.64,1449.72,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3011.6,3011.6,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3330.69,3330.69,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2709.3,2709.3,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2760.88,2760.88,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2819.66,2819.66,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",499.03,499.03,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",239.32,239.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,9,9,9,9,9,9,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,29,null,29]
["See CPT",3262.31,3262.31,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3033.19,3033.19,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",641.19000000000005,641.19000000000005,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3571.21,3571.21,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3085.97,3085.97,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",703.57,703.57,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2307.4299999999998,2307.4299999999998,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3066.78,3066.78,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2771.08,2771.08,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",576.41,576.41,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3691.77,3691.77,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2903.63,2903.63,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2778.27,2778.27,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2391.4,2391.4,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2353.02,2353.02,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2879.64,2879.64,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",695.17,695.17,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2838.85,2838.85,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",569.21,569.21,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3283.31,3283.31,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",860.71,860.71,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2503.5700000000002,2503.5700000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3847.12,3847.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4409.7299999999996,4409.7299999999996,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3319.29,3319.29,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3656.98,3656.98,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4010.26,4010.26,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3905.9,3905.9,90,0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4497.3,4497.3,90,0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1514.5,1514.5,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,0,2,1,null,"X",null,null,2,null,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,0,2,1,null,"X",null,null,2,null,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,0,2,1,null,"X",null,null,2,null,null,29]
["See CPT",1344.75,1344.75,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,"Y-UR",2,29,null,29]
["See CPT",1355.55,1355.55,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1451.52,1451.52,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1751.42,1751.42,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1289.57,1289.57,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1342.35,1342.35,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1431.12,1431.12,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",640.59,640.59,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2379.41,2379.41,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1356.75,1356.75,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1308.76,1308.76,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",457.65,457.65,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",595,595,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2024.92,2024.92,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2949.82,2949.82,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3184.94,3184.94,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",899.7,899.7,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",592,592,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,2,2,0,null,"X",null,null,2,29,null,29]
["See CPT",4183.6099999999997,4183.6099999999997,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4195,4195,90,0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3742.15,3742.15,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4095.43,4095.43,90,0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1958.35,1958.35,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",430.66,430.66,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",801.33,801.33,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",212.33,212.33,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,1,1,null,"N",null,"Y-UR",2,29,null,29]
["See CPT",1042.45,1042.45,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1221.19,1221.19,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",887.7,620.79,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",810.93,810.93,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,1,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,1,null,"X",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,"Y-UR",2,29,null,29]
["See CPT",1047.25,675.37,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1288.3699999999999,1288.3699999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",831.32,473.84,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",822.33,416.86,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1264.3800000000001,1264.3800000000001,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1338.15,1338.15,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1056.25,1056.25,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,1,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT",1088.6400000000001,696.37,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",777.94,777.94,90,0.1,0.8,0.1,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1284.77,1284.77,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",974.08,616.59,90,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1010.06,1010.06,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",957.28,957.28,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",864.91,864.91,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1202,1202,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",950.08,950.08,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1244.5899999999999,1244.5899999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1108.43,1108.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1325.56,1325.56,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1163.01,1163.01,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1045.45,1045.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1300.3699999999999,1300.3699999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1172.01,1172.01,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1248.78,1248.78,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1486.9,1486.9,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1269.78,1269.78,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1063.45,1063.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1073.6400000000001,1073.6400000000001,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1431.12,1431.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1232.5899999999999,1232.5899999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1261.3800000000001,1261.3800000000001,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1385.54,1385.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1081.44,1081.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1393.34,1393.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",574.01,316.08999999999997,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",891.9,891.9,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1954.15,1954.15,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2327.8200000000002,2327.8200000000002,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",307.7,89.37,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2368.61,2368.61,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2101.1,2101.1,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1799.4,1799.4,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1149.22,1149.22,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1358.55,1358.55,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1522.89,1522.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1582.27,1582.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1305.76,1305.76,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1807.8,1807.8,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1388.54,1388.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1407.73,1407.73,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1747.22,1747.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1818.59,1818.59,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2011.13,2011.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1966.14,1966.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2061.5100000000002,2061.5100000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2078.31,2078.31,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2201.87,2201.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2645.12,2645.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2938.42,2938.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3169.34,3169.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1522.89,1522.89,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1761.61,1761.61,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1596.07,1596.07,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1877.97,1877.97,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",437.25,448.05,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",698.17,645.98,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1346.55,1346.55,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",471.44,467.84,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",773.74,704.17,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1082.04,1082.04,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1175.6099999999999,1175.6099999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",466.64,463.05,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",704.17,628.59,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1073.6400000000001,1073.6400000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1215.19,1215.19,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",459.45,475.04,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",796.53,732.36,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1803,1803,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",653.78,618.99,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",906.9,819.33,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1641.05,1641.05,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2273.84,2273.84,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",531.41999999999996,508.03,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",749.15,680.77,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1458.11,1458.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",647.17999999999995,581.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",779.14,779.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1099.43,1099.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",842.12,770.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1620.06,1620.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1063.45,956.68,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1707.63,1707.63,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",366.48,366.48,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1898.37,1898.37,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2366.81,2366.81,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2539.5500000000002,2539.5500000000002,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2072.91,2072.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",892.5,892.5,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Bundled","Bundled",0,0,0,0,0,2,0,2,1,1,null,"B",null,"Y-UR",2,29,null,29]
["See CPT",678.37,399.47,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",578.80999999999995,304.7,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",970.48,970.48,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",903.3,903.3,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1334.56,1334.56,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",492.44,304.7,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1186.4000000000001,793.54,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",751.55,751.55,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1277.57,1277.57,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1003.47,617.19000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1019.66,1019.66,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",797.73,797.73,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",950.68,950.68,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1157.6099999999999,1157.6099999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",690.97,690.97,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1111.43,1111.43,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1375.34,1375.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1594.87,1594.87,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1004.07,1004.07,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1169.6099999999999,1169.6099999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1219.3900000000001,1219.3900000000001,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",965.08,965.08,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1393.94,1393.94,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1185.8,1185.8,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1295.57,1295.57,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1312.96,1312.96,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1116.23,1116.23,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1183.4100000000001,1183.4100000000001,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2194.0700000000002,2194.0700000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1579.27,1579.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2309.23,2309.23,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1350.75,1350.75,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",416.86,265.11,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1172.01,758.15,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",359.28,119.36,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",849.92,849.92,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1398.13,1398.13,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1090.44,1090.44,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",894.9,894.9,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1451.52,1451.52,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1340.55,1340.55,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1460.51,1460.51,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1158.21,1158.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1121.6300000000001,1121.6300000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1410.73,1410.73,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1440.72,1440.72,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1342.95,1342.95,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2050.7199999999998,2050.7199999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1336.35,1336.35,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2050.7199999999998,2050.7199999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",788.74,788.74,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1001.07,1001.07,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1242.79,1242.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1674.64,1674.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1862.38,1862.38,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1958.95,1958.95,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2657.71,2657.71,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1199.5999999999999,1199.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1270.3800000000001,1270.3800000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2814.26,2814.26,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3228.72,3228.72,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1540.29,1540.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1979.34,1979.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1949.95,1949.95,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2005.13,2005.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1258.98,1258.98,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1740.02,1740.02,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1608.06,1608.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",710.16,651.98,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",974.08,866.11,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1637.45,1637.45,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1591.87,1591.87,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",748.55,683.17,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1193,1089.8399999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1481.51,1481.51,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1721.43,1721.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1917.56,1917.56,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",652.58000000000004,575.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1043.6500000000001,948.28,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1356.15,1356.15,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1372.94,1372.94,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",692.77,614.20000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1071.24,971.08,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1555.88,1555.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1535.49,1535.49,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2005.73,2005.73,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2008.13,2008.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",728.76,656.18,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",910.5,910.5,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1330.96,1330.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1115.03,1115.03,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1267.98,1267.98,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,1,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT",520.63,483.44,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",874.51,783.94,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1236.79,1236.79,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1368.14,1368.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",574.61,523.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",890.1,801.93,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1228.99,1228.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1552.88,1552.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1853.98,1853.98,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1375.34,1375.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1365.14,1365.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1071.24,1071.24,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1437.12,1437.12,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1719.63,1719.63,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2264.25,2264.25,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2074.52,2074.52,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"F",null,"Y-UR",2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,"Y-UR",2,29,null,29]
["See CPT",664.58,664.58,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",666.38,666.38,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1405.33,1405.33,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2454.38,2454.38,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1451.52,1451.52,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2260.0500000000002,2260.0500000000002,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1317.76,1317.76,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",701.77,701.77,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1108.43,1108.43,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1048.45,1048.45,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",486.44,295.7,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",698.17,698.17,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",789.34,789.34,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1002.27,1002.27,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",982.47,594.4,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",974.68,974.68,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT",849.92,849.92,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",667.58,667.58,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",772.54,772.54,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",922.49,922.49,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1167.81,1167.81,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1011.26,1011.26,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",659.78,659.78,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",623.19000000000005,623.19000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",744.35,744.35,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1418.53,1418.53,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1142.02,1142.02,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",730.56,730.56,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",949.48,949.48,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",949.48,949.48,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1121.03,1121.03,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1128.82,1128.82,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",857.71,857.71,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1059.8499999999999,1059.8499999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",941.69,941.69,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",984.87,984.87,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1066.44,1066.44,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1099.43,1099.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",934.49,934.49,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1165.4100000000001,1165.4100000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",821.73,821.73,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",816.93,816.93,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",369.48,131.36000000000001,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",801.33,801.33,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1007.06,1007.06,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1343.55,1343.55,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",834.92,834.92,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1196,1196,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1193.5999999999999,1193.5999999999999,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1408.33,1408.33,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",935.09,935.09,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1054.45,1054.45,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1246.98,1246.98,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1261.3800000000001,1261.3800000000001,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1066.44,1066.44,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",827.12,827.12,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",995.07,995.07,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1294.97,1294.97,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1208.5999999999999,1208.5999999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1169.6099999999999,1169.6099999999999,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1341.15,1341.15,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1432.92,1432.92,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1699.83,1699.83,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1855.78,1855.78,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1575.07,1575.07,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT",1662.65,1662.65,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1263.78,1263.78,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1426.32,1426.32,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1230.79,1230.79,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1701.03,1701.03,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1877.37,1877.37,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1766.41,1766.41,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1432.92,1432.92,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1841.39,1841.39,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1873.18,1873.18,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2080.11,2080.11,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1461.11,1461.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1492.3,1492.3,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1916.96,1916.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1791.6,1791.6,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2149.08,2149.08,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1783.81,1783.81,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2068.71,2068.71,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1369.94,1369.94,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1467.11,1467.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1433.52,1433.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1738.22,1738.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1509.1,1509.1,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1465.91,1465.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1532.49,1532.49,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1345.95,1345.95,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2162.88,2162.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1556.48,1556.48,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1911.56,1911.56,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1160.6099999999999,1160.6099999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1366.94,1366.94,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1343.55,1343.55,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1378.94,1378.94,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1683.64,1683.64,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",560.21,505.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",983.07,885.3,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1260.18,1260.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1106.6300000000001,1040.05,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1479.11,1479.11,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1779.61,1779.61,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",523.03,478.64,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",956.08,878.71,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1178.01,1178.01,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",571.01,508.03,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",999.27,887.7,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1267.98,1267.98,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1685.44,1685.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",667.58,638.19000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1037.6500000000001,975.87,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1262.58,1262.58,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1390.94,1390.94,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1549.88,1549.88,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1960.75,1960.75,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",605.20000000000005,556.61,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",954.28,860.11,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1347.15,1347.15,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",598,554.22,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",905.1,817.53,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1074.8399999999999,1074.8399999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",644.79,595.6,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",934.49,934.49,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1173.21,1173.21,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",863.11,863.11,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1140.82,1140.82,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1015.46,1015.46,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",884.11,793.54,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1187,1187,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1011.86,1011.86,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1371.74,1371.74,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",940.49,940.49,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1188.2,1188.2,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1364.55,1364.55,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1576.87,1576.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1617.06,1617.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1223.5899999999999,1223.5899999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1491.1,1491.1,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1936.75,1936.75,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1340.55,1340.55,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1309.96,1309.96,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1154.02,1154.02,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1279.3699999999999,1279.3699999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2143.69,2143.69,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1368.14,1368.14,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1216.99,1216.99,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1336.95,1336.95,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1624.26,1624.26,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1125.22,1125.22,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1507.3,1507.3,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",659.18,266.91000000000003,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",910.5,347.88,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1050.25,1050.25,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",792.94,792.94,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",926.69,926.69,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1043.6500000000001,1043.6500000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1608.66,1608.66,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1052.05,1052.05,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",606.4,606.4,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",896.1,896.1,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1128.82,558.41,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",488.84,488.84,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",616.59,616.59,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",645.98,645.98,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",762.35,762.35,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",649.58000000000004,649.58000000000004,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",653.78,653.78,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",622.59,622.59,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",782.14,782.14,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1029.26,1029.26,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1047.8499999999999,630.99,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",989.07,989.07,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT",1128.82,1128.82,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1572.68,1572.68,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",484.04,484.04,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",890.7,890.7,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1044.25,1044.25,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",962.68,962.68,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",975.87,975.87,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1176.81,604,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",776.74,776.74,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",856.51,856.51,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1058.6500000000001,1058.6500000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",854.12,854.12,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1136.02,1136.02,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",852.32,852.32,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1068.24,1068.24,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",942.89,942.89,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",931.49,931.49,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",837.32,837.32,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1969.14,1969.14,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1479.71,1479.71,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1182.21,1182.21,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",665.18,665.18,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",694.57,694.57,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",223.73,147.55000000000001,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1423.93,1423.93,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1576.27,1576.27,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1499.5,1499.5,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1672.84,1672.84,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1839.59,1839.59,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1486.3,1486.3,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1728.02,1728.02,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1665.04,1665.04,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1651.25,1651.25,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1883.97,1883.97,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1149.22,1149.22,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1360.35,1360.35,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1606.26,1606.26,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1735.22,1735.22,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1198.4000000000001,1198.4000000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1409.53,1409.53,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",953.08,953.08,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1510.3,1510.3,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1041.25,1041.25,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1091.6400000000001,1091.6400000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1322.56,1322.56,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1269.18,1269.18,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1241.5899999999999,1241.5899999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1874.38,1874.38,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1156.4100000000001,1156.4100000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1321.96,1321.96,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",888.9,888.9,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",882.91,882.91,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",866.11,866.11,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1256.58,1256.58,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1243.3900000000001,1243.3900000000001,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1228.99,1228.99,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1200.8,1200.8,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1251.78,1251.78,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1286.57,1286.57,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1494.1,1494.1,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1649.45,1649.45,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1585.27,1585.27,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1817.39,1817.39,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1583.47,1583.47,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1748.42,1748.42,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1590.07,1590.07,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1707.03,1707.03,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1704.63,1704.63,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2201.87,2201.87,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1643.45,1643.45,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1308.76,1308.76,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1431.72,1431.72,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1288.97,1288.97,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1220.5899999999999,1220.5899999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1408.93,1408.93,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1633.86,1633.86,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1653.65,1653.65,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1300.97,1300.97,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1308.1600000000001,1308.1600000000001,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1024.46,1024.46,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1189.4000000000001,1189.4000000000001,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",831.92,831.92,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1426.32,1426.32,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1327.96,1327.96,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1578.07,1578.07,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1370.54,1370.54,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1394.54,1394.54,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1959.55,1959.55,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1512.1,1512.1,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",3057.78,3057.78,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",6024.39,6024.39,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",5984.2,5984.2,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",6955.88,6955.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2580.34,2580.34,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",6228.92,6228.92,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1211,1211,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1844.39,1844.39,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2570.14,2570.14,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1348.35,1348.35,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1364.55,1364.55,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1755.01,1755.01,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT",939.89,939.89,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1229.5899999999999,1229.5899999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1539.09,1539.09,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",593.20000000000005,564.41,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",646.58000000000004,580.61,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",965.68,965.68,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",918.89,918.89,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1088.6400000000001,1088.6400000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",815.73,739.55,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",839.12,759.95,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",919.49,919.49,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1184.01,1184.01,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",681.37,605.20000000000005,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",894.3,812.13,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",974.08,974.08,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1092.24,1092.24,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1168.4100000000001,1168.4100000000001,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",659.78,605.20000000000005,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",849.32,765.34,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",854.12,854.12,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1085.04,1085.04,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",397.67,373.08,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",666.98,590.20000000000005,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",906.3,906.3,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1124.03,1124.03,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",459.45,433.66,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",723.96,645.98,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1390.34,1390.34,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",370.08,374.88,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",623.19000000000005,530.22,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",813.93,813.93,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",958.48,958.48,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",563.80999999999995,510.43,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",770.74,688.57,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",860.71,860.71,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1037.6500000000001,1037.6500000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1567.88,1567.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1471.31,1471.31,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1572.08,1572.08,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1480.31,1480.31,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1623.66,1623.66,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1393.34,1393.34,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1576.27,1576.27,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1172.01,1172.01,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",183.54,183.54,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1454.52,1454.52,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",409.06,409.06,0,0,0,0,0,0,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1439.52,1439.52,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1339.35,1339.35,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1298.57,1298.57,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,1,1,1,null,"N",null,null,2,29,null,29]
["See CPT",1276.3699999999999,1276.3699999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1332.76,984.27,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1876.77,1876.77,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",734.76,734.76,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1011.26,1011.26,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1125.22,1125.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1340.55,1340.55,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1335.15,1335.15,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1721.43,1721.43,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1633.26,1633.26,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1727.42,1727.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1792.8,1792.8,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2107.6999999999998,2107.6999999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1885.17,1885.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",639.99,367.68,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1312.36,1312.36,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",864.31,864.31,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1347.75,1347.75,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",930.89,672.98,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1131.22,1131.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",771.34,771.34,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1089.24,1089.24,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1286.57,1286.57,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1854.58,1854.58,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",880.51,880.51,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",855.91,855.91,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",985.47,985.47,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1517.49,1517.49,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1915.76,1915.76,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1645.85,1645.85,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1809,1809,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3787.14,3787.14,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",4565.68,4565.68,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",5086.3,5086.3,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3734.95,3734.95,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",944.69,944.69,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",593.20000000000005,318.49,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1137.82,1137.82,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1537.89,1537.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2910.23,2910.23,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",438.45,122.36,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",582.41,147.55000000000001,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",310.7,151.75,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1275.17,1275.17,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1299.77,1299.77,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1546.28,1546.28,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1617.66,1617.66,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1797,1797,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1676.44,1676.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2385.4,2385.4,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2032.72,2032.72,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2081.91,2081.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2350.62,2350.62,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3050.58,3050.58,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3460.25,3460.25,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2673.91,2673.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2775.87,2775.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1659.65,1659.65,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2350.02,2350.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2678.71,2678.71,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2890.44,2890.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3110.56,3110.56,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2563.5500000000002,2563.5500000000002,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2244.4499999999998,2244.4499999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2519.7600000000002,2519.7600000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2144.88,2144.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1239.79,1239.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1709.43,1709.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2058.5100000000002,2058.5100000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1709.43,1709.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1809,1809,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2066.91,2066.91,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1340.55,1340.55,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1841.99,1841.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",249.52,249.52,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",580.01,580.01,0,0,0,0,0,2,0,0,2,0,null,"R",null,null,2,29,null,29]
["See CPT",367.68,372.48,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",983.67,983.67,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1115.6300000000001,1115.6300000000001,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,29,null,29]
["See CPT",1645.85,1645.85,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,29,null,29]
["See CPT",1548.08,1548.08,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,29,null,29]
["See CPT",2117.29,2117.29,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,29,null,29]
["See CPT",786.34,774.94,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1810.8,1810.8,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1948.15,1948.15,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",3015.19,3015.19,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",3420.06,3420.06,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",926.69,908.7,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1332.16,1332.16,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1676.44,1676.44,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2195.27,2195.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",887.1,887.1,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1760.41,1760.41,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2255.85,2255.85,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2253.4499999999998,2253.4499999999998,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",742.55,734.76,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1376.54,1376.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",318.49,318.49,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1384.94,1384.94,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1734.62,1734.62,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2334.42,2334.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",589,437.25,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",665.18,665.18,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2048.92,2048.92,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2825.66,2825.66,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",794.14,794.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1092.24,1092.24,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",838.52,838.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1023.26,1023.26,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2269.64,2269.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",346.08,346.08,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,0,0,null,"X",null,null,2,null,null,29]
["See CPT",1471.91,1471.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2477.17,2477.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1597.87,1597.87,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2921.63,2921.63,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3000.2,3000.2,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2972.01,2972.01,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2303.83,2303.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,1,2,1,1,null,"N",null,"Y-UR",2,29,null,29]
["See CPT",1268.58,949.48,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1197.8,1197.8,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",909.9,909.9,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",650.78,650.78,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",768.94,768.94,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1366.34,1366.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",520.03,326.89,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",771.34,771.34,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1062.25,1062.25,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",986.67,986.67,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",947.68,591.4,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1155.21,1155.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1904.37,1904.37,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",801.93,801.93,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",900.3,900.3,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1211,1211,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1109.03,1109.03,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1284.17,1284.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1427.52,1427.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",776.74,776.74,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1390.94,1390.94,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",714.36,714.36,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",918.29,918.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",993.87,993.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1225.99,1225.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1139.6199999999999,1139.6199999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1380.74,1380.74,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1523.49,1523.49,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",491.24,491.24,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1684.84,1684.84,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",3733.16,3733.16,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",350.28,72.58,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1106.6300000000001,748.55,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1172.01,1172.01,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1530.69,1530.69,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1146.82,1146.82,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1598.47,1598.47,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",852.92,852.92,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1088.6400000000001,1088.6400000000001,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1332.76,1332.76,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",942.89,942.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1225.99,1225.99,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1639.25,1639.25,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1159.4100000000001,1159.4100000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1701.03,1701.03,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1300.3699999999999,1300.3699999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1208.5999999999999,1208.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1264.98,1264.98,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1485.1,1485.1,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1790.4,1790.4,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,"Y-UR",2,29,null,29]
["See CPT",2526.36,2526.36,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1810.8,1810.8,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1528.29,1528.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1398.13,1398.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1382.54,1382.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1395.73,1395.73,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",861.91,861.91,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1321.36,1321.36,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2071.11,2071.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2333.8200000000002,2333.8200000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1384.34,1384.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1505.5,1505.5,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1236.79,1236.79,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1560.08,1560.08,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1483.31,1483.31,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1530.09,1530.09,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1609.86,1609.86,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1516.89,1516.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2303.23,2303.23,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2108.3000000000002,2108.3000000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2347.02,2347.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1537.29,1537.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1864.78,1864.78,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2376.41,2376.41,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1779.61,1779.61,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1741.22,1741.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2290.64,2290.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2182.0700000000002,2182.0700000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2460.38,2460.38,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2176.67,2176.67,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2324.8200000000002,2324.8200000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,0,0,null,"X",null,"Y-UR",2,29,null,29]
["See CPT",2573.14,2573.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3198.13,3198.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2209.06,2209.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2080.71,2080.71,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1036.45,1036.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1087.44,1087.44,90,0.1,0.69,0.21,0,2,1,0,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1231.3900000000001,1231.3900000000001,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1311.76,1311.76,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",992.07,905.7,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",952.48,938.09,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1392.14,1392.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1485.1,1485.1,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2460.98,2460.98,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1777.81,1777.81,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1001.07,945.28,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1269.18,1269.18,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1268.58,1268.58,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1825.79,1825.79,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",2254.0500000000002,2254.0500000000002,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1771.21,1771.21,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",996.27,927.89,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1293.17,1293.17,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1636.25,1636.25,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",637.59,586.6,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1402.33,1402.33,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",604.6,566.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1176.81,1092.8399999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1647.65,1647.65,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",2186.87,2186.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",930.89,862.51,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1512.1,1512.1,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",977.67,893.1,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1193.5999999999999,1193.5999999999999,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1611.06,1611.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1912.16,1912.16,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2170.6799999999998,2170.6799999999998,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",724.56,657.98,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",931.49,931.49,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1653.65,1653.65,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",290.3,290.3,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2718.29,2718.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1405.33,1405.33,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1779.61,1779.61,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1208.5999999999999,1208.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",926.09,926.09,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1288.3699999999999,1288.3699999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1254.18,1254.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,1,2,1,1,null,"N",null,"Y-UR",2,29,null,29]
["See CPT",734.76,734.76,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",822.33,822.33,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",860.11,860.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",987.27,726.96,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",846.92,603.4,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",623.19000000000005,340.69,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",499.03,499.03,10,0.1,0.8,0.1,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1113.23,1113.23,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1202,1202,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1069.44,1069.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",481.04,301.7,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1112.03,777.34,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,1,0,null,"X",null,null,2,29,null,29]
["See CPT",921.29,574.01,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",876.31,876.31,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",841.52,841.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1068.8399999999999,1068.8399999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1154.02,1154.02,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1019.66,671.78,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",756.35,756.35,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1240.99,1240.99,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1082.6400000000001,1082.6400000000001,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1392.14,1392.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1377.74,1377.74,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1540.29,1540.29,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1211.5999999999999,1211.5999999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3223.93,3223.93,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2807.66,2807.66,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1818.59,1818.59,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",403.07,92.97,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1228.3900000000001,1228.3900000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1247.58,1247.58,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1333.96,1333.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",999.27,642.39,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",693.97,693.97,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",883.51,883.51,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",682.57,682.57,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",797.73,797.73,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",926.09,926.09,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1136.6199999999999,1136.6199999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",789.34,789.34,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",950.68,950.68,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1239.79,873.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",993.87,993.87,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",851.12,851.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1191.8,1191.8,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1384.34,1384.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",182.94,182.94,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",911.7,911.7,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1020.86,1020.86,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1184.6099999999999,1184.6099999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1326.76,1326.76,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1774.81,1774.81,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2043.52,2043.52,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1059.25,1059.25,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1390.34,1390.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",767.74,767.74,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2105.9,2105.9,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2035.12,2035.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1978.74,1978.74,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1617.66,1617.66,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1660.85,1660.85,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2295.4299999999998,2295.4299999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2245.0500000000002,2245.0500000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1761.61,1761.61,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1104.83,1104.83,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",860.11,860.11,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1230.79,1230.79,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1321.96,1321.96,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1449.12,1449.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1385.54,1385.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",678.37,627.99,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1023.26,929.09,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1086.8399999999999,1086.8399999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1662.65,1662.65,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1840.19,1840.19,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",651.98,599.20000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",939.89,842.12,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1134.22,1134.22,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",568.01,566.80999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",858.31,858.31,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1351.35,1351.35,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",605.79999999999995,556.01,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",848.12,776.74,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1335.75,1335.75,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",612.4,559.01,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",821.73,738.35,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1206.2,1206.2,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",658.58,596.79999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",914.1,818.13,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1422.13,1422.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",648.98,573.41,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",947.08,838.52,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1630.86,1630.86,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1831.79,1831.79,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",613,591.4,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1038.25,929.09,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1594.87,1594.87,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",2082.5100000000002,2082.5100000000002,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",2454.38,2454.38,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1325.56,1325.56,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",755.75,695.17,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",782.14,782.14,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1415.53,1415.53,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",740.15,740.15,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",930.29,930.29,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1352.55,1352.55,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1463.51,1463.51,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",304.7,304.7,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1860.58,1860.58,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1287.17,1287.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1611.06,1611.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1522.89,1522.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1064.6500000000001,1064.6500000000001,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1054.45,1054.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1178.6099999999999,1178.6099999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1021.46,1021.46,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1157.01,1157.01,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",989.07,989.07,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1152.82,1152.82,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1487.5,1487.5,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",320.89,173.94,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",460.65,255.51,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",700.57,467.84,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1061.05,1061.05,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",804.33,551.22,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",442.65,392.87,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",593.79999999999995,524.23,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1021.46,684.37,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",917.69,613.6,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",871.51,578.80999999999995,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",994.47,671.18,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",894.9,629.79,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",838.52,838.52,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",722.16,489.44,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",902.1,648.38,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",783.94,523.03,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",734.16,479.84,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",692.17,439.65,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",725.16,725.16,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",975.27,674.78,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1083.8399999999999,753.35,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",954.88,641.19000000000005,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",926.09,610,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1009.46,715.56,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",987.87,656.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",878.11,553.62,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",879.31,579.41,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",800.13,514.03,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1152.82,782.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1146.22,1146.22,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",720.96,720.96,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",989.07,663.38,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",791.74,791.74,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",953.08,645.98,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",818.73,542.22,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",874.51,551.82000000000005,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",891.9,593.79999999999995,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",908.7,586.6,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1101.23,801.93,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1997.33,1561.28,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1438.92,1082.04,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1138.42,790.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",990.27,682.57,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1257.78,924.89,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1112.03,820.53,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",899.7,627.99,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",738.95,470.84,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1151.6199999999999,1151.6199999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1058.6500000000001,785.74,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",788.74,523.63,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",764.75,497.23,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",771.34,502.03,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,1,0,null,"X",null,null,2,29,null,29]
["See CPT",455.25,247.12,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",863.11,580.01,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",977.07,681.97,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",931.49,613,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1119.23,797.13,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",915.29,603.4,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1113.83,791.74,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",849.32,572.80999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1011.26,691.57,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",780.94,497.83,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1168.4100000000001,755.15,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",814.53,533.82000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",712.56,454.05,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",776.74,509.83,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1257.18,909.3,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",834.92,550.02,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1106.03,770.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1366.94,1005.86,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2000.93,1560.08,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2552.15,2039.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1625.46,1241.5899999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",917.09,627.39,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",721.56,471.44,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",949.48,644.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1017.26,726.36,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",834.32,557.80999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1138.42,819.33,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1296.17,863.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1291.97,894.9,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1317.16,909.9,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1977.54,1123.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1669.24,958.48,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1927.16,1119.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1575.07,947.68,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1908.56,1109.03,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1208.5999999999999,1208.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1335.15,1335.15,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1550.48,1140.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1251.18,1251.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1149.22,761.75,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1480.91,972.28,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1078.44,728.76,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1673.44,1673.44,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1029.26,680.17,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1029.26,648.38,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",995.07,677.77,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",899.1,610,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1146.22,1146.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1475.51,1077.24,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT",482.24,446.85,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",869.71,776.14,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1119.23,1119.23,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2079.5100000000002,2079.5100000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2402.8000000000002,2402.8000000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",467.24,408.46,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",717.36,632.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",948.28,948.28,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1940.35,1940.35,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",411.46,371.28,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",490.04,436.65,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",715.56,715.56,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1202.5999999999999,1202.5999999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",424.66,399.47,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",501.43,439.65,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",742.55,742.55,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1062.25,1062.25,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",277.11,242.92,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",349.68,289.10000000000002,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",968.68,526.62,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1224.19,927.89,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",236.32,235.72,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",320.89,278.91000000000003,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1076.04,767.14,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",227.92,197.93,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",627.99,343.09,90,0.1,0.69,0.21,0,2,1,1,2,0,null,"R",null,null,2,29,null,29]
["See CPT",379.67,339.49,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",603.4,526.02,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1124.6300000000001,677.77,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1618.26,1234.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",462.45,385.67,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",734.16,654.98,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",738.95,738.95,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1683.64,1317.16,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",362.28,309.5,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",666.98,592.6,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",740.15,740.15,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1552.88,1552.88,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",294.5,206.33,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",325.69,245.32,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",672.98,419.26,10,0.1,0.8,0.1,0,2,0,1,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1225.99,911.1,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",240.52,176.94,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",287.3,237.52,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",328.69,328.69,10,0.1,0.8,0.1,0,2,0,1,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1089.24,779.14,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2240.25,2240.25,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1743.02,1743.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1447.32,1447.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1348.35,1348.35,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1436.52,1436.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1281.17,1281.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1547.48,1147.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1461.71,1073.04,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",951.28,627.39,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1445.52,1065.24,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",975.27,975.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1291.3699999999999,1291.3699999999999,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",780.34,780.34,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",554.22,322.08999999999997,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",545.22,313.7,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",690.97,365.88,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",535.62,297.5,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",571.61,333.49,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",505.63,268.11,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",574.01,321.49,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",563.80999999999995,310.7,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",614.79999999999995,348.48,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",191.94,129.56,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",435.45,255.51,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",235.12,172.74,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",186.54,126.56,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",168.54,116.36,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",184.74,125.96,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",148.75,92.97,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",158.35,74.98,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",128.96,75.569999999999993,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",150.55000000000001,91.77,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",79.17,52.78,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",103.17,63.58,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",59.98,32.99,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",55.78,32.39,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",53.98,34.19,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",55.78,36.590000000000003,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",481.04,293.89999999999998,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",530.22,328.69,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",256.70999999999998,182.94,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",268.70999999999998,195.53,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",311.3,190.14,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",238.12,162.55000000000001,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",153.55000000000001,109.16,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",143.94999999999999,100.77,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",236.92,160.15,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",81.569999999999993,50.98,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",240.52,180.54,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,"Y-CM",2,29,null,29]
["See CPT",172.74,97.17,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",137.94999999999999,92.37,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",65.38,32.99,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",55.18,32.39,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",52.18,31.19,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",35.99,19.79,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",120.56,46.78,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",167.94,48.58,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",153.55000000000001,28.19,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,"Y-CM",2,29,null,29]
["See CPT",1098.23,1098.23,90,0.1,0.69,0.21,0,3,1,1,1,0,29805,"R",null,"Y-UR",2,29,null,29]
["See CPT",956.08,956.08,90,0.1,0.69,0.21,0,3,1,2,1,0,29830,"R",null,"Y-UR",2,29,null,29]
["See CPT",1100.03,1100.03,90,0.1,0.69,0.21,0,3,1,2,1,0,29840,"R",null,"Y-UR",2,29,null,29]
["See CPT",1950.55,1950.55,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1047.8499999999999,772.54,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1281.17,1281.17,90,0.1,0.69,0.21,0,3,1,1,0,0,29870,"R",null,"Y-UR",2,29,null,29]
["See CPT",1260.18,825.32,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1020.86,1020.86,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",268.11,127.16,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",210.53,111.56,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2654.12,2654.12,90,0.1,0.76,0.14000000000000001,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT",618.39,287.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",712.56,239.32,0,0,0,0,0,2,2,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1309.3599999999999,1309.3599999999999,90,0.1,0.76,0.14000000000000001,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2203.67,2203.67,90,0.1,0.76,0.14000000000000001,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",469.64,306.5,0,0,0,0,0,3,1,0,0,0,31231,"R",null,null,2,29,null,29]
["See CPT",481.64,481.64,0,0,0,0,0,3,1,1,0,0,31231,"R",null,null,2,29,null,29]
["See CPT",1970.34,1970.34,10,0.1,0.8,0.1,0,3,1,0,0,0,31231,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",250.12,250.12,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",407.86,222.53,0,0,0,0,0,3,0,0,0,0,31505,"R",null,null,2,29,null,29]
["See CPT",383.87,383.87,0,0,0,0,0,3,0,0,0,0,31526,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,0,1,0,null,"X",null,null,2,29,null,29]
["See CPT",514.03,219.53,0,0,0,0,0,3,0,1,0,0,31575,"R",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",323.29000000000002,212.33,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",147.55000000000001,111.56,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",452.25,452.25,0,0,0,0,0,3,0,1,0,0,31622,"R",null,"Y-CM",2,29,null,29]
["See CPT",254.32,254.32,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",140.94999999999999,140.94999999999999,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2471.1799999999998,2471.1799999999998,90,0.1,0.76,0.14000000000000001,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1445.52,1445.52,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2037.52,2037.52,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1609.86,270.51,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",336.49,284.91000000000003,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",592,194.34,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1198.4000000000001,1198.4000000000001,90,0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1277.57,1277.57,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2674.51,2674.51,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2369.81,2369.81,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",235.12,162.55000000000001,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",4337.75,4337.75,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1434.72,1434.72,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",918.89,918.89,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,2,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",607,607,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",666.38,666.38,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1618.26,1618.26,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1151.6199999999999,1151.6199999999999,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",809.13,809.13,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",691.57,691.57,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,null,2,null,null,29]
["See CPT",1892.37,1892.37,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",3271.31,3271.31,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",5049.12,5049.12,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",5474.37,5474.37,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",4274.7700000000004,4274.7700000000004,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",4287.37,4287.37,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2597.73,2597.73,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",3727.16,3727.16,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",3859.11,3859.11,90,0.09,0.82,0.09,0,2,0,2,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",4590.2700000000004,4590.2700000000004,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",3186.14,3186.14,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",2661.31,2661.31,90,0.09,0.84,7.0000000000000007E-2,0,2,2,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1671.04,1671.04,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",2410,2410,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,29,null,29]
["See CPT",407.86,407.86,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT",1258.3800000000001,1258.3800000000001,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2264.25,2264.25,0,0,0,0,0,2,0,2,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",785.74,785.74,0,0,0,0,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",618.99,618.99,0,0,0,0,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1872.58,1872.58,90,0.09,0.84,7.0000000000000007E-2,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2141.89,2141.89,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",211.73,211.73,0,0,0,0,0,0,1,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",354.48,354.48,0,0,0,0,0,0,1,2,2,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,2,0,null,"N",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,2,0,null,"N",null,null,2,29,null,29]
["See CPT",4487.7,4487.7,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2399.1999999999998,2399.1999999999998,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1642.85,1642.85,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2244.4499999999998,2244.4499999999998,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1963.75,1963.75,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1568.48,1568.48,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2520.96,2520.96,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2126.89,2126.89,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",4027.06,4027.06,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2414.79,2414.79,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1906.76,1906.76,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2771.08,2771.08,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1769.41,1769.41,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1975.14,1975.14,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",251.32,251.32,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",3529.82,3529.82,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",476.84,83.37,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1564.28,304.10000000000002,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2997.2,572.80999999999995,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2450.1799999999998,436.65,0,0,0,0,0,0,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT",70.78,70.78,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2278.04,317.29000000000002,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",3159.15,313.7,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,1,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT",1818.59,595,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2148.48,593.79999999999995,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",205.13,106.16,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,"Y-CM",2,29,null,29]
["See CPT",1272.18,1272.18,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",433.66,193.74,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",10179.81,893.7,0,0,0,0,0,2,0,1,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",878.11,282.51,0,0,0,0,0,0,2,1,2,0,null,"R",null,null,2,29,null,29]
["See CPT",2712.9,491.24,0,0,0,0,0,0,1,1,2,0,null,"R",null,null,2,29,null,29]
["See CPT",211.73,211.73,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",16508.3,1035.25,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2419.59,364.08,0,0,0,0,0,0,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",3397.87,605.20000000000005,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",665.18,665.18,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",806.73,806.73,90,0.09,0.84,7.0000000000000007E-2,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",907.5,585.4,10,0.1,0.8,0.1,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2091.5,2091.5,90,0.11,0.73,0.16,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,29,null,29]
["See CPT",308.89999999999998,127.76,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",226.72,226.72,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1040.6500000000001,1040.6500000000001,90,0.11,0.73,0.16,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1485.7,1485.7,90,0.11,0.73,0.16,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1911.56,1911.56,90,0.11,0.73,0.16,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",545.22,545.22,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1538.49,1538.49,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",981.87,677.77,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,2,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT",361.08,214.73,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",557.21,374.88,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",620.19000000000005,412.66,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",357.48,206.33,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT",305.89999999999998,205.73,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT",807.93,807.93,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",574.01,422.26,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",927.89,927.89,90,0.09,0.81,0.1,0,2,2,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT",768.94,768.94,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",6100.57,6100.57,90,0.09,0.81,0.1,0,2,0,2,2,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",7889.17,7889.17,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",398.27,176.94,0,0,0,0,0,3,0,1,0,0,43197,"R",null,"Y-CM",2,29,null,29]
["See CPT",768.94,768.94,0,0,0,0,0,3,0,1,0,0,43235,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,3,0,1,0,0,43200,"X",null,null,2,29,null,29]
["See CPT",762.35,250.72,0,0,0,0,0,3,0,1,0,0,43235,"R",null,null,2,29,null,29]
["See CPT",426.46,426.46,0,0,0,0,0,3,0,1,0,0,43235,"R",null,"Y-CM",2,29,null,29]
["See CPT",1187,360.48,0,0,0,0,0,3,0,1,0,0,43235,"R",null,null,2,29,null,29]
["See CPT",653.17999999999995,653.17999999999995,0,0,0,0,0,3,0,1,0,0,43260,"R",null,"Y-CM",2,29,null,29]
["See CPT",2748.88,2748.88,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1023.86,1023.86,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2621.13,2621.13,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2352.42,2352.42,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",199.13,199.13,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2736.29,2736.29,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1425.12,1425.12,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",71.38,71.38,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",191.34,191.34,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",2963.61,2963.61,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1979.34,1979.34,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3244.92,3244.92,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2546.75,2546.75,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",286.10000000000002,286.10000000000002,0,0,0,0,0,3,0,1,0,0,44360,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,3,0,0,0,0,44360,"X",null,null,2,29,null,29]
["See CPT",595,280.70999999999998,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",731.16,358.08,0,0,0,0,0,3,0,1,0,0,44388,"R",null,"Y-CM",2,29,null,29]
["See CPT",2897.03,2897.03,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1046.05,1046.05,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",3258.11,3258.11,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2882.04,2882.04,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1805.4,155.94999999999999,0,0,0,0,0,3,0,1,0,0,45300,"R",null,"Y-CM",2,29,null,29]
["See CPT",418.06,188.94,0,0,0,0,0,3,0,1,0,0,45300,"R",null,"Y-CM",2,29,null,29]
["See CPT",224.93,224.93,0,0,0,0,0,3,0,1,0,0,45330,"R",null,"Y-CM",2,29,null,29]
["See CPT",319.08999999999997,166.74,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",546.41999999999996,546.41999999999996,0,0,0,0,0,3,0,1,0,0,45378,"R",null,"Y-CM",2,29,null,29]
["See CPT",1902.57,1902.57,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2119.69,2119.69,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",316.08999999999997,316.08999999999997,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",541.02,288.5,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",976.47,657.38,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",595,346.68,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",550.62,152.94999999999999,0,0,0,0,0,3,0,1,0,0,46600,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT",2027.32,2027.32,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT",482.24,239.92,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",6105.96,6105.96,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",8428.99,8428.99,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2270.2399999999998,2270.2399999999998,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",799.53,125.96,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",7081.84,412.66,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",659.18,659.18,0,0,0,0,0,3,0,1,0,0,47552,"R",null,null,2,29,null,29]
["See CPT",2036.32,2036.32,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2471.1799999999998,2471.1799999999998,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2747.68,2747.68,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",3374.47,3374.47,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",5559.55,5559.55,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1982.94,1982.94,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1876.77,1876.77,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2385.4,211.73,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",601,601,10,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1164.21,1164.21,90,0.1,0.8,0.1,0,3,0,2,2,0,49320,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1220.5899999999999,1220.5899999999999,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1453.92,240.52,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1336.95,1336.95,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1637.45,1637.45,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",624.99,624.99,0,0,0,0,0,0,0,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",1290.77,1290.77,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1907.36,1907.36,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2351.2199999999998,2351.2199999999998,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",317.89,317.89,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1605.66,400.07,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1705.83,362.88,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2095.6999999999998,2095.6999999999998,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2179.0700000000002,2179.0700000000002,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",772.54,618.39,0,0,0,0,0,3,1,0,0,0,50551,"R",null,null,2,29,null,29]
["See CPT",1639.85,1639.85,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2070.5100000000002,2070.5100000000002,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.08,0.83,0.09,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",2088.5,2088.5,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2281.04,2281.04,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",697.57,550.02,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",869.11,869.11,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",915.29,915.29,90,0.08,0.83,0.09,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2658.91,2658.91,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.08,0.83,0.09,0,2,2,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",432.46,432.46,0,0,0,0,1,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",693.37,693.37,0,0,0,0,1,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",14.4,14.4,0,0,0,0,1,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",53.98,53.98,0,0,0,0,1,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1971.54,1971.54,90,0.08,0.83,0.09,0,2,2,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1067.04,1067.04,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",852.32,299.3,0,0,0,0,0,3,1,1,0,0,52000,"R",null,"Y-CM",2,29,null,29]
["See CPT",1421.53,311.89999999999998,0,0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,29,null,29]
["See CPT",1015.46,445.05,0,0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,29,null,29]
["See CPT",519.42999999999995,519.42999999999995,0,0,0,0,0,3,2,0,0,0,52000,"R",null,"Y-CM",2,29,null,29]
["See CPT",509.23,509.23,0,0,0,0,0,3,1,1,0,0,52000,"R",null,null,2,29,null,29]
["See CPT",633.39,633.39,0,0,0,0,0,3,1,1,0,0,52351,"R",null,"Y-CM",2,29,null,29]
["See CPT",749.15,749.15,90,0.08,0.83,0.09,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",3043.39,1266.18,90,0.08,0.83,0.09,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1162.4100000000001,1162.4100000000001,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2047.72,2047.72,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1470.71,1470.71,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",754.55,754.55,90,0.08,0.83,0.09,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",164.35,113.96,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",67.78,67.78,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",275.91000000000003,211.13,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,2,2,0,0,null,"X",null,"Y-CM",2,29,null,29]
["See CPT",199.73,145.75,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1471.91,1471.91,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1638.05,1638.05,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",385.07,385.07,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,1,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT",1044.8499999999999,1044.8499999999999,90,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1923.56,1923.56,90,0.1,0.8,0.1,0,2,2,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",843.32,843.32,90,0.1,0.8,0.1,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1015.46,1015.46,90,0.1,0.8,0.1,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",452.25,234.52,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,0,2,2,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1001.67,1001.67,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1655.45,1655.45,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1134.22,1134.22,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",940.49,940.49,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",928.49,928.49,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1029.26,1029.26,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",237.52,166.74,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",285.5,183.54,0,0,0,0,0,3,0,1,0,0,57452,"R",null,"Y-CM",2,29,null,29]
["See CPT",1141.42,1141.42,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",1814.99,1814.99,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT",1495.9,1495.9,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2040.52,2040.52,90,0.12,0.74,0.14000000000000001,0,2,0,2,2,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,3,0,0,2,0,58555,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,3,1,2,2,0,49320,"X",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,1,2,1,1,null,"N",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,2,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",218.93,145.15,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",67.78,67.78,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1717.83,1717.83,90,0.17,0.6,0.23,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1427.52,1427.52,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",160.75,160.75,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",854.12,854.12,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",785.74,678.97,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,1,1,null,"N",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.82,0.09,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.09,0.82,0.09,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",553.02,553.02,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2323.63,2323.63,90,0.11,0.76,0.13,0,2,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1591.27,1591.27,90,0.11,0.76,0.13,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2617.5300000000002,2617.5300000000002,90,0.11,0.76,0.13,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3808.13,3808.13,90,0.11,0.76,0.13,0,2,0,2,2,0,null,"R",null,null,2,29,null,29]
["See CPT",3952.08,3952.08,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",3930.49,3930.49,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",4511.7,4511.7,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",5014.93,5014.93,90,0.11,0.76,0.13,0,2,1,1,2,2,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",5266.24,5266.24,90,0.11,0.76,0.13,0,2,0,2,1,2,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",5935.02,5935.02,90,0.11,0.76,0.13,0,2,1,2,1,2,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT",8028.32,8028.32,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2317.0300000000002,2317.0300000000002,90,0.11,0.76,0.13,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,0,1,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,0,2,0,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,1,1,0,0,null,"X",null,null,2,null,null,29]
["See CPT",1909.16,1909.16,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",3424.86,3424.86,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1540.29,1540.29,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",345.48,163.75,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",648.38,283.11,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",472.64,199.73,0,0,0,0,0,2,9,1,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",512.83000000000004,512.83000000000004,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",710.16,710.16,10,0.1,0.8,0.1,0,2,0,0,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2697.9,2697.9,90,0.11,0.76,0.13,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2368.61,2368.61,90,0.11,0.76,0.13,0,2,1,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2708.1,2708.1,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2667.31,2667.31,90,0.11,0.76,0.13,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2571.34,2571.34,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",2504.17,2504.17,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3245.52,3245.52,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",3836.92,3836.92,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",4177.01,4177.01,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1035.25,1035.25,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2619.9299999999998,2619.9299999999998,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1260.78,1260.78,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",184.74,99.57,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",131.96,86.37,0,0,0,0,0,0,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",405.46,112.76,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",364.08,192.54,0,0,0,0,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,"Y-CM",2,29,null,29]
["See CPT",825.32,538.02,10,0.1,0.8,0.1,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",1437.12,870.91,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,1,0,0,0,null,"X",null,null,2,29,null,29]
["See CPT",172.74,125.96,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1106.03,1106.03,90,0.11,0.76,0.13,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",693.37,693.37,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29,null,29]
["See CPT",850.52,850.52,90,0.11,0.76,0.13,0,2,1,2,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",956.08,956.08,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1819.19,1819.19,90,0.11,0.76,0.13,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1303.3699999999999,1303.3699999999999,90,0.11,0.76,0.13,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",649.58000000000004,649.58000000000004,0,0,0,0,0,0,0,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",206.33,206.33,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",2503.5700000000002,2503.5700000000002,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1835.99,1835.99,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1388.54,1388.54,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",113.36,74.98,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1819.79,1819.79,90,0.1,0.7,0.2,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1019.06,710.76,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2112.5,2112.5,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1069.44,1069.44,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",574.61,458.25,90,0.1,0.7,0.2,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1190,1190,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1317.76,1042.45,90,0.1,0.7,0.2,0,2,1,0,0,0,null,"R",null,null,2,29,null,29]
["See CPT",806.73,806.73,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",797.73,797.73,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",990.27,893.7,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1549.28,1549.28,90,0.1,0.7,0.2,0,2,1,0,1,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",90,0.1,0.7,0.2,0,2,1,0,1,1,null,"N",null,"Y-CM",2,29,null,29]
["See CPT",210.53,167.94,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",2184.4699999999998,2184.4699999999998,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",927.89,927.89,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",845.12,845.12,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,1,2,1,1,null,"N",null,null,2,29,null,29]
["See CPT",2838.25,2838.25,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT",541.02,217.13,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",349.68,123.56,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1341.15,1341.15,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",932.09,932.09,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1098.23,855.91,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2,29,null,29]
["See CPT",1401.13,1004.07,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,29,null,29]
["See CPT",1021.46,762.35,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",818.13,467.24,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",1603.87,1603.87,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,29,null,29]
["See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,29,null,29]
["See CPT",443.25,272.31,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT","Not Covered","Not Covered",90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",364.08,227.92,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT","Not Covered","Not Covered",90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,1,0,null,"X",null,null,2,29,null,29]
["See CPT",2408.1999999999998,2408.1999999999998,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2282.84,2282.84,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2152.6799999999998,2152.6799999999998,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R",null,null,2,29,null,29]
["See CPT",1041.8499999999999,1041.8499999999999,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29,null,29]
["See CPT",2299.0300000000002,2299.0300000000002,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,0,0,null,"R",null,null,2,29,null,29]
["See CPT",3209.53,3209.53,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,1,0,null,"R",null,"Y-CM",2,26,null,29]
["See CPT","Not Covered","Not Covered",90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,1,0,null,"X",null,null,2,26,null,29]
["See CPT",73.180000000000007,73.180000000000007,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",118.16,118.16,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",71.98,71.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",91.77,91.77,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",16.79,16.79,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",24.59,24.59,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",101.37,101.37,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",157.75,157.75,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",174.54,174.54,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",132.56,132.56,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",133.76,133.76,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26,null,29]
["See CPT",353.88,353.88,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",359.88,359.88,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",241.12,241.12,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",328.69,328.69,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",388.07,388.07,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",103.17,103.17,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",154.15,154.15,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,4,3,0,0,0,null,"X",null,null,2,26,null,29]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26,null,29]
["See CPT",44.99,44.99,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",26.39,26.39,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",28.19,28.19,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",17.39,17.39,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",550.62,550.62,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",541.02,541.02,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",194.34,194.34,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",23.39,23.39,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",21.59,21.59,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",134.96,134.96,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",31.19,31.19,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",91.17,91.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",85.77,85.77,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",104.97,104.97,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",329.89,329.89,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",371.88,371.88,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26,null,26]
["See CPT",626.79,626.79,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26,null,26]
["See CPT",625.59,625.59,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26,null,26]
["See CPT",153.55000000000001,153.55000000000001,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",93.57,93.57,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",665.18,665.18,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",63.58,63.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",46.78,46.78,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",170.94,170.94,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",140.35,140.35,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR",2,26,null,26]
["See CPT",252.52,252.52,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",62.98,62.98,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",41.99,41.99,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",209.93,209.93,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",45.58,45.58,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",12,12,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",153.55000000000001,153.55000000000001,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",617.19000000000005,617.19000000000005,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR",2,26,null,26]
["See CPT",524.83000000000004,524.83000000000004,0,0,0,0,1,4,0,9,0,0,null,"R",null,null,2,26,null,26]
["See CPT",59.38,59.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",27.59,27.59,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",15,15,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",20.39,20.39,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",155.94999999999999,155.94999999999999,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",54.58,54.58,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",13.2,13.2,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",85.77,85.77,0,0,0,0,1,4,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",115.76,115.76,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR",2,26,null,26]
["See CPT",397.07,397.07,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR",2,26,null,26]
["See CPT",57.58,57.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",50.38,50.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",27.59,27.59,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",187.74,187.74,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",595,595,0,0,0,0,1,4,0,9,0,0,null,"R",null,null,2,26,null,26]
["See CPT",663.38,663.38,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",185.94,185.94,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",209.33,209.33,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",59.98,59.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",68.98,68.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",915.89,915.89,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",484.04,484.04,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26,null,26]
["See CPT",74.38,74.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",290.3,290.3,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",187.14,187.14,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26,null,26]
["See CPT",171.54,171.54,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT",343.69,343.69,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",830.72,830.72,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,4,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT",131.96,131.96,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",262.70999999999998,262.70999999999998,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",139.15,139.15,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",150.55000000000001,150.55000000000001,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",107.96,107.96,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",215.33,215.33,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26,null,26]
["See CPT",40.79,40.79,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",94.77,94.77,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",97.77,97.77,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",293.3,293.3,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",256.70999999999998,256.70999999999998,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",139.75,139.75,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",45.58,45.58,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",32.39,32.39,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26,null,26]
["See CPT",209.93,209.93,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",80.97,80.97,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",34.79,34.79,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",23.99,23.99,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",749.79,749.79,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-CM",2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26,null,26]
["See CPT",159.55000000000001,159.55000000000001,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",42.59,42.59,0,0,0,0,1,7,3,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",14.4,14.4,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",195.53,195.53,0,0,0,0,1,0,1,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",152.35,152.35,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",115.76,115.76,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",110.96,110.96,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",85.17,85.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",170.94,170.94,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",53.98,53.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",133.76,133.76,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",355.68,355.68,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",50.38,50.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",43.79,43.79,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",386.87,386.87,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,"Y-CM",2,26,null,26]
["See CPT",132.56,132.56,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",326.29000000000002,326.29000000000002,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",54.58,54.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT",4.8,4.8,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",139.75,139.75,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,null,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26,null,26]
["See CPT",149.35,149.35,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",125.36,125.36,0,0,0,0,1,0,0,9,0,0,null,"R",null,null,2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT",659.18,659.18,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,9,0,0,null,"X",null,"Y-CM",2,26,null,26]
["See CPT",239.32,239.32,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT",62.38,62.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",59.38,59.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",17.39,17.39,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",14.4,14.4,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",307.7,307.7,0,0,0,0,2,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",413.26,413.26,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT",335.29,335.29,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",442.05,442.05,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",71.98,71.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",110.96,110.96,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,3,0,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,3,0,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT",1075.44,1075.44,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",482.24,482.24,90,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,"Y-CM",2,26,null,26]
["See CPT",139.75,139.75,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",427.06,427.06,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",476.24,476.24,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",63.58,63.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT",15.59,15.59,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",124.16,124.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",268.70999999999998,268.70999999999998,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",100.17,100.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",40.79,40.79,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",766.54,766.54,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",379.07,379.07,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",434.86,434.86,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",612.4,612.4,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26,null,26]
["See CPT",397.67,397.67,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",445.65,445.65,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-UR",2,26,null,26]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-UR",2,26,null,26]
["See CPT",52.18,52.18,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR",2,26,null,26]
["See CPT",553.62,553.62,0,0,0,0,1,6,9,9,9,9,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",293.89999999999998,293.89999999999998,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",351.48,351.48,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",320.29000000000002,320.29000000000002,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",3194.8,3194.8,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-UR",2,26,null,26]
["See CPT",79.17,79.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR",2,26,null,26]
["See CPT",582.41,582.41,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",352.08,352.08,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",311.89999999999998,311.89999999999998,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",526.62,526.62,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",130.16,130.16,0,0,0,0,1,9,9,9,9,9,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",521.23,521.23,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",400.67,400.67,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",232.12,232.12,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",356.88,356.88,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",316.69,316.69,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",90.57,90.57,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",84.57,84.57,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT",836.12,836.12,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT",169.14,169.14,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",142.15,142.15,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23,null,26]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT",54.58,54.58,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,26]
["See CPT",18.79,18.79,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,26]
["See CPT",9.35,9.35,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,26]
["See CPT",23.7,23.7,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,26]
["See CPT",22.82,22.82,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,26]
["See CPT",17.829999999999998,17.829999999999998,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,26]
["See CPT",87.93,87.93,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT",46.16,46.16,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT",128.99,128.99,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,26]
["See CPT",42.42,42.42,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,26]
["See CPT",12.18,12.18,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",180.31,180.31,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",17.39,17.39,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",8.18,8.18,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",36.049999999999997,36.049999999999997,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",20.62,20.62,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",22.5,22.5,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",7.3,7.3,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",8.5299999999999994,8.5299999999999994,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",18.25,18.25,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",8.5,8.5,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",17.559999999999999,17.559999999999999,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",13.39,13.39,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",17.329999999999998,17.329999999999998,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",34.21,34.21,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23,null,23]
["See CPT",32.5,32.5,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",19.29,19.29,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",23.29,23.29,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",24.95,24.95,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",4.6399999999999997,4.6399999999999997,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",26.29,26.29,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23,null,23]
["See CPT",18.21,18.21,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",13.4,13.4,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",25.33,25.33,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",18.11,18.11,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",27.88,27.88,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",48.38,48.38,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23,null,23]
["See CPT",24.34,24.34,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",9.65,9.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",7.78,7.78,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23,null,23]
["See CPT",10.81,10.81,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",6.74,6.74,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",5.19,5.19,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",25.23,25.23,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",28.64,28.64,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",25.47,25.47,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",18.059999999999999,18.059999999999999,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",5.59,5.59,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",6.33,6.33,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",21.64,21.64,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",5.38,5.38,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",7.88,7.88,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",25.33,25.33,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",12.89,12.89,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",6.64,6.64,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",17.59,17.59,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",14.4,14.4,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",16.75,16.75,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",6.07,6.07,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",13.56,13.56,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",25.37,25.37,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",7.33,7.33,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",36.01,36.01,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",18.75,18.75,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",31.79,31.79,0,0,0,0,6,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT",10.43,10.43,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",25.6,25.6,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",14.7,14.7,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",23.93,23.93,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",16.329999999999998,16.329999999999998,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",15,15,0,0,0,0,3,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT",18.21,18.21,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",16.73,16.73,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",18.440000000000001,18.440000000000001,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",23.84,23.84,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",12.86,12.86,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",15.93,15.93,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",21.65,21.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",17.53,17.53,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",18.23,18.23,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",22.51,22.51,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",36.520000000000003,36.520000000000003,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",461.01,461.01,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,23,null,23]
["See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,23,null,23]
["See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,23,null,23]
["See CPT",9.3800000000000008,9.3800000000000008,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",14.6,14.6,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",163.22999999999999,163.22999999999999,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",34.79,34.79,0,0,0,0,6,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT",6.04,6.04,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",31.79,31.79,0,0,0,0,6,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT",27.68,27.68,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",22.74,22.74,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",21.23,21.23,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",22.64,22.64,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",19.989999999999998,19.989999999999998,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",49.99,49.99,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23,null,23]
["See CPT",49.65,49.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",49.65,49.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",49.65,49.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",59.09,59.09,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",60.62,60.62,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",31.02,31.02,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",60.62,60.62,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",28.37,28.37,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",49.65,49.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",49.65,49.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",49.65,49.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT",58.55,58.55,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23,null,23]
["See CPT",364.29,364.29,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",49.18,49.18,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23,null,23]
["See CPT",129.56,129.56,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",28.67,28.67,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23,null,23]
["See CPT",20.73,20.73,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23,null,23]
["See CPT",25.13,25.13,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23,null,23]
["See CPT",16.190000000000001,16.190000000000001,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23,null,23]
["See CPT",150.55000000000001,150.55000000000001,0,0,0,0,2,0,0,0,0,0,null,"R",null,"Y-CM",2,23,null,23]
["See CPT",245.04,245.04,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23,null,23]
["See CPT",245.73,245.73,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23,null,23]
["See CPT",31.19,31.19,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT",63.58,63.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT",66.58,66.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT",133.76,133.76,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT",262.70999999999998,262.70999999999998,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT",102.57,102.57,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT",202.73,202.73,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT",223.13,223.13,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,23,null,23]
["See CPT",434.26,434.26,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23,null,23]
["See CPT",109.76,109.76,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,23,null,23]
["See CPT",47.38,47.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23,null,23]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,23,null,23]
["See CPT",7.92,7.92,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2,23,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23,null,23]
["See CPT",13.92,13.92,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,16,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,23]
["See CPT",16.190000000000001,16.190000000000001,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,16,null,23]
["See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,16,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,23]
["See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,16,null,23]
["See CPT",257.99,257.99,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,17,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,17,null,23]
["See CPT",73.819999999999993,73.819999999999993,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,17,null,23]
["See CPT",167.34,148.15,0,0,0,0,0,0,0,9,0,0,null,"R",null,"Y-CM",2,17,null,23]
["See CPT",269.91000000000003,235.72,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,17,null,23]
["See CPT",323.29000000000002,190.14,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,17,null,23]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,17,null,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,23]
["See CPT",536.22,536.22,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,null,null,23]
["See CPT",158.94999999999999,158.94999999999999,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,null,null,23]
["See CPT",198.53,198.53,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,23]
["See CPT",89.37,89.37,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,null,null,23]
["See CPT",146.35,146.35,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,null,null,23]
["See CPT",82.17,82.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,23]
["See CPT",1722.63,1722.63,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,16]
["See CPT",47.38,47.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,16]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,null,null,16]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,16]
["See CPT",33.590000000000003,33.590000000000003,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2,null,null,16]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,2,0,0,0,null,"X",null,null,2,null,null,16]
["See CPT",51.58,51.58,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2,null,null,16]
["See CPT",29.39,29.39,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2,null,null,16]
["See CPT",24.59,24.59,0,0,0,0,1,7,2,0,0,0,null,"R",null,"Y-CM",2,null,null,16]
["See CPT",234.52,234.52,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2,null,null,16]
["See CPT",98.37,98.37,0,0,0,0,1,7,2,0,0,0,null,"R",null,"Y-CM",2,null,null,16]
["See CPT",170.34,170.34,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2,null,null,17]
["See CPT",73.78,73.78,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2,null,null,17]
["See CPT",79.17,79.17,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,null,null,17]
["See CPT",74.38,41.39,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2,null,null,17]
["See CPT",224.33,70.180000000000007,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,null,null,17]
["See CPT",145.75,77.37,0,0,0,0,0,0,2,0,0,0,null,"R",null,"Y-CM",2,null,null,17]
["See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,null,null,17]
["See CPT",200.33,200.33,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
["See CPT",7.2,7.2,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
["See CPT",40.79,40.79,0,0,0,0,7,0,2,0,0,0,null,"R",null,null,2,29]
["See CPT",17.39,15.59,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2]
["See CPT",40.79,40.79,0,0,0,0,3,0,2,0,0,0,null,"R",null,null,2,29]
["See CPT",61.78,61.78,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2,26]
["See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,26]
["See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,"Y-CM",2,26]
["See CPT",159.55000000000001,130.16,0,0,0,0,7,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",37.79,32.39,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,26]
["See CPT",605.20000000000005,326.89,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,26]
["See CPT",131.36000000000001,131.36000000000001,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",1934.95,1934.95,0,0.09,0.84,7.0000000000000007E-2,0,2,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",67.180000000000007,67.180000000000007,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",188.94,77.37,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
["See CPT",433.66,433.66,0,0,0,0,3,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",74.38,74.38,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",22.79,22.79,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
["See CPT",70.78,70.78,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",109.16,109.16,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",59.38,59.38,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",62.98,62.98,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",37.19,37.19,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",297.5,297.5,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
["See CPT",181.74,181.74,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26,null,29]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26,null,29]
["See CPT",352.68,352.68,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,29]
["See CPT",441.45,441.45,0,0,0,0,1,6,0,9,9,9,null,"R",null,null,2,26]
["See CPT",1278.17,1278.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",1401.73,1401.73,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",1509.1,1509.1,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",720.96,720.96,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,26]
["See CPT",1905.56,1905.56,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-UR",2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26,null,26]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT",673.58,673.58,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",1080.24,1080.24,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","By Report","By Report",0,0,0,0,1,2,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT","By Report","By Report",0,0,0,0,1,2,0,0,0,0,null,"N",null,"Y-CM",2,26,null,26]
["See CPT",164.35,164.35,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",140.94999999999999,140.94999999999999,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,26,null,26]
["See CPT",32.39,16.190000000000001,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,26,null,26]
["See CPT",443.85,443.85,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",92.37,92.37,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",20.99,20.99,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",38.39,38.39,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",311.3,311.3,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",190.14,190.14,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",183.54,183.54,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",37.79,37.79,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT",115.76,115.76,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,26,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,26]
["See CPT","Bundled","Bundled",0,0,0,0,1,9,9,9,9,9,null,"B",null,null,2,null,null,26]
["See CPT",28.79,28.79,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,26]
["See CPT",123.56,123.56,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-ONC",2,null,null,26]
["See CPT",121.76,121.76,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,26]
["See CPT",39.590000000000003,39.590000000000003,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,null,null,26]
["See CPT",93.57,93.57,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,26]
["See CPT",108.56,108.56,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,null,null,26]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,null,null,26]
["See CPT",9.6,9.6,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,null,null,26]
["See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,null,null,26]
["See CPT",31.79,6,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,null,null,26]
["See CPT",20.99,5.4,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,null,null,26]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,null,null,26]
["See CPT",381.47,373.68,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,null,null,26]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,null,null,26]
["See CPT",830.72,830.72,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,null,null,26]
["See CPT",178.74,178.74,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,null,null,26]
["See CPT",571.61,571.61,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,26]
["See CPT",696.37,696.37,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,26]
["See CPT",103.17,103.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,26]
["See CPT",91.77,91.77,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,26]
["See CPT",248.32,248.32,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,null,null,26]
["See CPT",114.56,114.56,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2]
["See CPT",35.99,35.99,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
["See CPT",145.75,145.75,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
["See CPT",157.15,157.15,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2]
["See CPT",91.17,91.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
["See CPT",179.94,179.94,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
["See CPT",151.75,151.75,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
["See CPT",50.38,50.38,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2]
["See CPT",142.75,142.75,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2]
["See CPT",198.53,198.53,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
["See CPT",857.11,857.11,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2]
["See CPT",95.97,95.97,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
["See CPT",619.59,619.59,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
["See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT",199.73,199.73,0,0,0,0,7,0,2,0,0,0,null,"R",null,null,2]
["See CPT",169.74,144.55000000000001,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-ONC",2,25]
["See CPT",78.569999999999993,41.99,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-ONC",2,25]
["See CPT",130.16,113.36,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,17]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,17]
["See CPT",53.98,53.98,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,25]
["See CPT",137.35,137.35,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,25]
["See CPT",52.78,52.78,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,25]
["See CPT",47.98,47.98,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,21]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT",245.92,245.92,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM",2]
["See CPT",13.8,13.8,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,23]
["See CPT",26.39,26.39,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,23]
["See CPT",55.18,55.18,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,23]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,25]
["See CPT",147.97,147.97,0,0,0,0,7,5,0,0,0,0,null,"F",null,null,2,25,null,17]
["See CPT",59.38,59.38,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,10]
["See CPT","Bundled","Bundled",0,0,0,0,0,0,0,0,0,0,null,"B",null,"Y-CM",2,10]
["See CPT",78.569999999999993,78.569999999999993,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,10]
["See CPT",109.16,83.97,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10]
["See CPT",59.38,59.38,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2,10]
["See CPT",23.99,20.99,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,10]
["See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,10]
["See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,10]
["See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,10,null,25]
["See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,10,null,25]
["See CPT",238.72,176.94,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10,null,25]
["See CPT",215.33,215.33,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10,null,17]
["See CPT",148.15,148.15,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10,null,25]
["See CPT",127.16,127.16,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10,null,25]
["See CPT",244.12,244.12,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10,null,25]
["See CPT",82.77,82.77,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10,null,25]
["See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,10,null,25]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,23]
["See CPT",62.98,57.58,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2,null,null,23]
["See CPT",56.38,54.58,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2,null,null,23]
["See CPT",105.56,63.58,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23,null,25]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,25]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,10]
["See CPT",40,40,0,0,0,0,0,0,0,0,0,0,null,"D",null,"Y-CM",2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,10]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","By Report","By Report",0,0,0,0,0,0,1,0,0,0,null,"N",null,"Y-UR",2]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-UR",2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["See CPT",12.71,12.71,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,30]
["See CPT","State Rate","State Rate",0,0,0,0,0,0,0,0,0,0,null,"S",null,"Y-CM",2,30]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,9,9,9,9,9,null,"X",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT","Contracted","Contracted",0,0,0,0,0,0,0,0,0,0,null,"C",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,3,0,0,0,null,"X",null,null,2]
["See CPT","By Report","By Report",0,0,0,0,0,2,0,1,0,0,null,"N",null,"Y-UR",2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,4,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,0,3,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,4,9,9,9,9,9,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,2,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2]
["See CPT","Not Covered","Not Covered",0,0,0,0,1,4,0,0,0,0,null,"X",null,null,2]
["See CPT",8.99,8.99,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,30]
["See CPT",10.55,10.55,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,30]
["See CPT",50,50,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,null,null,25]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["AP final report at request of insurer",30.4,30.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,27]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["Occupational disease hx, detailed, non-i, occupati",223.21,223.21,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,22]
["Activity prescription form, insurer requested",59.81,59.81,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,27]
["Opioid req for subacute pain w/doc",69.03,69.03,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,27]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,12]
["Ime - terminated examination",427.58,427.58,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,13]
["IME Forensic exam ",427.58,427.58,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,13]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["Impairment rating by a/p, complex",910.07,910.07,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,12]
["Impairment rating, addendum report",137.91,137.91,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,12]
["Ur contract:  prospective review - inpatient","Contracted","Contracted",0,0,0,0,0,0,0,0,0,0,null,"C",null,null,2]
["UR, spinal injection - full clinical review","Contracted","Contracted",0,0,0,0,0,0,0,0,0,0,null,"C",null,null,2]
["IME Taxi","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,3]
["See CPT",46.4,46.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,22]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,null,null,27]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,null,null,12]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,null,null,13]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,null,null,13]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,null,null,3]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,null,null,22]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,null,null,22]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,null,null,34]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,18]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,28]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,28]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,28]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,18]
["See CPT",1.25,1.25,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,5]
["Outpatient Day Program - Lunch","State Rate","State Rate",0,0,0,0,0,0,0,0,0,0,null,"S",null,null,2,22]
["See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["See CPT",749.61,749.61,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,null,null,18]
["See CPT",622.39,622.39,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,null,null,18]
["See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-ONC",2]
["See CPT",808.78,808.78,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,33]
["Electronic Provider Communication",52.6,49.84,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,10]
["Noninterest escort in non er","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28]
["Noner transport case worker","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28]
["Als iv drug therapy supplies",58.76,58.76,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,28]
["Als 1",770.82,770.82,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,3]
["Bls-emergency",673.74,673.74,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,3]
["Mirragen adv wnd mat per sq","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28,null,28]
["Permeaderm b, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["Innovabrn/innovamatx xl sqcm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["2 cc sterile syringe&needle",1.99,1.99,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,18]
["Supp non-insulin inf cath/wk",27.83,27.83,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,28]
["Silvr oxide batt glucose mon",2.84,2.84,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["Chlorhexidine antisept",0.1,0.1,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["Blood glucose/reagent strips",66.34,66.34,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["Spermicide","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["Replacement breastpump cap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28,null,33]
["Cath w/o bag 2-way silicone",23.76,23.76,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["Irrigation syringe",4.22,4.22,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,22]
["Indwelling catheter latex",16.989999999999998,16.989999999999998,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Ext ureth clmp or compr dvc",53.71,53.71,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Adhesive, liquid or equal",3.78,3.78,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Drainable rubber pch w/o fp",42.58,42.58,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Drainable pch w ex wear barr",6.04,6.04,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Urinary pouch w ex wear barr",9.7799999999999994,9.7799999999999994,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Pectin based ostomy paste",7.93,7.93,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["2 pc drainable ost pouch",7.63,7.63,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Ost pch drain for barrier fl",4.95,4.95,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Urine ost pouch w bltinconv",11.43,11.43,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Reusable enema bag",8.26,8.26,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Surgical dress holder reuse",18.43,18.43,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Surgical trays",110.84,110.84,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Ca tx e-stim electr/transduc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28,null,28]
["Splint","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28,null,28]
["Ces system monthly supp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28,null,28]
["Battery charger",41.3,41.3,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28,null,28]
["Repl bat t.e.n.s. own by pt","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28,null,28]
["Infrared ht sys replcmnt pad","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28,null,28]
["In111 satumomab","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,28,null,28]
["Dialyzer, each",187.24,187.24,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,28,null,28]
["Acetate conc sol per gallon","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28,null,28]
["Fistula cannulation set, ea",19.920000000000002,19.920000000000002,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28,null,28]
["Blood glucose test strips",0.89,0.89,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28,null,28]
["Venous pressure clamp","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28,null,28]
["Pouch clsd w barr attached",2.85,2.85,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Urinary pouch on barr w/flng",4.34,4.34,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Stoma absorptive cover",0.89,0.89,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Diabetic shoe with wedge",44.91,44.91,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,28,null,28]
["Modification diabetic shoe",44.91,44.91,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,28,null,28]
["Collagen dressing >48 sq in",263.57,263.57,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Composite drsg >16<=48 sq in",8.6199999999999992,8.6199999999999992,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Non-sterile gauze<=16 sq in",0.05,0.05,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Gauze >16<=48 no w/sal w/o b",3.36,3.36,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Hydrocolld drg >16<=48 w/bdr",31.58,31.58,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Hydrocolloid drg filler dry",3.56,3.56,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Absorpt drg >16 <=48 w/o bdr",4.51,4.51,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Wound filler dry form / gram",1.99,1.99,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Conform band n/s w>=3\"<5\"/yd",0.39,0.39,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Lt compres band >=5\"/yd",2.4300000000000002,2.4300000000000002,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Compres burngarment facehood","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28,null,28]
["Compres burn garment leotard","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,9,null,28]
["G com garment bra nighttime",639.45000000000005,639.45000000000005,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Gc stocking waistlngth 18-30",93.9,93.9,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9,null,28]
["Grad com stocking bk 40+",76.489999999999995,76.489999999999995,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["G com stcking thgh30-40 cust",297.69,297.69,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Grad com garmnt toe cap cust",239.34,239.34,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Custom grad com sleeve med",187.27,187.27,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Grad com wrap w straps arm",234,234,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["G comp bandge conform gauze",0.17,0.17,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["G com bandge low dn foamchnl",2.2599999999999998,2.2599999999999998,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9,null,28]
["Nondisposable pump canister",39.840000000000003,39.840000000000003,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,9,null,28]
["Water distilled w/nebulizer",0.48,0.48,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9,null,28]
["Replace chest compress vest","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,9,null,28]
["Water seal drain container",102.75,102.75,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9,null,28]
["Repl water chamber, pap dev",61.13,61.13,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9,null,28]
["Heat & moisture exchange sys",1.95,1.95,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9,null,9]
["Trach/laryn tube plug/stop",4.95,4.95,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9,null,9]
["Programmer orally ingest cap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,9]
["Disposable sensor, cgm sys",21.84,21.84,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,9,null,9]
["Pres dig visual therapy fda","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC",2,null,null,9]
["Tc99m sestamibi",546.04999999999995,546.04999999999995,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Tc99m exametazime",2605.0500000000002,2605.0500000000002,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9,null,9]
["I131 max 100uci",32.67,32.67,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Y90 ibritumomab, rx","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Cr51 chromate","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9,null,9]
["Tc99m fanolesomab","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9,null,9]
["Inj, gadopiclenol, 1 ml",15.43,15.43,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,16,null,9]
["Gadobutrol injection",0.34,0.34,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,9,null,9]
["Fluciclovine f-18",587.9,587.9,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,9,null,9]
["Lutetium lu 177 vipivotide",231.2,231.2,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,9,null,9]
["Inj, magtrace per study dose","Facility Only","By Report ",0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-ONC",2,null,null,9]
["Enteral ng tubing w/o stylet",17.670000000000002,17.670000000000002,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,null,null,9]
["Additive for enteral formula",1.1599999999999999,1.1599999999999999,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,null,null,9]
["Ef ped caloric dense>/=0.7kc","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,"Y-CM",2,null,null,9]
["Parenteral sol amino acid >",82.75,82.75,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,null,null,9]
["Parenteral sol renal-amirosy",17.100000000000001,17.100000000000001,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,null,null,9]
["Parenteral infus pump statio",574.41999999999996,574.41999999999996,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,null,null,9]
["Brachytherapy needle","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Brachytx, ns, non-hdrir-192","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Cath, brachytx seed adm","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Cath,hemodialysis,short-term","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Event recorder, cardiac","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Rep dev, urinary, w/sling","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Pmkr, single, rate-resp","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Prosthesis, breast, imp","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Power bone marrow bx needle","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["CARDIAC MONITOR SYS","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Matrl for vocal cord","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Intro/sheath,fixed,peel-away","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Lead, pmkr/aicd combination","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Prosthesis, penile, non-inf","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Brachy linear, non-str,p-103","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Brachytx, non-stranded,c-131","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Low cost skin substitute app","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Perc bx breast lesions mr","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR",2]
["Dx bronch w/ navigation","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR",2]
["R hrt angio w/flow resrv","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR",2,28]
["Fem/pop revasc w/arthr & us","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR",2]
["Ercp w/bx & pancreatoscopy","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Cystureth blu li cyst fl img","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR",2]
["Hopd mntl hlt, 30-60 min","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-CM",2]
["Mra w/o fol w/cont, chest","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Mra w/o fol w/cont, lwr ext","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Mra, w/dye, spinal canal","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Cad breast mri","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Injection, teprotumumab-trbw","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Cocaine hcl nasal (numbrino)","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2]
["Inj, bupivacaine liposome",46.38,46.38,0,0,0,0,0,0,0,0,0,0,null,"D",null,null,2]
["Surgimend, fetal","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Injection, eteplirsen","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["COVID-19 CONVALESCENT PLASMA","Facility Only",800.3,0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["Perc d-e cor revasc w ami s","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Microwave bronch, 3d, ebus","Facility Only",8973.9500000000007,0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR",2,28]
["Non-blind interatrial shunt","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Revasc lithotr-ather tib/per","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2]
["Echo cad for hf preserved ef","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-ONC",2]
["Mri hyperpolarized xenon129","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-UR",2]
["Assessment of a patient",103.2,103.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,8]
["Intraoral periapical ea add",33.6,33.6,0,0,0,0,1,0,0,0,0,0,null,"F",null,null,2,8]
["Bitewings four images",81.599999999999994,81.599999999999994,0,0,0,0,1,0,0,0,0,0,null,"F",null,null,2,8]
["Cone beam ct interp both jaw",400,400,0,0,0,0,1,0,0,0,0,0,null,"F",null,null,2,8]
["Tomo periapical image","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,8]
["Trtmnt simulation 3d image",368.8,368.8,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-CM",2,8,null,8]
["Diag tst detect mucos abnorm","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8,null,8]
["Decalcification procedure","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,8,null,8]
["Other oral pathology procedu",200.8,200.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,8,null,8]
["Caries risk assess mod risk",96.8,96.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8,null,8]
["2d oral/facial photo image","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,8,null,8]
["Dental prophylaxis child","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8,null,8]
["Oral hygiene instruction","Bundled","Bundled",0,0,0,0,0,0,0,0,0,0,null,"B",null,null,2,8,null,8]
["Remove bilat space main, max",548,548,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Janssen Covid-19 vaccine administration","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8,null,8]
["Amalgam three surfaces perma",290.39999999999998,290.39999999999998,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8,null,8]
["Dental gold foil two surface","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8,null,8]
["Dental onlay metl 4/more sur","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8,null,8]
["Dental onlay porc 3/more sur","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8,null,8]
["Crown resin w/ base metal",1264,1264,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Crown 3/4 cast hi noble met",1414.4,1414.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Reattach tooth fragment",333.6,333.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Tooth pin retention",101.6,101.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8,null,8]
["Lab labial veneer resin",1279.2,1279.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Dental unspec restorative pr","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,8,null,8]
["Pulpal therapy posterior pri","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8,null,8]
["Apexification/recalc initial",468.8,468.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8,null,8]
["Apicoectomy - anterior",940,940,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8,null,8]
["Biological materials",703.2,703.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Intraorifice barrier","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,8,null,8]
["Gingivectomy/plasty rest",363.2,363.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Guided tiss regen resorble",860.8,860.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Remove non-resorb barrier","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,8,null,8]
["Splint intra-coronal",620,620,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Unspecified periodontal proc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,8,null,8]
["Immed mand part dent metal",2197.6,2197.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8,null,8]
["Rem unilat dent flex base",1464,1464,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,8,null,8]
["Rep cast part frame max",364,364,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Dentures rebase cmplt maxil",753.6,753.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Denture reln part mand lab",586.4,586.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Overdenture complete mandib",2804.8,2804.8,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Auricular prosthesis",8594.4,8594.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8,null,8]
["Facial prosthesis","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,8,null,8]
["Mandibular flange prosthesis","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,8,null,8]
["Superimposed prosthesis","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,8,null,8]
["Vesiculobullous disease carr","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8,null,8]
["Odontics eposteal implant",8495.2000000000007,8495.2000000000007,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8,null,8]
["Abutment supported mtl crown",1680,1680,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Abutment supported retainer",1636,1636,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Imp crown porc to noble allo",1878.4,1878.4,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-ONC",2,8,null,8]
["Implant crown noble alloys",1855.2,1855.2,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-ONC",2,8,null,8]
["Bone graft repair perimplant",860.8,860.8,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Tissue regen resorbable","By Report","By Report",0,0,0,0,0,9,9,9,9,9,null,"N",null,"Y-CM",2,8,null,8]
["Imp/abut int fixed dent man",4527.2,4527.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8,null,8]
["Abut retain porc to titanium",1803.2,1803.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,8,null,8]
["Pontic porcelain to titanium",1476,1476,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-ONC",2,8,null,8]
["Cst hgh nble mtl inlay >=3sr","Not Covered","Not Covered",0,0,0,0,0,9,9,9,9,9,null,"X",null,null,2,8,null,8]
["Onlay cst hgh nbl mtl 2 srfc","Not Covered","Not Covered",0,0,0,0,0,9,9,9,9,9,null,"X",null,null,2,8,null,8]
["Onlay cst base mtl >=3 surfa","Not Covered","Not Covered",0,0,0,0,0,9,9,9,9,9,null,"X",null,null,2,8,null,8]
["Crown 3/4 cast noble metal",1361.6,1361.6,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Crown titanium",1364.8,1364.8,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Extraction erupted tooth/exr",252.8,252.8,0,0,0,0,0,9,9,9,9,9,null,"F",null,null,2,8,null,8]
["Coronectomy",583.20000000000005,583.20000000000005,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Brush biopsy",269.60000000000002,269.60000000000002,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8,null,8]
["Corticotomy, 1-3 teeth",1220,1220,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Excision benign lesion>1.25c",820.8,820.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Excision malig lesion>1.25cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8,null,8]
["I&d abscess extraoral",644.79999999999995,644.79999999999995,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Removal of fb reaction",804,804,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Maxilla open reduct compound",5564.8,5564.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Alveolus clsd reduc stblz te",2381.6,2381.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Tmj reshaping components",9002.4,9002.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Tmj arthroscopy discectomy","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,8,null,8]
["Dental suture wound to 5 cm",707.2,707.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8,null,8]
["Bone cutting body mandible",9093.6,9093.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Excision pericoronal gingiva",351.2,351.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,8,null,8]
["Surgical sialolithotomy","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8,null,8]
["Oral surgery procedure","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,8,null,8]
["Compre dental tx adult",5649.6,5649.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8,null,8]
["Repair fixed retainer max",348,348,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,8,null,8]
["Temporomandibular joint dysf","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8,null,8]
["Consult w/med hlth care prof",218.4,218.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8,null,8]
["Office visit during hours",103.2,103.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,8,null,8]
["Fab removable appliance","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,8,null,8]
["Repair/reline occlusal guard",301.60000000000002,301.60000000000002,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8,null,8]
["Enamel microabrasion","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8,null,8]
["Extrnl bleaching per tooth",292,292,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8,null,8]
["Case mgmt, appt barriers",108.8,108.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8,null,8]
["Crutch underarm each wood",29.28,29.28,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,8]
["Rigid wheeled walker adj/fix",16.46,16.46,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,8]
["Enclosed walker w rear seat",355.05,355.05,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,8]
["Walker seat attachment",3.06,3.06,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Walker leg extenders set of4",33.36,33.36,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Press pad alternating w/ pum",282.37,282.37,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Press underlay alter w/pump",282.37,282.37,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Positioning cushion","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Air pressure pad for mattres",33.06,33.06,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Infrared heating pad system","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Wound warming device","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,9,null,9]
["Hosp bed fixed ht w/ mattres",953.8,953.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Hospital bed var ht w/o matt",88.72,88.72,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Mattress foam rubber",206.41,206.41,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Over-bed table",134.24,134.24,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Hosp bed var ht no sr no mat",789.06,789.06,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9,null,9]
["Hosp bed total elect w/ matt",166.88,166.88,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9,null,9]
["Rails bed side half length",176.81,176.81,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9,null,9]
["Bed safety enclosure",242.41,242.41,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Nonpowered pressure mattress",4929.25,4929.25,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Gas system stationary compre","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Oxygen tent excl croup/ped t","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-PHL",2,9,null,9]
["Chest wrap",258.14999999999998,258.14999999999998,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9,null,9]
["Rad w/backup non inv intrfc",5611.02,5611.02,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Intrpulmnry percuss vent sys","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9,null,9]
["Oral dv/app neuromus mouthpi","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,9]
["Humidifier for use w/ regula",5.16,5.16,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9,null,9]
["Nebulizer w/ compressor & he",39.299999999999997,39.299999999999997,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Cont airway pressure device",939.38,939.38,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Apnea monitor w recorder","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Patient lift sling or seat",121.3,121.3,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Seat lift mech, non-electric",39.92,39.92,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9,null,9]
["Fixed patient lift system","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9,null,9]
["Pneumatic appliance half arm",15.04,15.04,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Pneumatic appliance full arm",175.68,175.68,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Pressure pneum appl full leg",575.23,575.23,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Pressure pneum appl full arm",44.73,44.73,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Safety equipment","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9,null,9]
["Restraints any type","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9,null,9]
["Neuromuscular stim for scoli","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Elec osteogen stim implanted",3847.87,3847.87,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,9,null,9]
["Electric wound treatment dev","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Mech amb infusion pump <8hrs",14.36,14.36,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Parenteral infusion pump sta",3952.61,3952.61,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Ambulatory traction device",57.69,57.69,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Traction frame attach pelvic",166.74,166.74,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Trapeze bar attached to bed",184.12,184.12,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Fracture frame attached to b",59.07,59.07,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Fracture frame attachmnts pe",86.58,86.58,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["W/c lateral trunk/hip suppor",108.18,108.18,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Amputee adapter",5.94,5.94,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Wheelchair narrowing device",21.48,21.48,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["W/ch access anti-rollback",101.67,101.67,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Add pwr joystick",3461.35,3461.35,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Man w/c push-rim powr system",6736.76,6736.76,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Wheelchair arm rest",24.42,24.42,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Pwr seat combo w/o shear",7705.68,7705.68,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Reclining back add ped w/c","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["W/c manual swingaway",210.11,210.11,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Transport chair pt wt >300lb",449.65,449.65,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Wheelchair detachable foot r",151.69999999999999,151.69999999999999,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Wheelchair lightweight det a",208.81,208.81,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Wheelchair lightweight det a",2581.5100000000002,2581.5100000000002,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Whchr s-recl fxd arm leg res",143.75,143.75,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Manual adult wc w tiltinspac",327.67,327.67,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9,null,9]
["Wheelchair amputee heavy dut",173.97,173.97,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9,null,9]
["Wheelchair spec size w foot",572.55999999999995,572.55999999999995,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9,null,9]
["Pediatric wheelchair nos","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Folding ped wc adjustable","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Whchr h-duty det arm leg res",1797.97,1797.97,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Wheelchair heavy duty fixed",153.86000000000001,153.86000000000001,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Wheelchair special seat dept",144.87,144.87,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Battery charger, port conc","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-PHL",2,9,null,9]
["O2/water vapor enrich w/o he",186.44,186.44,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9,null,9]
["Unipuncture control system","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9,null,9]
["Peritoneal dialysis clamp","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9,null,9]
["Jaw motion rehab system",40.6,40.6,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Sps ankle device",188.69,188.69,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Replacement interface spsd",145.74,145.74,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Vr cbt therapy","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Man w/ch acc seat w>=20\"<24\"",45.6,45.6,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Man wc whl lock comp repl ea",5.25,5.25,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Pneumatic caster tire tube",13.07,13.07,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Gear reduction drive wheel",259.08999999999997,259.08999999999997,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Planar back for ped size wc","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Mini-prop remote joystick",2792.77,2792.77,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Chin cup interface",52.3,52.3,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Chin cup interface",5.21,5.21,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Head control proximity switc",408.47,408.47,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["W/c dpth 20-21 in seat frame",620.42999999999995,620.42999999999995,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Gr24 nonsealed leadacid",127.39,127.39,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Pwr wc drivewheel motor repl",570.84,570.84,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Gr27 non-sealed leadacid","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9,null,9]
["Expandable controller, initl",56.6,56.6,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Tube, pneumatic caster tire",55.78,55.78,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Foam filled drive wheel tire",15.56,15.56,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Solid caster tire, integrate",5.94,5.94,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Pwc acc, lith-based battery",572.44000000000005,572.44000000000005,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Sgd prerec msg > 40 min",320.31,320.31,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Gen w/c cushion wdth >=22 in",125.2,125.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Position back cush wd <22in",433.13,433.13,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Adj skin pro wc cus wd>=22in",487.58,487.58,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Monosuspension arm/hand supp",881.38,881.38,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Mobile arm support supinator",189.75,189.75,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Crisis psychotherapy add 30m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,null,null,9]
["Pt scr tob & cess int","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt no ref, rn spec","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt w/ lmted life expec","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Cardiology ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Care manag h vst new pt 60 m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Care man home care plan 30 m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Adm subq drug 1st home visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Diab manage trn ind/group",29.39,29.39,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
["Colon ca scrn; barium enema",85.77,85.77,0,0,0,0,1,9,9,9,9,9,null,"R",null,"Y-CM",2]
["Inten outpt svs,min 9 pr 7 d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Nav srv peer sup add 30 pr m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Hhc rn e&m plan svs, 15 min",47.06,47.06,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,11]
["Scr mammo bi incl cad","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Dx mammo incl cad uni",79.41,79.41,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2]
["Pet img wholbod melano nonco","Not Covered","Not Covered",0,0,0,0,1,9,9,9,9,9,null,"X",null,null,2]
["Current percep threshold tst","Not Covered","Not Covered",0,0,0,0,1,9,9,9,9,9,null,"X",null,null,2]
["Inject for sacroiliac joint","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["Elec stim unattend for press",21.59,21.59,0,0,0,0,7,5,0,0,0,0,null,"R",null,"Y-CM",2]
["Electromagnetic therapy onc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Two-way audio and video hhs","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Percutaneous islet celltrans","Not Covered","Not Covered",0,0,0,0,0,2,0,0,1,0,null,"X",null,null,2]
["Lev 1 hosp type b ed visit","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["Alcohol/subs interv >30 min","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Inter active grp psych parti","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["Pelvic ring fx treat int fix",1849.78,1849.78,0,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2]
["Collagen meniscus implant","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ppps, initial visit","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Md document visit by npp","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Fqhc visit, ippe or awv","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Drug test def 15-21 classes",281.22000000000003,281.22000000000003,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-ONC",2]
["Md/oth eval acut kid no esrd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Cocm by rhc/fqhc 60 min mo","Not Covered","Not Covered",0,0,0,0,0,9,9,9,9,9,null,"X",null,null,2]
["Insert drug del implant, >=4",372.48,176.34,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-ONC",2]
["Cdsm ndsc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Cdsm inveniqa","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Post-d/c h vst new pt 30 m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Post-d/c h vst ext pt 20 m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Benef refuses service, mod","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Med assist tx inject","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Off base opioid tx, 60 m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Pt 66+ frailty and adv ill","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt 66+ frailty and adv ill","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Psy/dep/anx/apandicd noasse","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Fs odi 9-15mo > 22","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No mpm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt not elig low neuro ex","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Bmi not doc medrsn ptref","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Screen hlthy etoh use","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No rsn no brief couns","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Brief chkin by md/qhp, 11-21","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Diagnostic rad ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Mentl/behav health ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ophthalmology ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Rheumatology ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Thoracic surgery ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Radiation treatment delivery",337.09,337.09,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM",2]
["Radiation treatment delivery",446.85,446.85,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM",2]
["Pt inelig footwear evaluatio","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Calc bmi out nrm param nof/u","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["High risk recurrence pro ca","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Flu immunize order/admin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt ref doc oto eval","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt inelig ref oto eval","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No tpa init w/in 3 hrs","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Rafscrs ki scor >= 0","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Rafscrs ewh scor >= 0","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Lvef <40%","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Doc pos elder mal scrn plan","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Dias bp > or = 90","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt not disch home day#2 evar","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Doc reas no ahi or rdi","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No assess bone loss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Doc pt reas no pneumococcal","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt doc no wrong event","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt w iv ab given on time","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pre-htn or htn doc, f/u indc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Assess vol mgmt not doc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Mccd,phys coor-care ovrsght","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Demo-smoking cessation coun","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Onc prac cond noadd by guide","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Onc dx nsclc stg2 no progres","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Onc dx prostate unknwn nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Onc dx colon t1-4 no dx prog","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Onc dx esophageal unknown","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Onc dx pancreatc p r1/r2 no","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Onc dx cml chronic phase","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Onc dx brst unknown nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Evaluation for wheelchair","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Beta not given no reason","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Doc viral load >=200","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Bp out of nrml limits","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pne scrn done doc not ind","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No pt category on report","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Unplnd hosp readm in 30d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No doc comm risk calc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Medrsn >1 sinus ct w 90d dx","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pp eval/edu perf","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Recd f/u w/in 30d disch","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Recd f/u w/in 7d dc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Admit w/in 180d req surg rev","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Site no lung or lung cx","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Doc med pt reas no hcc scrn","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Tob non-user","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Med reas no perf foot exam","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Doc reas on statin or contra","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Minor blunt trauma w/head ct","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Indic for head ct not valid","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No filt remov w/in 3mos plcm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Door to punc time <2hrs","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Intraop cyst eval not done","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt bl srg 30 day pst srg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt w/90d mrs 0-2","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Toc tool incl elem not used","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hospice anytime msmt per","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt in hos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Sys rsn no presc bronchdil","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Bilat mast/hx bi /unilat mas","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt unable cmplt knee fs prom","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Refused to participate","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Incid pulm nodule","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt had >= 2-3 hpv vaccines","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Recd 2 anti-emet pre/intraop","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pts breastfeeding","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Most rct bp >/= 140/90","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt no recd cerv cyto/hpv","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Endo abl proc yr prev ind dt","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt no recd anti-egfr ther","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["2 em core ms mo 7-9 no wl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["2 em ongoing ms mo 19-21 wl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Adr dep thrpy prescribed","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt 66+ snp or ltc pos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Node neg pre/post syst ther","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Safty cncrns scrn and neg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt 66+ snp or ltc pos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Systemic antimicro not presc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["DOC HAT RSN NO MAC EXM PERF ","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Doc pt pal or hospice","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Alcohol and/or drug services","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Alcohol and/or drug services","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Alcohol and/or drug services","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Alcohol and/or drug preventi","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Comm psy face-face per 15min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Spec coll non-blood:a/d test","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,17]
["Nonmed family planning ed","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,17]
["Comp comm supp svc, per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Sex offend tx svc, 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["A/d tx program, per hour","Facility Only","By Report",0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-CM",2,17]
["Skill train and dev/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Adalimumab injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["Inj, lecanemab-irmb, 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,17]
["Alefacept","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Inj. lumasiran, 0.5 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Amikacin sulfate injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Succinycholine chloride inj",0.6,0.6,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Inj metaraminol bitartrate","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Arbutamine hcl injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Baclofen intrathecal trial",37.44,37.44,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Inj, bezlotoxumab, 10 mg",39.86,39.86,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Injection,onabotulinumtoxina",6.33,6.33,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Inj., lanadelumab-flyo, 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Calcium glycer & lact/10 ml","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Inj mepivacaine hcl/10 ml",3.29,3.29,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Inj ceftolozane tazobactam",7.37,7.37,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Betamethasone acet&sod phosp",6.82,6.82,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Chloramphenicol sodium injec",40.270000000000003,40.270000000000003,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Inj, cabote rilpivir 2mg 3mg",22.6,22.6,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Hiv prep, fda approved, noc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,16]
["Inj, daptomycin (xellia)","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,16,null,16]
["Epoetin beta non esrd",1.62,1.62,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Brompheniramine maleate inj","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Phenylep ketorolac opth soln",116.25,116.25,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Acetazolamid sodium injectio",28.12,28.12,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Chlorothiazide sodium inj",121.35,121.35,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Dopamine injection",0.77,0.77,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Elosulfase alfa, injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Erythro lactobionate /500 mg",80.78,80.78,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Injection estrone per 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Inj ferric pyrophosphate cit",0.03,0.03,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Gallium nitrate injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Gamma globulin 1 cc inj",50.73,50.73,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Flebogamma injection",56.12,56.12,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Hyqvia 100mg immuneglobulin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Inj, granisetron, xr, 0.1 mg",5.67,5.67,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Inj heparin sodium per 10 u",0.02,0.02,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Diazoxide injection",112.16,112.16,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Imuglucerase injection",44.02,44.02,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Inj. insulin (fiasp)","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC",2,16,null,16]
["Insulin injection",0.9,0.9,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Furosemide injection",0.56999999999999995,0.56999999999999995,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Aripirazole lauroxil 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Lorazepam injection",1.1200000000000001,1.1200000000000001,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Meperidine hydrochl /100 mg",7.3,7.3,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Inj milrinone lactate / 5 mg",1.56,1.56,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Inj, naloxone hcl (zimhi)",5.76,5.76,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Inj ublituximab-xiiy, 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,16]
["Octreotide inj, non-depot",1.19,1.19,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Oxymorphone hcl injection",2.85,2.85,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Inj, invega hafyera/trinza",12.29,12.29,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,16,null,16]
["Pentastarch 10% solution","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Phenobarbital sodium inj",31.43,31.43,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Procainamide hcl injection",146.32,146.32,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Pralidoxime chloride inj",86.7,86.7,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Injection, reslizumab, 1mg",10.17,10.17,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Inj risperdal consta, 0.5 mg",12.15,12.15,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Injection, siltuximab","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Inj, methylpred sod succ 5mg",0.27,0.27,0,0,0,0,0,0,0,0,0,0,null,"D",null,null,2,16,null,16]
["Inj. eptinezumab-jjmr 1 mg",18.059999999999999,18.059999999999999,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2,16,null,16]
["Terbutaline sulfate inj",7.79,7.79,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Trimethobenzamide hcl inj",47.84,47.84,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Triamcinolone a inj prs-free",4.1900000000000004,4.1900000000000004,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Ustekinumab sub cu inj, 1 mg",153.96,153.96,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Urokinase 250,000 iu inj","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Inj hydroxocobalamin iv 25mg","Facility Only","By Report",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2,16,null,16]
["Injection, voriconazole",1.1599999999999999,1.1599999999999999,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Esrd on dialysi drug/bio noc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["5% dextrose/normal saline",1.59,1.59,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Inj., emicizumab-kxwh 0.5 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Factor viia",2.4300000000000002,2.4300000000000002,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Antithrombin recombinant","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,16,null,16]
["Hemophilia clot factor noc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,16,null,16]
["Eth estr and eton monthly","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Mirena, 52 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Genvisc 850, inj, 1mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,16,null,16]
["Euflexxa inj per dose","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,16,null,16]
["Aminolevulinic acid, 10% gel","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Azathioprine parenteral","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Cyclosporine oral 25 mg",0.84,0.84,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Mycophenolic acid","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Levalbuterol non-comp unit",0.05,0.05,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Beclomethasone comp unit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Dexamethasone comp con","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Ipratropium bromide comp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Metaproterenol non-comp unit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Tobramycin non-comp unit",21.79,21.79,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16,null,16]
["Cabergoline, oral 0.25mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Gefitinib oral","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Arsenic trioxide injection",15.78,15.78,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Inj, aspara, rylaze, 0.1 mg",50.96,50.96,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Carboplatin injection",3.6,3.6,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Inj, bortezomib freseniuskab",2.68,2.68,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Inj, elahere, 1 mg",66.790000000000006,66.790000000000006,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,16,null,16]
["Inj, cyclophosphamide, nos","Facility Only","By Report",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2,16,null,16]
["Degarelix injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Inj, epirubicin hcl, 2 mg",1.38,1.38,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Goserelin acetate implant",609.01,609.01,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Mesna injection",1.37,1.37,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,16]
["Inj inotuzumab ozogam 0.1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,16]
["Inj., evomela, 1 mg",16.489999999999998,16.489999999999998,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2,16,null,16]
["Paclitaxel (american regent)","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC",2,16,null,16]
["Inj, dostarlimab-gxly, 10 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,9]
["Injection, nivolumab","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,9]
["Inj rituximab, hyaluronidase","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,9]
["Inj pemetrexed (bluepoint)","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC",2,16,null,9]
["Inj talimogene laherparepvec",66.59,66.59,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16,null,9]
["Inj, ado-trastuzumab emt 1mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16,null,9]
["Valrubicin injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,16,null,9]
["Inj teclistamab cqyv 0.5 mg",31.4,31.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,16,null,9]
["Ultralightweight wheelchair",256.01,256.01,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Cstm manual wheelchair/base","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9,null,9]
["Ltwt portbl power whlchr",4499.8,4499.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Detach adjust armrst upper",3.3,3.3,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Fixed adjust armrest pair",55.46,55.46,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Ftrst upr hanger brac rep ea",19.86,19.86,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Ftrst compl assembly repl ea",6.78,6.78,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Swingaway detach ftrest repl",100.84,100.84,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Caster pin lock each",46.95,46.95,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Sup/ext non-ins inf pump syr",2.95,2.95,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Repl batt for aed","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Absorp drg <= 16 suc pump","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9,null,9]
["Pov group 2 hd 301-450 lbs",2716.6,2716.6,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Pwc gp 2 std port seat/back",406,406,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Pwc gp 2 hd cap chair",655.46,655.46,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Pwc gp 2 vhd seat/back",10337.469999999999,10337.469999999999,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Pwc gp2 std sing pow opt s/b",5788.14,5788.14,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Pwc gp2 std mult pow opt s/b",6295.74,6295.74,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Pwc gp 3 std seat/back",946.18,946.18,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Pwc gp 3 xhd seat/back",1725.76,1725.76,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Pwc gp3 hd sing pow opt s/b",12600.72,12600.72,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Pwc gp3 std mult pow opt s/b",10172.33,10172.33,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9,null,9]
["Pwc gp 4 std cap chair","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,9,null,9]
["Pwc gp4 std sing pow opt s/b","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,9,null,9]
["Pwc gp4 hd mult pow s/b","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,9,null,9]
["Ext recharge bat replacement","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Flex thermoplastic collar mo",263.12,263.12,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Cerv col supp adj bar & thor",883.86,883.86,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Tlso 4mod sacro-scap pre",2074.0500000000002,2074.0500000000002,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Tlso rigid plastic pre one",394.73,394.73,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Sio flex pelvic/sacr pre ots",124.71,124.71,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Lso flex no ri stays pre ots",95.96,95.96,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Lso s/c shell/panel custom",1460.11,1460.11,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Lso sag-co shell pnl pre ots",1314.07,1314.07,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Protect body sock ea pre ots",91.4,91.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Sternal pad",137,137,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Ring flange plas/leather mol",399.54,399.54,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Body jacket mold to patient",2258.09,2258.09,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Spinal orthosis nos","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N","Y",null,2,9,null,9]
["Ho bi thighcuffs w sprdr bar",497.37,497.37,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Ko elastic with joints",152.4,152.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Ko adj jnt pos r sup pre ots",725.83,725.83,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Afo sprng wir drsflx calf bd",397.6,397.6,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Afo spiral prefabricated",1171.83,1171.83,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Kafo sng/dbl mechanical act",5717.66,5717.66,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Hkafo torsion ball bearing j",914.34,914.34,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Afo tib fx semi-rigid",793.44,793.44,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Kafo fem fx cast semi-rigid",1351.99,1351.99,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Dorsi & plantar flex ass/res",129.36000000000001,129.36000000000001,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Varus/valgus strap padded/li",95.72,95.72,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Torsion ank & half solid sti",151.04,151.04,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Thi/glut/ischia wgt bearing",452.76,452.76,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Thigh/wght bear high roll cu",418.88,418.88,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Pelv & thor control gluteal",213.89,213.89,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Extension per extension per",82.96,82.96,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Knee cap medial or lateral p",163.44,163.44,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Foot longitudinal arch suppo",243.17,243.17,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Arch suprt att to sho longit",44.32,44.32,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Hightop w/ supp/pronator inf","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Orthopedic mens shoes oxford",147.21,147.21,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Shoe molded to pt silicone s",762.7,762.7,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Ambulatory surgical boot eac",36.340000000000003,36.340000000000003,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Shoe metatarsal bar wedge ro",56.8,56.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Sho heel count plast reinfor",223.6,223.6,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Ortho shoe add half sole",44.32,44.32,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Ortho shoe add march bar",58.54,58.54,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["So vest canvas/web pre ots",222.86,222.86,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Cuffs adj lock w/ active con",1403.51,1403.51,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Torsion mechanism wrist/elbo",291.35000000000002,291.35000000000002,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,28]
["Ho w/o joints cf",343.93,343.93,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Hfo nontorsion jnts pre ots",123.88,123.88,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Fo nontorsion joint cf",280.52,280.52,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Up ext fx orthos humeral nos",404.38,404.38,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Replace strap, any orthosis",38.85,38.85,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Ortho dvc repair per 15 min",71.36,71.36,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,28,null,9]
["Pneum full leg splnt pre ots",336.47,336.47,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Ank symes mold sckt sach ft",3996.86,3996.86,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Hemipelvect canad sing axis",10066.040000000001,10066.040000000001,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Postop dsg bk ea add cast ch",762.21,762.21,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Postop app non-wgt bear dsg",654.19000000000005,654.19000000000005,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Prep ak ischial open end",4280.1000000000004,4280.1000000000004,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Ak 4 bar ling w/hydraul swig",3633.7,3633.7,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Symes type ptb brim design s",438.97,438.97,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Above knee leather socket",1224.8599999999999,1224.8599999999999,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Socket insert symes",574.45000000000005,574.45000000000005,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Bk knee joints single axis p",625.92999999999995,625.92999999999995,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Initial custom socket insert",1914.67,1914.67,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Bk back check",94.52,94.52,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Replace socket hip",7877.96,7877.96,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Knee-shin exo frict swg & st",819.9,819.9,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Exoskeletal bk ultralt mater",920.26,920.26,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Endo knee-shin polyc mch sta",1260.98,1260.98,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Mech hip extension assist",610.54999999999995,610.54999999999995,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Endo hip ultra-light materia",1519.16,1519.16,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Foot external keel sach foot",363.7,363.7,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Ank-foot sys dors-plant flex","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9,null,9]
["Part hand thumb rem",2626.77,2626.77,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Part hand myo exclu term dev",6475.13,6475.13,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Shoulder passive restor cap",2533.87,2533.87,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Postop ea cast chg & realign",684.45,684.45,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Shdr fair lead cable direct",4808.47,4808.47,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Quick disconn hook adapter o",857.51,857.51,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Excursion amplifier pulley t",254.63,254.63,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Multipo locking shoulder jnt",4590.91,4590.91,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Frame typ socket bel elbow/w",855.25,855.25,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Frame typ sock interscap-tho",1359.39,1359.39,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Term dev mech hook vol close",2085.1799999999998,2085.1799999999998,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Term device, multi art digit",4595.47,4595.47,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Custom glove for term device",919.26,919.26,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Below elbow myoelectronic ct",13229.9,13229.9,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Prehensile actuator",4465.9799999999996,4465.9799999999996,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Electronic elbow sequential",54323.46,54323.46,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9,null,9]
["Add ue prost b/e acrylic",536.02,536.02,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9,null,9]
["Upper extremity prosthes nos","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N","Y","Y-CM",2,9,null,9]
["Mastectomy form",357.22,357.22,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Partial facial prosthesis",3943.06,3943.06,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Truss add to std pad scrotal",73.19,73.19,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Pros sock multi ply upper lm",41.57,41.57,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9,null,9]
["Trach-esoph voice pros md in",158.94999999999999,158.94999999999999,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,9,null,9]
["Gel cap for trach voice pros",3.14,3.14,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,9]
["Coch implant headset replace",656.48,656.48,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["Coch implant tran cable repl",38.15,38.15,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["Cid transmit coil and cable",260.62,260.62,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["Pt prgrm for implt neurostim",1599.55,1599.55,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,9]
["Aud osseo dev, abutment","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["Pow ue rom dev ewhf uprt cus",83327.75,83327.75,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["Bebteleovimab injection","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["CASIRI AND IMDEV REPEAT HM",799.77,799.77,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2]
["Doc med rsn no srn tb","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Dc eoc doc med rec","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt dx lum sp reg fract","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt cr ft inf lm or pt id sl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt no prm nurs hm res in pp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Docu dx degen neuro","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Oc ni pt dc 1-2 vis","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Oc ni pt 1-2 vis","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Mfn drug add-on, per dose","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Pt self dschg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Dre w/o rtnopthy","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Iop dec <20% from base","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt no resp best int","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,16]
["Pt othr thn true heard","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,16]
["Pts w/ othr rsn vst,+prg tst","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,16]
["Pts hosp dialysis dt","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pts hosp exl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt scrn tbco id as non user","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Bp scrn perf rec interval","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Bmi not doc medrsn ptref","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["No tob scr/cess int","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,28]
["Pts 7wk inj, scrn iop =<25","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,28]
["Pts intravitreal/pci","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,28]
["Pts eval ini xm 2 wks","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,28]
["Pt pam incr 6 pt 6-12 mo","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,28]
["Suicd based cln eval","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,28]
["Qual care ent disorder mvp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,28]
["Rehab support msk care mvp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,28]
["Whole blood for transfusion","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Cryo fib comp path redu each","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Plate pheres leukoredu irrad","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Blood, l/r, cmv-neg","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Platelets pheresis path redu","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Cardiokymography","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2]
["Fern test",13.78,13.78,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2]
["Dronabinol 2.5mg oral",0.73,0.73,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["CASIRIVI AND IMDEVI 600MG",0.01,0.01,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["Bamlanivimab and etesevima","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,16]
["Microprcsr cu elec vad, rep","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["Emr pwr cbl combo vad, rep","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Lith-ion batt elec/pneum vad","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Sermorelin acetate injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Afluria vacc, 3 yrs & >, im","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Imported lipodox inj",484.5,484.5,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2]
["Cast sup body cast plaster",60.61,60.61,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["Cast sup shoulder cast fbrgl",150.66,150.66,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["Cast sup sht arm ped plaster","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["Cast sup sht arm splnt ped p","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["Cast sup lng leg ped fbrgls","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["Cast sup lng leg splnt ped p","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["Skin substitute, nos","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28]
["Graftjacket","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28]
["Dermacell, awm, porous sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Arthroflex","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hmatrix","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Allowrap ds or dry 1 sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Neoxflo or clarixflo 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Truskin, per sq centimeter","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Revita, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Fluid flow or fluid gf 1 cc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Surgigraft dual per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Progenamatrix, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Polycyte, topical only 0.5cc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Amniotext patch, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Novafix dl per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Neostim per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Epieffect, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Nudyn dl or dl mesh pr sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Membrane wrap hydr per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Activate matrix, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Sanopellis, per sq cm","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Hospice home care in hospice","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Inj herzuma 10 mg",40.31,40.31,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2]
["Inj, releuko 1 mcg",0.54,0.54,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2]
["Va chaplain counsel group","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Inj perflexane lip micros,ml",13.25,13.25,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["Non-heu tc-99m add-on/dose","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Transport port x-ray multipl",40.090000000000003,40.090000000000003,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,26]
["Transport portable ekg","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Esketamine, nasal spray",11.58,11.58,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2]
["Injection, ofloxacin, 400 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Zidovudine, oral, 100 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Inj menotropins 75 iu","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Becaplermin gel 1%, 0.5 gm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Procarbazine, oral",104.08,104.08,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["Prenatal vitamins 30 day","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Paramedicintercep nonhospals","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Home hospice case 30 days","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hospitalist visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Global eswl kidney","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Scleral lens liquid bandage","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ann breast exam","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Non-pvc intravenous administ","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Cranial remolding orthosis","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Transplantation of multivisc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Adoptive immunotherapy","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Low density lipoprotein(ldl)","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Implant semi-imp hear","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hip core decompression","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Fetal surg sacrococ teratoma","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Saliva test, hormone level;","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Gene test hippel-lindau","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Surface emg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ivf package","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ivf canc a aspir case rate","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Monit store cryo embryo 30 d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Contraceptive pills for bc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Adult day care per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Homaker service nos per 15m","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Adult companioncare per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Emer rspns sys serv permonth","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Hit picc insert kit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hip midline cath insert kit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Low dose ct lung screening","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Fluorine-18 fluorodeoxygluco","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Flutter device","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Infect control supplies nos","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Supplies for home delivery","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Custom gradient sleev/glov","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Ready gradient sleev/glov","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Custom grad sleeve med","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Custom grad sleeve heavy","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Ready gradient sleeve","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Custom grad glove med","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Custom grad glove heavy","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Ready gradient glove","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Ready gradient gauntlet","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Gradient pressure wrap","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Padding for comprssn bdg","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Compression bandage","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Splint digit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Splint wrist or ankle","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Splint elbow","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Camisole post-mast","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["100 insulin syringes","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Auricular electrostimulation","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hippotherapy per session","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Low-level laser trmt 15 min","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Complex lymphedema therapy,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt or manip for maint","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Resuscitation bag","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Home uterine monitor with or","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Intra-vag motion sens biofk","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Ultrafiltration monitor","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Paranasal sinus ultrasound","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Omnicardiogram/cardiointegra","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Eswl for gallstones","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Procuren or other growth fac","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Coma stimulation per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Medical supplies and equipme","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Urgent care center global","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Services provided in urgent","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Vertebral axial decompressio","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Home visit wound care","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Home phototherapy visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Telemonitoring/home per mnth","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Back school visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Home health aide or certifie",43,43,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2]
["Nursing care in home rn",86.43,86.43,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2]
["Nursing care, in the home; b",62.44,62.44,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2]
["Respite care, in the home, p","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hospice care, in the home, p","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Social work visit, in the ho","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Speech therapy, in the home,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Occupational therapy, in the","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt in the home per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Diabetic management program,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Diabetic management program,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Insulin pump initiation","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Evaluation by ocularist","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Speech therapy, re-eval","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Home mgmt preterm labor","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Home mgmt pprom","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Home mgmt gest hypertension","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hm postpar hyper per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hm preeclamp per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hm gest dm per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit pain mgmt per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit cont pain per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit int pain per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit pain imp pump diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit chemo per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit cont chem diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit intermit chemo diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ht hemodialysis diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit cont anticoag diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit immunotherapy diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit periton dialysis diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit enteral per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit enteral grav diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit enteral pump diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit enteral bolus nurs","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit anti-hemophil diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit alpha-1-proteinas diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit longterm infusion diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit sympathomim diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit tocolysis diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit cont antiemetic diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit cont insulin diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit chelation diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit enzyme replace diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit anti-tnf per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit diuretic infus diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit anti-spasmotic diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit tpn total diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit tpn 1 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit tpn 2 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit tpn 3 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit tpn over 3l diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ht inj antiemetic diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ht inj anticoag diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit hydra total diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit hydra 1 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit hydra 2 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit hydra 3 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit hydra over 3l diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit noc per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit high risk/escort","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Anticoag clinic per session","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pharmacy comp/disp serv","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Med food non inborn err meta","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Medical food oral 100% nutr","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Mod solid food suppl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Medical foods for inborn err","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Lamaze class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Childbirth refresher class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Cesarean birth class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Vbac class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Asthma education","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Birthing class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Lactation class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Parenting class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pt education noc individ",46.23,46.23,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2]
["Pt education noc group","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Infant safety class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Weight mgmt class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Exercise class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Nutrition class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Smoking cessation class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Stress mgmt class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Diabetic management program,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Diabetic management program,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Diabetic management program,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Nutritional counseling, diet","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Cardiac rehabilitation progr","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Pulmonary rehabilitation pro","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Enterostomal therapy by a re","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ambulatory setting substance","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Vestibular rehab per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Intensive outpatient psychia","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,17]
["Family stabilization 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Crisis intervention per hour","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Crisis intervention mental h","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit corticosteroid/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit antibiotic total diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit antibiotic q3h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit antibiotic q24h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit antibiotic q12h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit antibiotic q8h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit antibiotic q6h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit antibiotic q4h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Venipuncture home/snf","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ht hem horm inj diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit blood products diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ht inj noc per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ht inj growth horm diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hit inj interferon diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ht inj hormone diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ht inj palivizumab diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ht inj immuno diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ht irrigation diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ht pharm per hour","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Christian sci pract visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Christian sci nurse visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Air ambulanc nonemerg fixed","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Air ambulan nonemerg rotary","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Health club membership yr","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Transplant related per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Lodging per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Meals per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Med record copy admin",29.93,29.93,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,null,null,5]
["Med record copy per page",0.59,0.59,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,null,null,5]
["Not medically necessary svc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Serv part of phase i trial","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Services outside us","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Services provided as part of","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Services provided as part of","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Transportation costs to and","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Lodging costs (e.g. hotel ch","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Meals for clinical trial par","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Sales tax","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Private duty/independent nsg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Nursing assessment/evaluatn","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Rn services up to 15 minutes","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Lpn/lvn services up to 15min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Nsg aide service up to 15min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Respite care service 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Family/couple counseling","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Treatment plan development","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Child sitting services","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Meals when receive services","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Alcohol/substance abuse skil","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Sign lang/oral interpreter","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Telehealth transmit, per min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Clinic service","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,null,null,5]
["Case management","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Targeted case management","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["School-based iep ser bundled","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Personal care ser per 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Personal care ser per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Hh aide or cn aide per visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Contracted services per day","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Program intake assessment","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Team evaluation & management","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Ped compr care pkg, per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Ped compr care pkg, per hour","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Family training & counseling","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Home environment assessment","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Dwelling lead investigation","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Rn home care per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Lpn home care per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Sv doula brth wrk per 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Sv doula brth wrk per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Comm bh clinic svc per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Comm bh clinic svc per month","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Medication admin visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Med admin, not oral/inject","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Elec med comp dev, noc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Noc retail items andsupplies","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["N-et; patient attend/escort","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["N-et; per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["N-et; encounter/trip","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["N-et; commerc carrier pass","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["N-et; stretcher van","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Non-emer transport wait time","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Pasrr level i","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Pasrr level ii","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Habil ed waiver, per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Habil ed waiver per hour","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Habil prevoc waiver, per d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Habil prevoc waiver per hr","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Habil res waiver per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Habil res waiver 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Habil sup empl waiver/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Habil sup empl waiver 15min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Day habil waiver per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Day habil waiver per 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Case management, per month","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Targeted case mgmt per month","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Serv asmnt/care plan waiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Waiver service, nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Special childcare waiver/d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Spec childcare waiver 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,null,null,5]
["Special supply, nos waiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Special med equip, noswaiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Assist living waiver/month","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Assist living waiver/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Res care, nos waiver/month","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Res, nos waiver per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Crisis interven waiver/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Utility services waiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Camp overnite waiver/session","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Camp day waiver/session","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Comm trans waiver/service","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Vehicle mod waiver/service","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Financial mgt waiver/15min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Support broker waiver/15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hospice routine home care","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hospice continuous home care","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hospice respite care","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hospice general care","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hospice long term care, r&b","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Hab prevo waiver per 15","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Bh ltc res r&b, per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["N-et; stretcher van, mileage","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Financial mgt waiver/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Support broker waiver/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Breast milk proc/store/dist","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Adult size brief/diaper sm","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Adult size brief/diaper med","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Adult size brief/diaper lg","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Adult size brief/diaper xl","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Adult size pull-on sm","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Adult size pull-on med","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Adult size pull-on lg","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Adult size pull-on xl","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Ped size brief/diaper sm/med","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ped size brief/diaper lg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ped size pull-on sm/med","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Ped size pull-on lg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Youth size brief/diaper","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Youth size pull-on","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Disposable liner/shield/pad","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Reusable pull-on any size","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Reusable underpad bed size","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Diaper serv reusable diaper","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Reuse diaper/brief any size","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Reusable underpad chair size","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Large disposable underpad","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Small disposable underpad","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Adult disp brief/diap abv xl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Adlt disp und/pull on abv xl","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Incon disposable penile wrap","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["Position seat spec orth need","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Supply, nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["2019-ncov diagnostic p",50.83,50.83,0,0,0,0,0,0,0,0,0,0,null,"L",null,"Y-CM",2]
["Covid-19 lab test non-cdc",72.599999999999994,72.599999999999994,0,0,0,0,0,0,0,0,0,0,null,"L",null,"Y-CM",2]
["Travel, vocational services, claimant","State Rate","State Rate",0,0,0,0,0,0,0,0,0,0,null,"S",null,null,2,30]
["Vision svcs frames purchases","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Eyeglasses delux frames","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens spher single plano 4.00","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Single visn sphere 4.12-7.00","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Singl visn sphere 7.12-20.00","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylindr 4.00d/12-2.00d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylindr 4.00d/2.12-4d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylinder 4.00d/4.25-6d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylinder 4.00d/>6.00d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylinder 4.25d/12-2d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylinder 4.25d/2.12-4d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylinder 4.25d/4.25-6d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylinder 4.25d/over 6d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylindr 7.25d/.25-2.25","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylindr 7.25d/2.25-4d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylindr 7.25d/4.25-6d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Spherocylinder over 12.00d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens lenticular bifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens aniseikonic single","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lenticular lens, single","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Lens single vision not oth c","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens spher bifoc plano 4.00d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphere bifocal 4.12-7.0","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphere bifocal 7.12-20.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcyl bifocal 4.00d/.1","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy bifocal 4.00d/2.1","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy bifocal 4.00d/4.2","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy bifocal 4.00d/ove","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy bifocal 4.25-7d/.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy bifocal 4.25-7/2.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy bifocal 4.25-7/4.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy bifocal 4.25-7/ov","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy bifo 7.25-12/.25-","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcyl bifo 7.25-12/2.2","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcyl bifo 7.25-12/4.2","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcyl bifocal over 12.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens lenticular bifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens aniseikonic bifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens bifocal seg width over","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens bifocal add over 3.25d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lenticular lens, bifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Lens bifocal speciality","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphere trifocal 4.00d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphere trifocal 4.12-7.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphere trifocal 7.12-20","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy trifocal 4.0/.12-","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy trifocal 4.0/2.25","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy trifocal 4.0/4.25","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcyl trifocal 4.00/>6","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcy trifocal 4.25-7/.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphc trifocal 4.25-7/2.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphc trifocal 4.25-7/4.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphc trifocal 4.25-7/>6","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphc trifo 7.25-12/.25-","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphc trifo 7.25-12/2.25","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphc trifo 7.25-12/4.25","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens sphcyl trifocal over 12","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens lenticular trifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens aniseikonic trifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens trifocal seg width > 28","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens trifocal add over 3.25d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lenticular lens, trifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Lens trifocal speciality","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens variab asphericity sing","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Lens variable asphericity bi","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Variable asphericity lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Contact lens pmma spherical","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Cntct lens pmma-toric/prism","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Contact lens pmma bifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Cntct lens pmma color vision","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Cntct gas permeable sphericl","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Cntct toric prism ballast","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Cntct lens gas permbl bifocl","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Contact lens extended wear","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Contact lens hydrophilic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Cntct lens hydrophilic toric","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Cntct lens hydrophil bifocl","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Cntct lens hydrophil extend","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Cntct lens hydrophil photoch","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Cl, hydrophilic, dual focus","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Cntct lens blue violet","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Contact lens gas impermeable","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Contact lens gas permeable","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Contact lens/es other type","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Hand held low vision aids","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Single lens spectacle mount","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Telescop/othr compound lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Plastic eye prosth custom","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Polishing artifical eye","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Enlargemnt of eye prosthesis","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Reduction of eye prosthesis","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Scleral cover shell","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Fabrication & fitting","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Prosthetic eye other type","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Anter chamber intraocul lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Iris support intraoclr lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Post chmbr intraocular lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Balance lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Deluxe lens feature","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Glass/plastic slab off prism","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Prism lens/es","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Fresnell prism press-on lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Special base curve","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Tint photochromatic lens/es","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Tint, any color/solid/grad","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Anti-reflective coating","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Uv lens/es","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Eye glass case","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Scratch resistant coating","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Mirror coating","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Polarization, any lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Occluder lens/es","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Oversize lens/es","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Progressive lens per lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Lens, 1.54-1.65 p/1.60-1.79g","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Lens, >= 1.66 p/>=1.80 g","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Lens polycarb or equal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Corneal tissue processing","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Occupational multifocal lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Astigmatism-correct function","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Presbyopia-correct function","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Amniotic membrane","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Vis item/svc in other code","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Misc vision item or service","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Hearing screening",93.09,93.09,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["Assessment for hearing aid","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,5]
["Hearing aid fitting/checking","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,5]
["Hearing aid repair/modifying",62.07,62.07,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["Conformity evaluation","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,5]
["Body-worn hearing aid air","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Body-worn hearing aid bone","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid monaural in ear","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Behind ear hearing aid","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Glasses air conduction","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Glasses bone conduction","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid dispensing fee","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Implant mid ear hearing pros","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Body-worn bilat hearing aid","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid dispensing fee","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Body-worn binaur hearing aid","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["In ear binaural hearing aid","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Behind ear binaur hearing ai","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Glasses binaural hearing aid","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Dispensing fee binaural",1762.64,1762.64,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["Hearing aid monaural ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid monaural itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid monaural bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid monaural glasses","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Disp fee contralateral monau",1056.48,1056.48,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["Hearing aid binaural ite/ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid binaural ite/itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid binaural ite/bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid binaural itc/itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid binaural itc/bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid binaural bte/bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid binaural glasses","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Disp fee contralateral binau",1056.48,1056.48,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["Dispensing fee, monaural",881.32,881.32,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["Hearing aid, monaural, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, monaural, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, prog, mon, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, prog, mon, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, prog, mon, ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, prog, mon, bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, binaural, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, binaural, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, prog, bin, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, prog, bin, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, prog, bin, ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, prog, bin, bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing id, digit, mon, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, digit, mon, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, digit, mon, ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, digit, mon, bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, digit, bin, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, digit, bin, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, digit, bin, ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, digit, bin, bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["Hearing aid, disp, monaural","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Hearing aid, disp, binaural","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ear mold/insert","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL",2,5]
["Ear mold/insert, disp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Battery for hearing device",1.0900000000000001,1.0900000000000001,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,5]
["Hearing aid sup/access/dev","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL",2,5]
["Ald telephone amplifier","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Alerting device, any type","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald, tv amplifier, any type","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald, tv caption decoder","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Tdd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald for cochlear implant","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald unspecified","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ear impression","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald fm/dm system, monaural","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald fm/dm system binaural","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald neck, loop ind receiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald fm/dm ear level receiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald fm/dm aud input receiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald blu tooth fm/dm receiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald fm/dm receiver, nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald fm/dm transmitter ald","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald fm/dm adapt/boot couplin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Ald transmitter microphone","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Hearing aid noc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["Hearing service","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,5]
["Repair communication device","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Speech screening","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Language screening","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["Dysphagia screening","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]

{"sheet":"Table","index":5,"n_rows":20793,"n_cols":23,"rows_kept":4500,"cut":true,"hidden":true,"merged":[],"bounds":{"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0}}
[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"]
["01953",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",58.35,58.35,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,4]
["01996",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",77.290000000000006,77.290000000000006,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,4]
["01999",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,4]
[10004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",95.97,77.97,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[10005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",251.92,131.36000000000001,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[10006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",110.96,89.97,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[10007,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",578.21,160.15,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[10008,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",266.31,91.17,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[10009,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",814.53,194.34,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[10010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",445.65,127.76,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[10011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,0,0,0,0,null,"N",null,"Y-CM",2,29]
[10012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,29]
[10021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29]
[10030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1211.5999999999999,240.52,0,0,0,0,9,2,9,0,0,0,null,"R",null,"Y-CM",2,29]
[10035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,29]
[10036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,29]
[10040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",220.73,94.77,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[10060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",240.52,200.93,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[10061,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",403.07,344.29,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[10080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",479.24,197.33,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[10081,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",651.38,314.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[10120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",289.10000000000002,199.13,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[10121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",497.83,339.49,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[10140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",321.49,220.73,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[10160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",245.32,180.54,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[10180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",494.24,330.49,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",112.16,49.78,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",51.58,26.99,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[11004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1010.06,1010.06,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1368.14,1368.14,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[11006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1241.5899999999999,1241.5899999999999,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11008,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",481.04,481.04,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[11010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",839.72,505.03,10,0.1,0.8,0.1,0,2,2,1,0,0,null,"R",null,null,2,29]
[11011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",934.49,538.02,0,0,0,0,0,2,2,1,0,0,null,"R",null,null,2,29]
[11012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1212.8,751.55,0,0,0,0,0,2,2,1,0,0,null,"R",null,null,2,29]
[11042,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",245.92,110.96,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11043,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",434.26,278.31,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",577.01,406.66,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",74.38,44.99,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[11046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",134.36000000000001,97.77,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[11047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",220.73,173.34,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[11055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",136.75,27.59,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11056,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",157.75,39.590000000000003,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11057,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",171.54,51.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",191.34,68.38,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",95.37,39.590000000000003,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[11104,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",238.12,85.17,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",112.76,46.18,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[11106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",295.7,102.57,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",134.96,55.78,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[11200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",175.74,144.55000000000001,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",34.19,29.39,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",191.94,61.78,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",230.92,92.97,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",260.31,108.56,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11303,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",287.3,128.96,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",199.73,67.180000000000007,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",232.72,88.17,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",262.11,112.76,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11308,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",275.31,125.96,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",220.13,82.77,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11311,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",259.11,113.96,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",294.5,134.96,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",341.89,174.54,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,29]
[11400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",244.72,159.55000000000001,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11401,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",296.89999999999998,198.53,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11402,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",326.29000000000002,216.53,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11403,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",374.88,280.11,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11404,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",423.46,307.10000000000002,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",597.4,458.85,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",241.12,154.75,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11421,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",302.89999999999998,203.93,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11422,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",339.49,254.92,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11423,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",388.07,293.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11424,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",448.05,337.09,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",612.4,494.24,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",274.11,203.33,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11441,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",330.49,251.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",366.48,275.91000000000003,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11443,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",430.06,334.69,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11444,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",532.02,418.66,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",717.36,585.4,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",813.93,487.64,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,null,2,29]
[11451,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",988.47,614.20000000000005,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,29]
[11462,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",792.34,465.44,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,29]
[11463,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1001.67,617.79,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,29]
[11470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",858.91,533.22,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[11471,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1028.6600000000001,651.38,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[11600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",374.28,227.92,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11601,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",433.06,275.31,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",463.05,299.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11603,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",525.41999999999996,356.28,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11604,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",584.80999999999995,391.07,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",837.32,577.01,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",376.07,229.72,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11621,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",434.26,276.51,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11622,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",478.64,313.10000000000002,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11623,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",557.21,385.07,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11624,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",632.79,436.65,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11626,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",758.15,530.22,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",386.27,236.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",448.65,287.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11642,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",506.23,336.49,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11643,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",591.4,417.46,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11644,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",728.76,515.83000000000004,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11646,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",939.29,708.96,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11719,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.99,13.2,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",62.38,25.19,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[11721,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",83.97,42.59,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[11730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",218.33,97.77,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11732,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",61.78,30.59,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[11740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",110.36,60.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",304.7,189.54,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",230.92,109.76,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[11760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",349.68,203.33,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11762,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",542.82000000000005,345.48,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11765,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",316.69,174.54,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[11770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",668.78,341.29,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11771,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1180.4100000000001,832.52,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11772,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1446.72,1074.24,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[11900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",108.56,54.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11901,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",131.96,82.77,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[11920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",379.07,208.73,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[11921,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",417.46,239.32,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[11922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",115.76,52.18,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[11950,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",152.94999999999999,94.17,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[11951,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",202.73,131.96,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[11952,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",270.51,185.34,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[11954,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",298.10000000000002,202.13,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[11960,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1897.77,1897.77,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[11970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1042.45,1042.45,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,null,2,29]
[11971,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1029.8599999999999,1029.8599999999999,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,29]
[11976,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29]
[11980,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2,29]
[11981,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",187.74,112.76,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[11982,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",206.33,131.36000000000001,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[11983,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",262.70999999999998,185.94,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[12001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",177.54,80.37,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[12002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",214.13,105.56,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[12004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",248.32,131.36000000000001,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[12005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",330.49,168.54,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[12006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",380.87,206.33,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[12007,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",430.66,256.70999999999998,0,0,0,0,0,2,0,1,1,0,null,"R",null,null,2,29]
[12011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",210.53,99.57,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[12013,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",218.33,103.17,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[12014,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",266.31,133.16,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[12015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",320.89,166.74,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[12016,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",405.46,226.12,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[12017,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",272.91000000000003,272.91000000000003,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[12018,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",307.10000000000002,307.10000000000002,0,0,0,0,0,2,0,2,0,0,null,"R",null,null,2,29]
[12020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",566.21,347.88,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",332.89,262.11,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",499.03,281.31,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12032,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",575.80999999999995,353.88,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12034,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",632.79,379.07,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",732.36,443.25,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",812.13,515.83000000000004,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12037,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",909.9,598,10,0.1,0.8,0.1,0,2,0,0,1,0,null,"R",null,null,2,29]
[12041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",500.23,268.70999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12042,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",586.6,362.28,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",724.56,394.67,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",777.34,505.03,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",938.09,583.01,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[12047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1025.06,644.79,10,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,null,2,29]
[12051,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",536.82000000000005,313.7,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12052,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",596.20000000000005,368.88,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12053,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",687.37,397.07,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12054,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",721.56,403.07,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",946.48,553.62,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[12056,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1088.6400000000001,707.16,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[12057,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1135.42,769.54,10,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,null,2,29]
[13100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",642.99,368.28,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[13101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",749.15,454.65,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[13102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",217.13,129.56,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[13120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",669.38,427.06,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[13121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",801.33,472.64,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[13122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",236.32,148.75,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[13131,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",730.56,443.85,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[13132,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",884.71,553.62,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[13133,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",312.5,226.72,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[13151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",794.14,509.23,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[13152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",930.89,613,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[13153,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",342.49,245.92,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[13160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1461.11,1461.11,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[14000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1198.4000000000001,938.09,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[14001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1519.89,1208,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[14020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1326.76,1056.25,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[14021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1629.06,1313.56,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[14040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1428.72,1157.6099999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[14041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1732.82,1410.73,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[14060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1441.32,1233.79,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[14061,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1871.38,1516.29,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[14301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2021.93,1599.07,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R",null,null,2,29]
[14302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",387.47,387.47,0,0,0,0,0,0,0,2,0,0,null,"R",null,null,2,29]
[14350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1248.78,1248.78,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",639.99,396.47,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[15003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",128.36000000000001,80.37,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[15004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",731.76,469.64,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[15005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",212.93,160.15,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[15040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",492.44,227.32,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1103.03,851.72,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1617.06,1318.36,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",346.08,199.73,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1541.49,1309.3599999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",204.53,180.54,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1497.7,1276.97,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",277.11,246.52,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29]
[15120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1577.47,1271.58,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",386.27,238.72,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29]
[15130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1346.55,1107.83,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15131,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",177.54,160.75,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29]
[15135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1624.86,1399.33,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15136,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",175.14,160.75,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29]
[15150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1293.77,1166.01,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",212.33,192.54,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",266.31,248.32,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1471.31,1341.15,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15156,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",285.5,265.70999999999998,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29]
[15157,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",317.29000000000002,289.7,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29]
[15200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1572.68,1244.5899999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",261.51,137.35,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1448.52,1133.6199999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15221,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",241.72,124.16,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1745.42,1480.91,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15241,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",325.69,193.14,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1876.77,1569.08,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",382.67,245.32,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15271,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",289.7,151.75,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[15272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",45.58,29.99,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15273,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",574.01,350.28,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[15274,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",151.15,79.17,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",298.10000000000002,168.54,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[15276,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",59.38,44.39,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15277,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",632.79,398.87,0,0,0,0,0,2,0,1,1,0,null,"R",null,null,2,29]
[15278,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",176.34,99.57,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29]
[15570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1689.04,1341.15,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15572,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1647.05,1361.55,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15574,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1653.65,1366.34,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15576,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1462.31,1199,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",646.58000000000004,401.27,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",701.17,460.65,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",848.72,613,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",877.51,645.38,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1023.86,754.55,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2678.71,1690.84,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29]
[15731,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2089.1,1840.19,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15733,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1888.77,1888.77,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29]
[15734,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2733.29,2733.29,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29]
[15736,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2239.65,2239.65,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29]
[15738,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2317.63,2317.63,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29]
[15740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1896.57,1557.68,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1721.43,1721.43,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R",null,null,2,29]
[15756,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4159.6099999999997,4159.6099999999997,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R",null,null,2,29]
[15757,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4133.82,4133.82,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R",null,null,2,29]
[15758,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4117.63,4117.63,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R",null,null,2,29]
[15760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1585.27,1293.17,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15769,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",888.3,888.3,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[15770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1252.98,1252.98,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29]
[15771,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,29]
[15772,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2,29]
[15773,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,29]
[15774,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2,29]
[15775,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",702.37,463.65,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[15776,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",948.28,634.59,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[15777,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",385.07,385.07,0,0,0,0,0,0,1,1,0,0,null,"R",null,null,2,29]
[15778,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",686.77,686.77,0,0,0,0,0,2,0,2,1,0,null,"R",null,null,2,29]
[15780,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1598.47,1238.5899999999999,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15781,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1010.06,797.73,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15782,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",921.29,695.17,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15783,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",852.92,666.98,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15786,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",434.26,248.92,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[15787,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",56.38,29.99,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[15788,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,1,0,0,null,"X",null,null,2,29]
[15789,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,1,0,0,null,"X",null,null,2,29]
[15792,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,0,0,0,null,"X",null,null,2,29]
[15793,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,0,0,0,null,"X",null,null,2,29]
[15819,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,0,0,0,null,"X",null,null,2,29]
[15820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1094.6400000000001,968.08,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[15821,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1169.01,1029.8599999999999,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[15822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",872.11,747.95,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[15823,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1172.01,1031.06,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[15824,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1632.14,1632.14,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,29]
[15825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1403.36,1403.36,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,29]
[15826,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1327.08,1327.08,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,29]
[15828,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4545.6099999999997,4545.6099999999997,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,29]
[15829,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,1,0,0,0,null,"N",null,"Y-CM",2,29]
[15830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2149.08,2149.08,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[15832,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1699.83,1699.83,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[15833,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1621.26,1621.26,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[15834,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1650.05,1650.05,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[15835,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1717.23,1717.23,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[15836,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1476.11,1476.11,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[15837,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1622.46,1326.76,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[15838,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1207.4000000000001,1207.4000000000001,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[15839,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1665.04,1364.55,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[15840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1865.38,1865.38,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15841,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3259.91,3259.91,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29]
[15842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4918.3599999999997,4918.3599999999997,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29]
[15845,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1962.55,1962.55,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R",null,null,2,29]
[15847,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,2,1,0,null,"N",null,"Y-CM",2,29]
[15851,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",103.77,119.96,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[15852,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",80.37,80.37,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[15853,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",22.19,22.19,0,0,0,0,5,0,0,1,0,0,null,"R",null,null,2,29]
[15854,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",30.59,30.59,0,0,0,0,5,0,0,1,0,0,null,"R",null,null,2,29]
[15860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",190.14,190.14,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[15876,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29]
[15877,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29]
[15878,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,29]
[15879,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,29]
[15920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1166.01,1166.01,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1479.11,1479.11,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29]
[15931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1293.17,1293.17,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15933,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1609.26,1609.26,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15934,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1817.39,1817.39,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2132.89,2132.89,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29]
[15936,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1644.65,1644.65,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29]
[15937,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1901.37,1901.37,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29]
[15940,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1303.3699999999999,1303.3699999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15941,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1716.03,1716.03,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15944,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1729.22,1729.22,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15945,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1886.97,1886.97,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,29]
[15946,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2946.82,2946.82,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29]
[15950,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1184.6099999999999,1184.6099999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,29]
[15951,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1667.44,1667.44,90,0.1,0.71,0.19,0,2,0,0,1,0,null,"R",null,null,2,29]
[15952,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1695.63,1695.63,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29]
[15953,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1866.58,1866.58,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29]
[15956,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2178.4699999999998,2178.4699999999998,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29]
[15958,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2159.2800000000002,2159.2800000000002,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,29]
[15999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29]
[16000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",149.35,82.17,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[16020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",162.55000000000001,103.77,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[16025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",294.5,203.93,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[16030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",368.88,239.92,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[16035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",352.08,352.08,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[16036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",146.94999999999999,146.94999999999999,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[17000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",128.36000000000001,103.77,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",12.6,3.6,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",317.89,182.94,10,0.1,0.8,0.1,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",650.78,515.23,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",844.52,671.18,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17108,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1192.4000000000001,978.27,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[17110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",217.73,130.16,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",253.72,156.55000000000001,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",166.14,69.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[17260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",188.94,131.36000000000001,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",282.51,162.55000000000001,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17262,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",338.29,204.53,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",365.88,226.12,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17264,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",392.27,241.12,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17266,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",444.45,282.51,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",284.31,177.54,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17271,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",315.49,194.94,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",357.48,224.33,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17273,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",395.87,253.12,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17274,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",461.25,308.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17276,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",533.82000000000005,371.28,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",267.51,161.94999999999999,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17281,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",340.69,218.93,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",388.67,251.92,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17283,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",458.25,314.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",519.42999999999995,364.68,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",663.98,494.84,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17311,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1286.57,644.79,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",783.34,343.09,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1211,578.21,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17314,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",750.95,317.89,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",149.94999999999999,90.57,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29]
[17340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[17360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[17380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29]
[17999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29]
[19000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",189.54,75.569999999999993,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[19001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",48.58,37.79,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29]
[19020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",885.3,584.21,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,null,2,29]
[19030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",308.89999999999998,135.55000000000001,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[19081,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",941.69,290.89999999999998,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[19082,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",728.16,145.75,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[19083,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",939.29,275.31,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[19084,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",717.36,137.35,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[19085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1445.52,320.29000000000002,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[19086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1123.43,159.55000000000001,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[19100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",279.51,122.96,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[19101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",612.4,409.06,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[19105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2,29]
[19110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",913.5,654.38,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[19112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",868.51,602.79999999999995,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[19120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",968.08,769.54,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[19125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1064.6500000000001,849.32,90,0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29]
[19126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",283.70999999999998,283.70999999999998,0,0,0,0,0,0,0,1,1,0,null,"R",null,"Y-CM",2,29]
[19281,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",455.25,175.74,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[19282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",324.49,88.17,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[19283,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",488.24,177.54,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[19284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",359.28,88.77,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[19285,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",695.77,149.94999999999999,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[19286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",571.01,75.569999999999993,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[19287,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1202.5999999999999,224.33,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[19288,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",929.69,112.16,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[19294,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",291.5,291.5,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[19296,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,29]
[19297,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,29]
[19298,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,29]
[19300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,1,0,0,null,"X",null,null,2,29]
[19301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,0,0,0,null,"X",null,null,2,29]
[19302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,29]
[19303,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,29]
[19305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,29]
[19306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,29]
[19307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,29]
[19316,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1461.11,1461.11,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[19318,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2007.53,2007.53,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[19325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1142.02,1142.02,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[19328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1026.26,1026.26,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[19330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1193,1193,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[19340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1401.73,1401.73,90,0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29]
[19342,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1407.73,1407.73,90,0.1,0.71,0.19,0,2,1,0,1,0,null,"R",null,"Y-CM",2,29]
[19350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1554.08,1246.3800000000001,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[19355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,0,0,0,null,"X",null,null,2,29]
[19357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2150.2800000000002,2150.2800000000002,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[19361,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2850.85,2850.85,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[19364,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4945.3500000000004,4945.3500000000004,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[19367,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3234.72,3234.72,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[19368,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3947.88,3947.88,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[19369,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3670.78,3670.78,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[19370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1243.3900000000001,1243.3900000000001,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[19371,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1314.16,1314.16,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[19380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1491.7,1491.7,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[19396,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",512.83000000000004,260.31,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[19499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,29]
[20100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1083.8399999999999,1083.8399999999999,10,0.1,0.8,0.1,0,2,1,2,0,0,null,"R",null,null,2,29]
[20101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1088.04,380.27,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[20102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1157.01,466.04,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[20103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1057.45,632.19000000000005,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[20150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1846.78,1846.78,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[20200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",407.86,172.74,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[20205,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",571.01,280.70999999999998,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[20206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",418.06,103.77,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[20220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",439.05,157.15,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[20225,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",717.96,232.12,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[20240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",254.92,254.92,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[20245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",620.79,620.79,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[20250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",719.76,719.76,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[20251,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",769.54,769.54,10,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,null,2,29]
[20500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",233.32,166.14,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[20501,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",269.31,64.78,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[20520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",412.66,276.51,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[20525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",876.31,456.45,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[20526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",153.55000000000001,103.17,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[20527,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",163.75,119.96,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[20550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",107.96,70.180000000000007,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[20551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",107.36,69.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[20552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",98.37,67.180000000000007,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[20553,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",113.36,76.17,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[20555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29]
[20560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",48.58,26.99,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29]
[20561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",69.58,40.19,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,29]
[20600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",100.77,64.78,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[20604,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",155.94999999999999,82.77,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[20605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",103.17,67.180000000000007,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[20606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",169.14,94.17,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[20610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",121.16,82.77,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[20611,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",186.54,106.76,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[20612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",122.36,74.98,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[20615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",481.04,302.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[20650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",437.85,311.89999999999998,10,0.1,0.8,0.1,0,2,0,1,1,0,null,"R",null,null,2,29]
[20660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",427.66,427.66,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[20661,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",985.47,985.47,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[20662,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",981.27,981.27,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[20663,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",907.5,907.5,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[20664,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1648.25,1648.25,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[20665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",222.53,182.94,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[20670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",678.97,271.70999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[20680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1128.82,779.74,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[20690,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1101.83,1101.83,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[20692,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2090.3000000000002,2090.3000000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20693,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",836.72,836.72,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[20694,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",816.93,643.59,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[20696,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2146.6799999999998,2146.6799999999998,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20697,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3432.66,3432.66,0,0,0,0,3,0,0,2,1,0,null,"R",null,null,2,29]
[20700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",151.75,151.75,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[20701,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",115.16,115.16,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[20702,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",255.51,255.51,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[20703,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",187.14,187.14,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[20704,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",269.31,269.31,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[20705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",222.53,222.53,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[20802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4993.93,4993.93,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[20805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5921.23,5921.23,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[20808,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7130.42,7130.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[20816,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3738.55,3738.55,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3241.92,3241.92,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20824,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3746.35,3746.35,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[20827,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3326.49,3326.49,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[20838,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5070.71,5070.71,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[20900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",726.96,328.09,0,0,0,0,0,2,0,2,1,0,null,"R",null,null,2,29]
[20902,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",498.43,498.43,0,0,0,0,0,2,0,2,1,0,null,"R",null,null,2,29]
[20910,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",899.1,899.1,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[20912,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",901.5,901.5,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[20920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",748.55,748.55,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29]
[20922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1149.82,922.49,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20924,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",942.89,942.89,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,29]
[20931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",196.13,196.13,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,29]
[20932,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1352.55,1352.55,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29]
[20933,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1240.3900000000001,1240.3900000000001,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29]
[20934,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1350.75,1350.75,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29]
[20936,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,29]
[20937,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",296.89999999999998,296.89999999999998,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,29]
[20938,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",325.69,325.69,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,29]
[20939,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",124.16,124.16,0,0,0,0,0,0,1,0,0,0,null,"R",null,"Y-UR",2,29]
[20950,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",505.63,163.15,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[20955,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4451.12,4451.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20956,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4799.6000000000004,4799.6000000000004,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20957,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5003.53,5003.53,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20962,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4885.97,4885.97,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20969,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4947.1499999999996,4947.1499999999996,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5176.2700000000004,5176.2700000000004,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[20972,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5160.68,5160.68,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[20973,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5447.98,5447.98,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[20974,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",158.35,94.17,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-UR",2,29]
[20975,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",319.69,319.69,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29]
[20979,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",107.36,57.58,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-UR",2,29]
[20982,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2,29]
[20983,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2,29]
[20985,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",259.11,259.11,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[20999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29]
[21010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1372.94,1372.94,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[21011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",710.16,490.64,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",632.19000000000005,632.19000000000005,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21013,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1007.06,749.15,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21014,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",968.68,968.68,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1292.57,1292.57,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[21016,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,29]
[21025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1483.91,1227.79,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21026,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1009.46,801.93,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21029,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1450.32,1163.6099999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29]
[21030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",862.51,673.58,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[21031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",725.76,511.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[21032,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",704.77,488.24,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[21034,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2411.1999999999998,2074.71,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",872.11,675.97,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[21044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1596.07,1596.07,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2209.66,2209.66,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1830.59,1830.59,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR",2,29]
[21047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2222.86,2222.86,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21048,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1844.98,1844.98,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR",2,29]
[21049,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2110.6999999999998,2110.6999999999998,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1605.06,1605.06,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[21060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1452.12,1452.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[21070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1137.82,1137.82,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[21073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",719.76,445.65,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[21076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1602.07,1286.57,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[21077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3914.89,3163.35,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[21079,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2690.1,2128.69,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3071.58,2402.1999999999998,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21081,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2843.05,2205.46,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21082,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2658.91,2036.32,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21083,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2529.96,1882.77,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21084,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2883.24,2176.67,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1269.18,884.11,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[21086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2908.43,2330.8200000000002,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[21087,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2908.43,2330.8200000000002,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21088,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",90,0.1,0.69,0.21,0,0,0,0,0,0,null,"N",null,null,2,29]
[21089,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,1,1,1,null,"N",null,null,2,29]
[21100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1175.6099999999999,666.98,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1628.46,1344.75,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",406.66,80.97,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[21120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1252.98,953.08,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29]
[21121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1184.6099999999999,984.27,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1393.34,1393.34,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21123,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1569.68,1569.68,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4948.3500000000004,1233.19,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21127,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7683.44,1428.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21137,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1389.14,1389.14,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21138,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1685.44,1685.44,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21139,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2006.93,2006.93,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21141,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2458.58,2458.58,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21142,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2522.16,2522.16,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21143,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2598.33,2598.33,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2849.05,2849.05,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2975.61,2975.61,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3128.56,3128.56,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3017.59,3017.59,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3316.89,3316.89,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21154,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3570.01,3570.01,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3955.68,3955.68,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21159,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4729.42,4729.42,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5125.8900000000003,5125.8900000000003,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21172,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3844.12,3844.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4028.26,4028.26,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21179,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2779.47,2779.47,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3100.37,3100.37,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21181,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1368.74,1368.74,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29]
[21182,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3852.52,3852.52,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21183,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4187.8,4187.8,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21184,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4502.7,4502.7,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21188,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2910.23,2910.23,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21193,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2265.44,2265.44,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,29]
[21194,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2618.73,2618.73,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-UR",2,29]
[21195,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2472.98,2472.98,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-UR",2,29]
[21196,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2639.72,2639.72,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,29]
[21198,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1858.18,1858.18,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21199,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1864.18,1864.18,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1787.4,1787.4,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21208,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3101.57,1363.95,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21209,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1498.3,1132.42,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[21210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3337.89,1404.13,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7792,1458.71,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29]
[21230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1378.94,1378.94,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1390.94,1067.04,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1931.96,1931.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[21242,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1872.58,1872.58,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[21243,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3096.17,3096.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[21244,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1868.98,1868.98,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2288.84,1753.82,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21246,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1566.08,1566.08,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21247,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2906.03,2906.03,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21248,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1830.59,1463.51,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21249,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2471.7800000000002,2037.52,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21255,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2471.1799999999998,2471.1799999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21256,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2281.64,2281.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,29]
[21261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,29]
[21263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,29]
[21267,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[21268,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[21270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1906.16,1378.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1556.48,1556.48,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1103.6300000000001,1103.6300000000001,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[21282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",753.95,753.95,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[21295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,0,0,null,"X",null,null,2,29]
[21296,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,0,0,null,"X",null,null,2,29]
[21299,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29]
[21315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",290.89999999999998,109.16,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[21320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",410.86,173.94,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[21325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",842.72,842.72,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1007.66,1007.66,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1339.95,1339.95,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21336,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1199.5999999999999,1199.5999999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",793.54,568.61,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21338,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1263.78,1263.78,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21339,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1422.73,1422.73,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1396.33,1396.33,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21343,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2025.52,2025.52,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2565.94,2565.94,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,29]
[21345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1514.5,1196,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21346,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1912.76,1912.76,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29]
[21347,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1929.56,1929.56,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21348,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2016.53,2016.53,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,29]
[21355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",849.92,615.99,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29]
[21356,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1031.6600000000001,753.95,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29]
[21360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",983.07,983.07,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[21365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1985.94,1985.94,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21366,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2342.2199999999998,2342.2199999999998,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[21385,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1357.95,1357.95,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21386,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1279.97,1279.97,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[21387,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1416.13,1416.13,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[21390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1490.5,1490.5,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21395,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1849.78,1849.78,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",417.46,324.49,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[21401,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",968.68,621.39,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[21406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1086.8399999999999,1086.8399999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21407,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1193.5999999999999,1193.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21408,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1662.65,1662.65,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[21421,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1218.19,1023.86,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21422,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1157.01,1157.01,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21423,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1470.71,1470.71,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,29]
[21431,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1298.57,1298.57,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[21432,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1321.96,1321.96,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[21433,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3165.74,3165.74,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2585.14,2585.14,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[21436,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3726.56,3726.56,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,29]
[21440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1455.71,1159.4100000000001,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1470.71,1184.6099999999999,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[21450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1125.22,911.7,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21451,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1458.71,1211,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21452,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1406.53,875.11,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21453,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2080.11,1764.01,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21454,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",909.9,909.9,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,29]
[21461,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3498.03,2005.13,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29]
[21462,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3721.76,2182.0700000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1473.71,1473.71,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2151.48,2151.48,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",270.51,55.78,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[21485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1830.59,1490.5,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[21490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1452.72,1452.72,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[21497,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1347.15,1115.6300000000001,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29]
[21501,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",924.89,632.79,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",927.89,927.89,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[21510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",833.72,833.72,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[21550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",506.23,290.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[21552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",824.73,824.73,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21554,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1343.55,1343.55,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",818.73,574.01,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[21556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",980.67,980.67,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[21557,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1754.42,1754.42,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,29]
[21600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1053.8499999999999,1053.8499999999999,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21601,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2080.11,2080.11,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29]
[21602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2786.07,2786.07,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29]
[21603,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3045.18,3045.18,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,29]
[21610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2205.46,2205.46,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1120.43,1120.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[21616,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1273.3800000000001,1273.3800000000001,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[21620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",921.89,921.89,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21627,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1011.86,1011.86,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[21630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2412.4,2412.4,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2183.27,2183.27,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29]
[21700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",635.19000000000005,635.19000000000005,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[21705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",942.89,942.89,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[21720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",993.27,993.27,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1015.46,1015.46,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1832.99,1832.99,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[21742,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"N",null,"Y-UR",2,29]
[21743,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"N",null,"Y-UR",2,29]
[21750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1213.4000000000001,1213.4000000000001,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21811,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1054.45,1054.45,0,0,0,0,0,2,1,2,0,0,null,"R",null,null,2,29]
[21812,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1272.78,1272.78,0,0,0,0,0,2,1,2,0,0,null,"R",null,null,2,29]
[21813,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1740.02,1740.02,0,0,0,0,0,2,1,2,0,0,null,"R",null,null,2,29]
[21820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",291.5,287.89999999999998,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1016.06,1016.06,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[21899,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,"Y-UR",2,29]
[21920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",486.44,287.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[21925,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",933.89,708.96,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",946.48,679.57,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[21931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",864.91,864.91,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[21932,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1218.19,1218.19,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[21933,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1351.95,1351.95,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[21935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1863.58,1863.58,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29]
[21936,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,29]
[22010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1791,1791,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[22015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1752.02,1752.02,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[22100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1750.22,1750.22,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1624.86,1624.86,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1428.12,1428.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",239.92,239.92,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1951.15,1951.15,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2093.3000000000002,2093.3000000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22114,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2093.3000000000002,2093.3000000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",250.12,250.12,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4436.12,4436.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22207,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4349.75,4349.75,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22208,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1046.05,1046.05,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3268.91,3268.91,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22212,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2777.67,2777.67,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22214,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2777.07,2777.07,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22216,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",644.79,644.79,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2964.81,2964.81,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22222,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3219.13,3219.13,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22224,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2904.83,2904.83,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22226,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",638.79,638.79,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",589,561.41,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[22315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1686.64,1449.72,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[22318,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3011.6,3011.6,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22319,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3330.69,3330.69,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2709.3,2709.3,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22326,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2760.88,2760.88,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22327,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2819.66,2819.66,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",499.03,499.03,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",239.32,239.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[22510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[22511,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[22512,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2,29]
[22513,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[22514,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[22515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2,29]
[22526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,9,9,9,9,9,9,null,"X",null,null,2,29]
[22527,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,29]
[22532,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3262.31,3262.31,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22533,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3033.19,3033.19,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22534,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",641.19000000000005,641.19000000000005,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22548,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3571.21,3571.21,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3085.97,3085.97,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",703.57,703.57,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22554,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2307.4299999999998,2307.4299999999998,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3066.78,3066.78,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2771.08,2771.08,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",576.41,576.41,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22586,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3691.77,3691.77,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2903.63,2903.63,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22595,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2778.27,2778.27,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2391.4,2391.4,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2353.02,2353.02,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2879.64,2879.64,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22614,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",695.17,695.17,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2838.85,2838.85,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",569.21,569.21,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22633,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3283.31,3283.31,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22634,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",860.71,860.71,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2503.5700000000002,2503.5700000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3847.12,3847.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22804,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4409.7299999999996,4409.7299999999996,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22808,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3319.29,3319.29,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3656.98,3656.98,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22812,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4010.26,4010.26,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22818,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3905.9,3905.9,90,0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR",2,29]
[22819,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4497.3,4497.3,90,0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR",2,29]
[22830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1514.5,1514.5,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22836,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,0,2,1,null,"X",null,null,2]
[22837,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,0,2,1,null,"X",null,null,2]
[22838,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,0,2,1,null,"X",null,null,2]
[22840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1344.75,1344.75,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22841,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,"Y-UR",2,29]
[22842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1355.55,1355.55,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22843,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1451.52,1451.52,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22844,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1751.42,1751.42,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22845,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1289.57,1289.57,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22846,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1342.35,1342.35,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22847,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1431.12,1431.12,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22848,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",640.59,640.59,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22849,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2379.41,2379.41,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22850,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1356.75,1356.75,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22852,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1308.76,1308.76,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22853,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",457.65,457.65,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22854,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",595,595,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22855,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2024.92,2024.92,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22856,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2949.82,2949.82,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22857,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3184.94,3184.94,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22858,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",899.7,899.7,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22859,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",592,592,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,2,2,0,null,"X",null,null,2,29]
[22861,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4183.6099999999997,4183.6099999999997,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22862,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4195,4195,90,0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR",2,29]
[22864,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3742.15,3742.15,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22865,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4095.43,4095.43,90,0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR",2,29]
[22867,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1958.35,1958.35,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[22868,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",430.66,430.66,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22869,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",801.33,801.33,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[22870,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",212.33,212.33,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[22899,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,1,1,null,"N",null,"Y-UR",2,29]
[22900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1042.45,1042.45,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22901,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1221.19,1221.19,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22902,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",887.7,620.79,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22903,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",810.93,810.93,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[22904,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,1,null,"X",null,null,2,29]
[22905,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,1,null,"X",null,null,2,29]
[22999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,"Y-UR",2,29]
[23000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1047.25,675.37,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1288.3699999999999,1288.3699999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[23030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",831.32,473.84,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[23031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",822.33,416.86,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[23035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1264.3800000000001,1264.3800000000001,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[23040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1338.15,1338.15,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1056.25,1056.25,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[23065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,1,1,0,0,null,"X",null,null,2,29]
[23066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1088.6400000000001,696.37,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[23071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",777.94,777.94,90,0.1,0.8,0.1,0,2,1,2,0,0,null,"R",null,null,2,29]
[23073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1284.77,1284.77,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[23075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.08,616.59,90,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[23076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1010.06,1010.06,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[23078,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[23100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",957.28,957.28,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",864.91,864.91,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[23105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1202,1202,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",950.08,950.08,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[23107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1244.5899999999999,1244.5899999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1108.43,1108.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1325.56,1325.56,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1163.01,1163.01,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[23140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1045.45,1045.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[23145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1300.3699999999999,1300.3699999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1172.01,1172.01,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[23150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1248.78,1248.78,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1486.9,1486.9,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23156,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1269.78,1269.78,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[23170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1063.45,1063.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[23172,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1073.6400000000001,1073.6400000000001,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[23174,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1431.12,1431.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1232.5899999999999,1232.5899999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[23182,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1261.3800000000001,1261.3800000000001,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[23184,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1385.54,1385.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23190,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1081.44,1081.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23195,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1393.34,1393.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[23210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[23220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[23330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",574.01,316.08999999999997,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29]
[23333,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",891.9,891.9,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[23334,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1954.15,1954.15,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[23335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2327.8200000000002,2327.8200000000002,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[23350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",307.7,89.37,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[23395,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2368.61,2368.61,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[23397,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2101.1,2101.1,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[23400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1799.4,1799.4,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1149.22,1149.22,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[23406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1358.55,1358.55,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[23410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1522.89,1522.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23412,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1582.27,1582.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1305.76,1305.76,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[23420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1807.8,1807.8,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1388.54,1388.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1407.73,1407.73,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1747.22,1747.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1818.59,1818.59,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23460,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2011.13,2011.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23462,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1966.14,1966.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2061.5100000000002,2061.5100000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23466,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2078.31,2078.31,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2201.87,2201.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23472,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2645.12,2645.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23473,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2938.42,2938.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23474,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3169.34,3169.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1522.89,1522.89,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[23485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1761.61,1761.61,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1596.07,1596.07,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[23491,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1877.97,1877.97,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[23500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",437.25,448.05,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",698.17,645.98,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1346.55,1346.55,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[23520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",471.44,467.84,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[23525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",773.74,704.17,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[23530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1082.04,1082.04,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[23532,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1175.6099999999999,1175.6099999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[23540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",466.64,463.05,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",704.17,628.59,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[23550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1073.6400000000001,1073.6400000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1215.19,1215.19,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",459.45,475.04,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",796.53,732.36,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[23585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1803,1803,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[23600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",653.78,618.99,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",906.9,819.33,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1641.05,1641.05,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[23616,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2273.84,2273.84,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[23620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",531.41999999999996,508.03,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23625,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",749.15,680.77,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1458.11,1458.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[23650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",647.17999999999995,581.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23655,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",779.14,779.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1099.43,1099.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[23665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",842.12,770.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1620.06,1620.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[23675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1063.45,956.68,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[23680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1707.63,1707.63,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[23700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",366.48,366.48,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[23800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1898.37,1898.37,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2366.81,2366.81,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2539.5500000000002,2539.5500000000002,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[23920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2072.91,2072.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[23921,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",892.5,892.5,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[23929,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,0,2,0,2,1,1,null,"B",null,"Y-UR",2,29]
[23930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",678.37,399.47,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[23931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",578.80999999999995,304.7,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[23935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",970.48,970.48,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[24000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",903.3,903.3,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,"Y-UR",2,29]
[24006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1334.56,1334.56,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,"Y-UR",2,29]
[24065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",492.44,304.7,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[24066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1186.4000000000001,793.54,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",751.55,751.55,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[24073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1277.57,1277.57,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[24075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1003.47,617.19000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1019.66,1019.66,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,null,2,29]
[24079,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[24100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",797.73,797.73,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",950.68,950.68,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1157.6099999999999,1157.6099999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",690.97,690.97,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1111.43,1111.43,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[24115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1375.34,1375.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1594.87,1594.87,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[24120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1004.07,1004.07,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[24125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1169.6099999999999,1169.6099999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1219.3900000000001,1219.3900000000001,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[24130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",965.08,965.08,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[24134,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1393.94,1393.94,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[24136,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1185.8,1185.8,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24138,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1295.57,1295.57,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[24140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1312.96,1312.96,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[24145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1116.23,1116.23,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[24147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1183.4100000000001,1183.4100000000001,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[24149,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2194.0700000000002,2194.0700000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[24152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[24155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1579.27,1579.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2309.23,2309.23,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[24164,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1350.75,1350.75,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[24200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",416.86,265.11,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29]
[24201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1172.01,758.15,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",359.28,119.36,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29]
[24300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",849.92,849.92,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1398.13,1398.13,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[24305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1090.44,1090.44,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29]
[24310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",894.9,894.9,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29]
[24320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1451.52,1451.52,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[24330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1340.55,1340.55,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24331,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1460.51,1460.51,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1158.21,1158.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[24340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1121.6300000000001,1121.6300000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24341,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1410.73,1410.73,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24342,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1440.72,1440.72,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24343,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1342.95,1342.95,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2050.7199999999998,2050.7199999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1336.35,1336.35,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24346,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2050.7199999999998,2050.7199999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",788.74,788.74,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[24358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1001.07,1001.07,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[24359,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1242.79,1242.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[24360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1674.64,1674.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24361,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1862.38,1862.38,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24362,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1958.95,1958.95,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24363,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2657.71,2657.71,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1199.5999999999999,1199.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24366,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1270.3800000000001,1270.3800000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2814.26,2814.26,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24371,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3228.72,3228.72,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1540.29,1540.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[24420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1979.34,1979.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1949.95,1949.95,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2005.13,2005.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1258.98,1258.98,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24495,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1740.02,1740.02,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[24498,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1608.06,1608.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",710.16,651.98,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.08,866.11,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1637.45,1637.45,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24516,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1591.87,1591.87,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[24530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",748.55,683.17,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1193,1089.8399999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24538,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1481.51,1481.51,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1721.43,1721.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1917.56,1917.56,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[24560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",652.58000000000004,575.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1043.6500000000001,948.28,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24566,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1356.15,1356.15,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1372.94,1372.94,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24576,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",692.77,614.20000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24577,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1071.24,971.08,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24579,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1555.88,1555.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24582,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1535.49,1535.49,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24586,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2005.73,2005.73,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24587,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2008.13,2008.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",728.76,656.18,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",910.5,910.5,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1330.96,1330.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1115.03,1115.03,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[24635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1267.98,1267.98,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,1,0,0,0,null,"X",null,null,2,29]
[24650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",520.63,483.44,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24655,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",874.51,783.94,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1236.79,1236.79,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24666,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1368.14,1368.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",574.61,523.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",890.1,801.93,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[24685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1228.99,1228.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[24800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1552.88,1552.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1853.98,1853.98,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1375.34,1375.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1365.14,1365.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[24925,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1071.24,1071.24,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1437.12,1437.12,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1719.63,1719.63,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[24935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2264.25,2264.25,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[24940,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2074.52,2074.52,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"F",null,"Y-UR",2,29]
[24999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,"Y-UR",2,29]
[25000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",664.58,664.58,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[25001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",666.38,666.38,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[25020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1405.33,1405.33,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[25023,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2454.38,2454.38,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[25024,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1451.52,1451.52,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[25025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2260.0500000000002,2260.0500000000002,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[25028,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1317.76,1317.76,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",701.77,701.77,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1108.43,1108.43,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1048.45,1048.45,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",486.44,295.7,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[25066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",698.17,698.17,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",789.34,789.34,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1002.27,1002.27,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",982.47,594.4,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.68,974.68,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,0,0,null,"X",null,null,2,29]
[25078,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,null,2,29]
[25085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",849.92,849.92,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",667.58,667.58,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",772.54,772.54,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",922.49,922.49,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29]
[25107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1167.81,1167.81,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[25109,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1011.26,1011.26,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[25110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",659.78,659.78,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[25111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",623.19000000000005,623.19000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",744.35,744.35,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1418.53,1418.53,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1142.02,1142.02,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29]
[25118,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",730.56,730.56,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25119,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",949.48,949.48,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",949.48,949.48,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29]
[25125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1121.03,1121.03,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1128.82,1128.82,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",857.71,857.71,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1059.8499999999999,1059.8499999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25136,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",941.69,941.69,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",984.87,984.87,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1066.44,1066.44,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[25151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1099.43,1099.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[25210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",934.49,934.49,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,29]
[25215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1165.4100000000001,1165.4100000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",821.73,821.73,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[25240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",816.93,816.93,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29]
[25246,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",369.48,131.36000000000001,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[25248,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",801.33,801.33,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1007.06,1007.06,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25251,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1343.55,1343.55,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25259,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",834.92,834.92,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1196,1196,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[25263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1193.5999999999999,1193.5999999999999,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[25265,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1408.33,1408.33,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[25270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",935.09,935.09,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[25272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1054.45,1054.45,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[25274,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1246.98,1246.98,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,29]
[25275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1261.3800000000001,1261.3800000000001,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29]
[25280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1066.44,1066.44,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,29]
[25290,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",827.12,827.12,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[25295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",995.07,995.07,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[25300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1294.97,1294.97,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1208.5999999999999,1208.5999999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1169.6099999999999,1169.6099999999999,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[25312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1341.15,1341.15,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[25315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1432.92,1432.92,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25316,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1699.83,1699.83,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1855.78,1855.78,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[25332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1575.07,1575.07,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,null,2,29]
[25337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1662.65,1662.65,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1263.78,1263.78,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1426.32,1426.32,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1230.79,1230.79,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1701.03,1701.03,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1877.37,1877.37,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25375,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1766.41,1766.41,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1432.92,1432.92,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25391,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1841.39,1841.39,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25392,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1873.18,1873.18,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25393,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2080.11,2080.11,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25394,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1461.11,1461.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1492.3,1492.3,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1916.96,1916.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1791.6,1791.6,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2149.08,2149.08,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1783.81,1783.81,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2068.71,2068.71,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1369.94,1369.94,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25431,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1467.11,1467.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1433.52,1433.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25441,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1738.22,1738.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1509.1,1509.1,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25443,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1465.91,1465.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25444,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1532.49,1532.49,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1345.95,1345.95,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[25446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2162.88,2162.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25447,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1556.48,1556.48,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25449,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1911.56,1911.56,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1160.6099999999999,1160.6099999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[25455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1366.94,1366.94,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[25490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1343.55,1343.55,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25491,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1378.94,1378.94,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25492,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1683.64,1683.64,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",560.21,505.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",983.07,885.3,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1260.18,1260.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1106.6300000000001,1040.05,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1479.11,1479.11,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[25526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1779.61,1779.61,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[25530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",523.03,478.64,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",956.08,878.71,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1178.01,1178.01,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",571.01,508.03,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",999.27,887.7,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25574,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1267.98,1267.98,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[25575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1685.44,1685.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",667.58,638.19000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1037.6500000000001,975.87,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1262.58,1262.58,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1390.94,1390.94,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25608,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1549.88,1549.88,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25609,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1960.75,1960.75,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25622,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",605.20000000000005,556.61,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25624,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",954.28,860.11,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25628,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1347.15,1347.15,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",598,554.22,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",905.1,817.53,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1074.8399999999999,1074.8399999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",644.79,595.6,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25651,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",934.49,934.49,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25652,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1173.21,1173.21,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[25660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",863.11,863.11,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1140.82,1140.82,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25671,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1015.46,1015.46,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",884.11,793.54,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25676,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1187,1187,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1011.86,1011.86,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1371.74,1371.74,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25690,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",940.49,940.49,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25695,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1188.2,1188.2,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[25800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1364.55,1364.55,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[25805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1576.87,1576.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[25810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1617.06,1617.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[25820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1223.5899999999999,1223.5899999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[25825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1491.1,1491.1,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[25830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1936.75,1936.75,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[25900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1340.55,1340.55,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25905,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1309.96,1309.96,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25907,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1154.02,1154.02,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25909,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1279.3699999999999,1279.3699999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25915,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2143.69,2143.69,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1368.14,1368.14,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1216.99,1216.99,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25924,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1336.95,1336.95,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25927,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1624.26,1624.26,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[25929,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1125.22,1125.22,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[25931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1507.3,1507.3,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[25999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,29]
[26010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",659.18,266.91000000000003,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[26011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",910.5,347.88,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[26020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1050.25,1050.25,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",792.94,792.94,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[26030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.69,926.69,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[26034,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1043.6500000000001,1043.6500000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1608.66,1608.66,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26037,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1052.05,1052.05,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[26040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",606.4,606.4,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[26045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",896.1,896.1,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[26055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1128.82,558.41,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",488.84,488.84,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",616.59,616.59,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[26075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",645.98,645.98,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[26080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",762.35,762.35,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",649.58000000000004,649.58000000000004,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[26105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",653.78,653.78,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[26110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",622.59,622.59,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",782.14,782.14,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26113,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1029.26,1029.26,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1047.8499999999999,630.99,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",989.07,989.07,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26117,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,29]
[26118,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,29]
[26121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1128.82,1128.82,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[26123,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1572.68,1572.68,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[26125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",484.04,484.04,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[26130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",890.7,890.7,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[26135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1044.25,1044.25,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",962.68,962.68,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",975.87,975.87,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1176.81,604,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",776.74,776.74,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",856.51,856.51,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26185,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1058.6500000000001,1058.6500000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[26200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",854.12,854.12,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26205,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1136.02,1136.02,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",852.32,852.32,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1068.24,1068.24,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",942.89,942.89,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",931.49,931.49,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26236,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",837.32,837.32,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1969.14,1969.14,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1479.71,1479.71,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26262,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1182.21,1182.21,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",665.18,665.18,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",694.57,694.57,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[26341,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",223.73,147.55000000000001,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[26350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1423.93,1423.93,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26352,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1576.27,1576.27,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26356,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1499.5,1499.5,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1672.84,1672.84,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1839.59,1839.59,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1486.3,1486.3,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26372,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1728.02,1728.02,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26373,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1665.04,1665.04,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1651.25,1651.25,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26392,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1883.97,1883.97,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1149.22,1149.22,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26412,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1360.35,1360.35,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1606.26,1606.26,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26416,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1735.22,1735.22,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26418,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1198.4000000000001,1198.4000000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1409.53,1409.53,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",953.08,953.08,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26428,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1510.3,1510.3,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26432,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1041.25,1041.25,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26433,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1091.6400000000001,1091.6400000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26434,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1322.56,1322.56,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26437,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1269.18,1269.18,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1241.5899999999999,1241.5899999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1874.38,1874.38,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1156.4100000000001,1156.4100000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26449,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1321.96,1321.96,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",888.9,888.9,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",882.91,882.91,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26460,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",866.11,866.11,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26471,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1256.58,1256.58,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26474,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1243.3900000000001,1243.3900000000001,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26476,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1228.99,1228.99,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26477,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1200.8,1200.8,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29]
[26478,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1251.78,1251.78,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26479,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1286.57,1286.57,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1494.1,1494.1,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26483,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1649.45,1649.45,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1585.27,1585.27,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26489,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1817.39,1817.39,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1583.47,1583.47,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26492,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1748.42,1748.42,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26494,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1590.07,1590.07,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26496,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1707.03,1707.03,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26497,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1704.63,1704.63,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26498,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2201.87,2201.87,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1643.45,1643.45,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1308.76,1308.76,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1431.72,1431.72,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26508,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1288.97,1288.97,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[26510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1220.5899999999999,1220.5899999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26516,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1408.93,1408.93,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[26517,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1633.86,1633.86,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[26518,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1653.65,1653.65,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[26520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1300.97,1300.97,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1308.1600000000001,1308.1600000000001,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29]
[26530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1024.46,1024.46,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26531,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1189.4000000000001,1189.4000000000001,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",831.92,831.92,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26536,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1426.32,1426.32,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1327.96,1327.96,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,29]
[26541,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1578.07,1578.07,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26542,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1370.54,1370.54,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1394.54,1394.54,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1959.55,1959.55,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[26548,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1512.1,1512.1,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3057.78,3057.78,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[26551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6024.39,6024.39,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[26553,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5984.2,5984.2,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[26554,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6955.88,6955.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[26555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2580.34,2580.34,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6228.92,6228.92,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1211,1211,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1844.39,1844.39,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26562,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2570.14,2570.14,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1348.35,1348.35,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26567,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1364.55,1364.55,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26568,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1755.01,1755.01,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26580,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,null,2,29]
[26587,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,29]
[26590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,29]
[26591,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",939.89,939.89,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26593,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1229.5899999999999,1229.5899999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26596,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1539.09,1539.09,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",593.20000000000005,564.41,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",646.58000000000004,580.61,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",965.68,965.68,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26608,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",918.89,918.89,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1088.6400000000001,1088.6400000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",815.73,739.55,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[26645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",839.12,759.95,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[26650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",919.49,919.49,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[26665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1184.01,1184.01,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[26670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",681.37,605.20000000000005,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",894.3,812.13,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26676,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.08,974.08,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1092.24,1092.24,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29]
[26686,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1168.4100000000001,1168.4100000000001,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[26700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",659.78,605.20000000000005,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",849.32,765.34,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26706,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",854.12,854.12,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1085.04,1085.04,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",397.67,373.08,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",666.98,590.20000000000005,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26727,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",906.3,906.3,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26735,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1124.03,1124.03,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",459.45,433.66,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26742,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",723.96,645.98,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26746,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1390.34,1390.34,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",370.08,374.88,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",623.19000000000005,530.22,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26756,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",813.93,813.93,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26765,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",958.48,958.48,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",563.80999999999995,510.43,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26775,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",770.74,688.57,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26776,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",860.71,860.71,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26785,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1037.6500000000001,1037.6500000000001,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1567.88,1567.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[26841,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1471.31,1471.31,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29]
[26842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1572.08,1572.08,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[26843,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1480.31,1480.31,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26844,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1623.66,1623.66,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26850,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1393.34,1393.34,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26852,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1576.27,1576.27,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1172.01,1172.01,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26861,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",183.54,183.54,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[26862,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1454.52,1454.52,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[26863,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",409.06,409.06,0,0,0,0,0,0,0,2,0,0,null,"R",null,null,2,29]
[26910,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1439.52,1439.52,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26951,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1339.35,1339.35,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26952,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1298.57,1298.57,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26989,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,1,1,1,null,"N",null,null,2,29]
[26990,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1276.3699999999999,1276.3699999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[26991,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1332.76,984.27,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[26992,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1876.77,1876.77,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[27000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",734.76,734.76,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1011.26,1011.26,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1125.22,1125.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1340.55,1340.55,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1335.15,1335.15,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1721.43,1721.43,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29]
[27027,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1633.26,1633.26,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1727.42,1727.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27033,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1792.8,1792.8,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2107.6999999999998,2107.6999999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[27036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1885.17,1885.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",639.99,367.68,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[27041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1312.36,1312.36,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27043,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",864.31,864.31,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1347.75,1347.75,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",930.89,672.98,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27048,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1131.22,1131.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27049,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[27050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",771.34,771.34,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29]
[27052,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1089.24,1089.24,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27054,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1286.57,1286.57,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27057,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1854.58,1854.58,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27059,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[27060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",880.51,880.51,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27062,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",855.91,855.91,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",985.47,985.47,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1517.49,1517.49,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27067,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1915.76,1915.76,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1645.85,1645.85,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1809,1809,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3787.14,3787.14,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[27076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4565.68,4565.68,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[27077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5086.3,5086.3,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[27078,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3734.95,3734.95,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",944.69,944.69,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[27086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",593.20000000000005,318.49,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29]
[27087,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1137.82,1137.82,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27090,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1537.89,1537.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27091,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2910.23,2910.23,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27093,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",438.45,122.36,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[27095,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",582.41,147.55000000000001,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[27096,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",310.7,151.75,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[27097,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1275.17,1275.17,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27098,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1299.77,1299.77,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1546.28,1546.28,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1617.66,1617.66,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1797,1797,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1676.44,1676.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2385.4,2385.4,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2032.72,2032.72,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2081.91,2081.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2350.62,2350.62,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27132,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3050.58,3050.58,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27134,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3460.25,3460.25,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27137,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2673.91,2673.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27138,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2775.87,2775.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1659.65,1659.65,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2350.02,2350.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2678.71,2678.71,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2890.44,2890.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27156,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3110.56,3110.56,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27158,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2563.5500000000002,2563.5500000000002,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,null,2,29]
[27161,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2244.4499999999998,2244.4499999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27165,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2519.7600000000002,2519.7600000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2144.88,2144.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1239.79,1239.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[27176,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1709.43,1709.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[27177,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2058.5100000000002,2058.5100000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[27178,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1709.43,1709.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[27179,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1809,1809,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,29]
[27181,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2066.91,2066.91,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,29]
[27185,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1340.55,1340.55,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29]
[27187,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1841.99,1841.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[27197,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",249.52,249.52,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[27198,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",580.01,580.01,0,0,0,0,0,2,0,0,2,0,null,"R",null,null,2,29]
[27200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",367.68,372.48,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[27202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",983.67,983.67,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[27215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1115.6300000000001,1115.6300000000001,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,29]
[27216,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1645.85,1645.85,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,29]
[27217,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1548.08,1548.08,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,29]
[27218,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2117.29,2117.29,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,29]
[27220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",786.34,774.94,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27222,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1810.8,1810.8,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27226,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1948.15,1948.15,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27227,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3015.19,3015.19,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27228,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3420.06,3420.06,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.69,908.7,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27232,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1332.16,1332.16,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1676.44,1676.44,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27236,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2195.27,2195.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27238,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",887.1,887.1,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1760.41,1760.41,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27244,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2255.85,2255.85,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2253.4499999999998,2253.4499999999998,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27246,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",742.55,734.76,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27248,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1376.54,1376.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",318.49,318.49,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[27252,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1384.94,1384.94,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27253,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1734.62,1734.62,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27254,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2334.42,2334.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27256,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",589,437.25,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29]
[27257,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",665.18,665.18,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29]
[27258,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2048.92,2048.92,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27259,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2825.66,2825.66,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27265,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",794.14,794.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27266,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1092.24,1092.24,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27267,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",838.52,838.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27268,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1023.26,1023.26,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27269,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2269.64,2269.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",346.08,346.08,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[27278,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,0,0,null,"X",null,null,2]
[27279,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1471.91,1471.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2477.17,2477.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1597.87,1597.87,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[27284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2921.63,2921.63,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3000.2,3000.2,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27290,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2972.01,2972.01,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[27295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2303.83,2303.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27299,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,2,1,1,null,"N",null,"Y-UR",2,29]
[27301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1268.58,949.48,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27303,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1197.8,1197.8,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",909.9,909.9,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",650.78,650.78,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",768.94,768.94,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,29]
[27310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1366.34,1366.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27323,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",520.03,326.89,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[27324,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",771.34,771.34,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1062.25,1062.25,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,29]
[27326,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",986.67,986.67,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[27327,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",947.68,591.4,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1155.21,1155.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27329,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1904.37,1904.37,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",801.93,801.93,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[27331,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",900.3,900.3,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1211,1211,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27333,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1109.03,1109.03,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27334,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1284.17,1284.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1427.52,1427.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",776.74,776.74,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27339,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1390.94,1390.94,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",714.36,714.36,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[27345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",918.29,918.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27347,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",993.87,993.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1225.99,1225.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1139.6199999999999,1139.6199999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27356,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1380.74,1380.74,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1523.49,1523.49,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",491.24,491.24,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-UR",2,29]
[27360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1684.84,1684.84,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27364,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[27365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3733.16,3733.16,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27369,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",350.28,72.58,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[27372,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1106.6300000000001,748.55,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1172.01,1172.01,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27381,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1530.69,1530.69,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27385,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1146.82,1146.82,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27386,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1598.47,1598.47,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",852.92,852.92,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[27391,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1088.6400000000001,1088.6400000000001,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR",2,29]
[27392,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1332.76,1332.76,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,29]
[27393,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",942.89,942.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27394,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1225.99,1225.99,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[27395,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1639.25,1639.25,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,29]
[27396,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1159.4100000000001,1159.4100000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27397,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1701.03,1701.03,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[27400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1300.3699999999999,1300.3699999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27403,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1208.5999999999999,1208.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1264.98,1264.98,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27407,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1485.1,1485.1,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27409,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1790.4,1790.4,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27412,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,"Y-UR",2,29]
[27415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2526.36,2526.36,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27416,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1810.8,1810.8,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[27418,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1528.29,1528.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1398.13,1398.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27422,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1382.54,1382.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27424,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1395.73,1395.73,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",861.91,861.91,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[27427,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1321.36,1321.36,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27428,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2071.11,2071.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27429,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2333.8200000000002,2333.8200000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1384.34,1384.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1505.5,1505.5,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27437,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1236.79,1236.79,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[27438,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1560.08,1560.08,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1483.31,1483.31,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27441,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1530.09,1530.09,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1609.86,1609.86,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27443,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1516.89,1516.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2303.23,2303.23,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2108.3000000000002,2108.3000000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27447,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2347.02,2347.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27448,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1537.29,1537.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1864.78,1864.78,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27454,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2376.41,2376.41,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1779.61,1779.61,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27457,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1741.22,1741.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2290.64,2290.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27466,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2182.0700000000002,2182.0700000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27468,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2460.38,2460.38,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2176.67,2176.67,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27472,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2324.8200000000002,2324.8200000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27475,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,"Y-UR",2,29]
[27477,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,"Y-UR",2,29]
[27479,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,"Y-UR",2,29]
[27485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,0,0,null,"X",null,"Y-UR",2,29]
[27486,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2573.14,2573.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27487,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3198.13,3198.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27488,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2209.06,2209.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27495,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2080.71,2080.71,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27496,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1036.45,1036.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27497,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1087.44,1087.44,90,0.1,0.69,0.21,0,2,1,0,2,0,null,"R",null,null,2,29]
[27498,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1231.3900000000001,1231.3900000000001,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1311.76,1311.76,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",992.07,905.7,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27501,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",952.48,938.09,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1392.14,1392.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27503,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1485.1,1485.1,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27506,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2460.98,2460.98,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27507,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1777.81,1777.81,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27508,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1001.07,945.28,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27509,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1269.18,1269.18,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1268.58,1268.58,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27511,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1825.79,1825.79,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27513,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2254.0500000000002,2254.0500000000002,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27514,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1771.21,1771.21,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27516,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",996.27,927.89,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27517,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1293.17,1293.17,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27519,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1636.25,1636.25,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",637.59,586.6,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27524,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1402.33,1402.33,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",604.6,566.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27532,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1176.81,1092.8399999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1647.65,1647.65,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27536,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2186.87,2186.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27538,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",930.89,862.51,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1512.1,1512.1,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",977.67,893.1,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1193.5999999999999,1193.5999999999999,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1611.06,1611.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27557,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1912.16,1912.16,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2170.6799999999998,2170.6799999999998,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",724.56,657.98,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27562,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",931.49,931.49,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27566,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1653.65,1653.65,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",290.3,290.3,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[27580,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2718.29,2718.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1405.33,1405.33,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27591,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1779.61,1779.61,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27592,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1208.5999999999999,1208.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27594,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.09,926.09,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[27596,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1288.3699999999999,1288.3699999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[27598,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1254.18,1254.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27599,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,2,1,1,null,"N",null,"Y-UR",2,29]
[27600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",734.76,734.76,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27601,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",822.33,822.33,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",860.11,860.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27603,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",987.27,726.96,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27604,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",846.92,603.4,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",623.19000000000005,340.69,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29]
[27606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",499.03,499.03,10,0.1,0.8,0.1,0,2,1,1,1,0,null,"R",null,null,2,29]
[27607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1113.23,1113.23,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1202,1202,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[27612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1069.44,1069.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27613,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",481.04,301.7,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[27614,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1112.03,777.34,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,1,0,null,"X",null,null,2,29]
[27616,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,1,0,null,"X",null,null,2,29]
[27618,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",921.29,574.01,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27619,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",876.31,876.31,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",841.52,841.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27625,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1068.8399999999999,1068.8399999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27626,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1154.02,1154.02,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[27630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1019.66,671.78,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",756.35,756.35,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27634,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1240.99,1240.99,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1082.6400000000001,1082.6400000000001,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27637,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1392.14,1392.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27638,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1377.74,1377.74,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1540.29,1540.29,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1211.5999999999999,1211.5999999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3223.93,3223.93,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27646,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2807.66,2807.66,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27647,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1818.59,1818.59,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27648,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",403.07,92.97,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29]
[27650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1228.3900000000001,1228.3900000000001,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27652,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1247.58,1247.58,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[27654,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1333.96,1333.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27656,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",999.27,642.39,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27658,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",693.97,693.97,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[27659,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",883.51,883.51,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[27664,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",682.57,682.57,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29]
[27665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",797.73,797.73,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[27675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.09,926.09,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27676,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1136.6199999999999,1136.6199999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[27680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",789.34,789.34,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29]
[27681,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",950.68,950.68,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[27685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1239.79,873.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27686,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",993.87,993.87,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[27687,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",851.12,851.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27690,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1191.8,1191.8,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27691,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1384.34,1384.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27692,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",182.94,182.94,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,29]
[27695,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",911.7,911.7,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[27696,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1020.86,1020.86,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[27698,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1184.6099999999999,1184.6099999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1326.76,1326.76,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27702,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1774.81,1774.81,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27703,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2043.52,2043.52,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[27704,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1059.25,1059.25,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[27705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1390.34,1390.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27707,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",767.74,767.74,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[27709,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2105.9,2105.9,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27712,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2035.12,2035.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1978.74,1978.74,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1617.66,1617.66,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27722,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1660.85,1660.85,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27724,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2295.4299999999998,2295.4299999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2245.0500000000002,2245.0500000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27726,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1761.61,1761.61,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27727,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[27730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1104.83,1104.83,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM",2,29]
[27732,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",860.11,860.11,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[27734,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1230.79,1230.79,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[27740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1321.96,1321.96,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,29]
[27742,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1449.12,1449.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[27745,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1385.54,1385.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",678.37,627.99,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27752,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1023.26,929.09,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27756,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1086.8399999999999,1086.8399999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27758,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1662.65,1662.65,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27759,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1840.19,1840.19,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",651.98,599.20000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27762,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",939.89,842.12,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27766,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1134.22,1134.22,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27767,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",568.01,566.80999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27768,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",858.31,858.31,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27769,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1351.35,1351.35,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27780,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",605.79999999999995,556.01,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27781,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",848.12,776.74,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27784,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1335.75,1335.75,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27786,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",612.4,559.01,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27788,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",821.73,738.35,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27792,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1206.2,1206.2,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27808,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",658.58,596.79999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",914.1,818.13,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27814,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1422.13,1422.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27816,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",648.98,573.41,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27818,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",947.08,838.52,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1630.86,1630.86,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27823,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1831.79,1831.79,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27824,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",613,591.4,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1038.25,929.09,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27826,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1594.87,1594.87,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27827,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2082.5100000000002,2082.5100000000002,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27828,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2454.38,2454.38,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27829,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1325.56,1325.56,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,29]
[27830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",755.75,695.17,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27831,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",782.14,782.14,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27832,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1415.53,1415.53,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",740.15,740.15,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",930.29,930.29,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27846,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1352.55,1352.55,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27848,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1463.51,1463.51,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",304.7,304.7,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,29]
[27870,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1860.58,1860.58,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27871,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1287.17,1287.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27880,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1611.06,1611.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27881,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1522.89,1522.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[27882,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1064.6500000000001,1064.6500000000001,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,"Y-UR",2,29]
[27884,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1054.45,1054.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[27886,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1178.6099999999999,1178.6099999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27888,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1021.46,1021.46,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[27889,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1157.01,1157.01,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[27892,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",989.07,989.07,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27893,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1152.82,1152.82,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[27894,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1487.5,1487.5,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[27899,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,29]
[28001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",320.89,173.94,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[28002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",460.65,255.51,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[28003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",700.57,467.84,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[28005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1061.05,1061.05,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28008,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",804.33,551.22,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",442.65,392.87,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",593.79999999999995,524.23,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1021.46,684.37,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29]
[28022,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",917.69,613.6,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[28024,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",871.51,578.80999999999995,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[28035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",994.47,671.18,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[28039,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",894.9,629.79,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[28041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",838.52,838.52,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28043,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",722.16,489.44,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",902.1,648.38,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,null,2,29]
[28047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[28050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",783.94,523.03,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[28052,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",734.16,479.84,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[28054,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",692.17,439.65,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",725.16,725.16,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",975.27,674.78,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28062,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1083.8399999999999,753.35,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[28070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",954.88,641.19000000000005,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28072,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.09,610,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1009.46,715.56,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[28086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",987.87,656.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28088,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",878.11,553.62,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28090,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",879.31,579.41,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28092,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",800.13,514.03,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1152.82,782.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1146.22,1146.22,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[28103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",720.96,720.96,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[28104,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",989.07,663.38,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[28106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",791.74,791.74,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[28107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",953.08,645.98,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,29]
[28108,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",818.73,542.22,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",874.51,551.82000000000005,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[28111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",891.9,593.79999999999995,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[28112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",908.7,586.6,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[28113,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1101.23,801.93,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[28114,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1997.33,1561.28,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1438.92,1082.04,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[28118,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1138.42,790.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28119,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",990.27,682.57,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[28120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1257.78,924.89,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[28122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1112.03,820.53,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28124,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",899.7,627.99,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[28126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",738.95,470.84,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1151.6199999999999,1151.6199999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1058.6500000000001,785.74,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29]
[28150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",788.74,523.63,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28153,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",764.75,497.23,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",771.34,502.03,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28171,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,29]
[28173,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,1,0,null,"X",null,null,2,29]
[28175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,1,0,null,"X",null,null,2,29]
[28190,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",455.25,247.12,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[28192,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",863.11,580.01,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28193,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",977.07,681.97,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",931.49,613,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29]
[28202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1119.23,797.13,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[28208,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",915.29,603.4,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,29]
[28210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1113.83,791.74,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[28220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",849.32,572.80999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[28222,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1011.26,691.57,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[28225,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",780.94,497.83,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[28226,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1168.4100000000001,755.15,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[28230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",814.53,533.82000000000005,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,29]
[28232,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",712.56,454.05,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[28234,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",776.74,509.83,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[28238,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1257.18,909.3,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",834.92,550.02,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1106.03,770.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1366.94,1005.86,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2000.93,1560.08,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28262,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2552.15,2039.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28264,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1625.46,1241.5899999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,29]
[28270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",917.09,627.39,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",721.56,471.44,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",949.48,644.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28285,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1017.26,726.36,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[28286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",834.32,557.80999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28288,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1138.42,819.33,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28289,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1296.17,863.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28291,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1291.97,894.9,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28292,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1317.16,909.9,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1977.54,1123.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28296,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1669.24,958.48,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28297,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1927.16,1119.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28298,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1575.07,947.68,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28299,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1908.56,1109.03,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1208.5999999999999,1208.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1335.15,1335.15,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28304,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1550.48,1140.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1251.18,1251.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1149.22,761.75,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1480.91,972.28,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28308,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1078.44,728.76,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28309,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1673.44,1673.44,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1029.26,680.17,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[28312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1029.26,648.38,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29]
[28313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",995.07,677.77,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",899.1,610,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,29]
[28320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1146.22,1146.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28322,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1475.51,1077.24,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[28340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,29]
[28341,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,29]
[28344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,null,2,29]
[28345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,0,0,0,null,"X",null,null,2,29]
[28360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,null,2,29]
[28400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",482.24,446.85,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",869.71,776.14,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1119.23,1119.23,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2079.5100000000002,2079.5100000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2402.8000000000002,2402.8000000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",467.24,408.46,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",717.36,632.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28436,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",948.28,948.28,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1940.35,1940.35,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,29]
[28450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",411.46,371.28,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",490.04,436.65,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[28456,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",715.56,715.56,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1202.5999999999999,1202.5999999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",424.66,399.47,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28475,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",501.43,439.65,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28476,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",742.55,742.55,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[28485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1062.25,1062.25,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29]
[28490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",277.11,242.92,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28495,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",349.68,289.10000000000002,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28496,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",968.68,526.62,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1224.19,927.89,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,29]
[28510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",236.32,235.72,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",320.89,278.91000000000003,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1076.04,767.14,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[28530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",227.92,197.93,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28531,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",627.99,343.09,90,0.1,0.69,0.21,0,2,1,1,2,0,null,"R",null,null,2,29]
[28540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",379.67,339.49,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",603.4,526.02,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1124.6300000000001,677.77,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1618.26,1234.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",462.45,385.67,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",734.16,654.98,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28576,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",738.95,738.95,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,29]
[28585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1683.64,1317.16,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,29]
[28600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",362.28,309.5,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[28605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",666.98,592.6,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[28606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",740.15,740.15,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1552.88,1552.88,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,29]
[28630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",294.5,206.33,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[28635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",325.69,245.32,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[28636,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",672.98,419.26,10,0.1,0.8,0.1,0,2,0,1,2,0,null,"R",null,null,2,29]
[28645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1225.99,911.1,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,29]
[28660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",240.52,176.94,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[28665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",287.3,237.52,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[28666,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",328.69,328.69,10,0.1,0.8,0.1,0,2,0,1,2,0,null,"R",null,null,2,29]
[28675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1089.24,779.14,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,29]
[28705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2240.25,2240.25,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1743.02,1743.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1447.32,1447.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1348.35,1348.35,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28735,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1436.52,1436.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28737,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1281.17,1281.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1547.48,1147.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1461.71,1073.04,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[28755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",951.28,627.39,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[28760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1445.52,1065.24,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",975.27,975.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[28805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1291.3699999999999,1291.3699999999999,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[28810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",780.34,780.34,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,29]
[28820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",554.22,322.08999999999997,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[28825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",545.22,313.7,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[28890,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,null,2,29]
[28899,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29]
[29000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",690.97,365.88,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",535.62,297.5,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",571.61,333.49,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",505.63,268.11,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",574.01,321.49,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",563.80999999999995,310.7,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",614.79999999999995,348.48,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29049,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",191.94,129.56,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",435.45,255.51,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29058,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",235.12,172.74,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",186.54,126.56,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",168.54,116.36,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",184.74,125.96,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",148.75,92.97,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",158.35,74.98,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",128.96,75.569999999999993,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",150.55000000000001,91.77,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",79.17,52.78,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29131,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",103.17,63.58,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",59.98,32.99,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[29240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",55.78,32.39,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",53.98,34.19,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",55.78,36.590000000000003,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",481.04,293.89999999999998,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",530.22,328.69,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,29]
[29345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",256.70999999999998,182.94,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",268.70999999999998,195.53,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",311.3,190.14,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",238.12,162.55000000000001,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",153.55000000000001,109.16,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",143.94999999999999,100.77,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",236.92,160.15,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",81.569999999999993,50.98,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",240.52,180.54,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,"Y-CM",2,29]
[29505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",172.74,97.17,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",137.94999999999999,92.37,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",65.38,32.99,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29]
[29530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",55.18,32.39,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",52.18,31.19,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",35.99,19.79,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29580,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",120.56,46.78,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29581,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",167.94,48.58,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29]
[29584,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",153.55000000000001,28.19,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29]
[29700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",122.36,59.98,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[29705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",119.36,80.97,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[29710,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",232.12,149.35,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29]
[29720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",166.14,79.77,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[29805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",877.51,877.51,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,29]
[29823,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1107.83,1107.83,90,0.1,0.69,0.21,0,3,1,2,1,0,29805,"R",null,"Y-UR",2,29]
[29840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",849.92,849.92,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,29]
[29850,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1168.4100000000001,1168.4100000000001,90,0.1,0.69,0.21,0,2,1,0,2,0,null,"R",null,null,2,29]
[29871,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",966.88,966.88,90,0.1,0.69,0.21,0,3,1,1,0,0,29870,"R",null,"Y-UR",2,29]
[29875,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",931.49,931.49,90,0.1,0.69,0.21,0,3,1,0,0,0,29870,"R",null,"Y-UR",2,29]
[29886,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1190.5999999999999,1190.5999999999999,90,0.1,0.69,0.21,0,3,1,1,0,0,29870,"R",null,"Y-UR",2,29]
[29898,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1041.8499999999999,1041.8499999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,29]
[29906,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1215.79,1215.79,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[30118,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1335.75,1335.75,90,0.1,0.76,0.14000000000000001,0,2,0,1,1,0,null,"R",null,null,2,29]
[30310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",394.67,394.67,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[30450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3261.71,3261.71,90,0.1,0.76,0.14000000000000001,0,2,0,2,0,0,null,"R",null,null,2,29]
[30620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1280.57,1280.57,90,0.1,0.76,0.14000000000000001,0,2,0,1,0,0,null,"R",null,null,2,29]
[30630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1261.3800000000001,1261.3800000000001,90,0.1,0.76,0.14000000000000001,0,2,0,0,0,0,null,"R",null,null,2,29]
[30999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29]
[31081,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2187.4699999999998,2187.4699999999998,90,0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"R",null,null,2,29]
[31201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1467.11,1467.11,90,0.1,0.76,0.14000000000000001,0,2,1,1,0,0,null,"R",null,null,2,29]
[31242,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,3,2,1,0,0,null,"X",null,null,2]
[31290,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2091.5,2091.5,10,0.1,0.8,0.1,0,3,1,0,0,0,31231,"R",null,null,2,29]
[31297,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3143.55,262.11,0,0,0,0,0,3,1,0,0,0,31231,"R",null,null,2,29]
[31368,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29]
[31511,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",396.47,246.52,0,0,0,0,0,3,0,1,0,0,31505,"R",null,null,2,29]
[31515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",402.47,203.33,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[31541,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,3,0,1,0,0,31526,"X",null,null,2,29]
[31560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,3,0,0,0,0,31525,"X",null,null,2,29]
[31580,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,0,1,0,null,"X",null,null,2,29]
[31611,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1008.86,1008.86,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,null,2,29]
[31625,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",656.78,278.91000000000003,0,0,0,0,0,3,0,1,0,0,31622,"R",null,null,2,29]
[31637,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",134.96,134.96,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[31647,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",365.88,365.88,0,0,0,0,0,3,0,1,0,0,31622,"R",null,null,2,29]
[31651,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",134.96,134.96,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[31760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2442.39,2442.39,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,null,2,29]
[31786,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29]
[32100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1445.52,1445.52,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,null,2,29]
[32160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1429.92,1429.92,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,null,2,29]
[32480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2617.5300000000002,2617.5300000000002,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[32540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3052.38,3052.38,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[32556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1412.53,220.13,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[32561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",175.14,119.96,0,0,0,0,0,2,0,2,0,0,null,"R",null,null,2,29]
[32654,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2100.5,2100.5,90,0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[32663,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2467.58,2467.58,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[32800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1678.84,1678.84,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[32853,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8013.33,8013.33,90,0.1,0.76,0.14000000000000001,0,2,2,2,1,2,null,"R",null,"Y-CM",2,29]
[32999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,1,1,1,null,"N",null,"Y-CM",2,29]
[33140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"X",null,null,2,29]
[33210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",282.51,282.51,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[33213,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",604.6,604.6,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[33231,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",715.56,715.56,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[33235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1135.42,1135.42,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[33255,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2855.05,2855.05,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",690.37,690.37,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[33276,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1027.46,1027.46,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,null,2]
[33305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7144.82,7144.82,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3271.31,3271.31,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33363,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,2,1,null,"X",null,null,2,29]
[33413,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5616.53,5616.53,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33416,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3555.01,3555.01,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33463,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5384.4,5384.4,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33476,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2696.1,2696.1,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33508,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",28.19,28.19,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33522,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1268.58,1268.58,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-CM",2,29]
[33535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4285.57,4285.57,90,0.09,0.82,0.09,0,2,0,2,0,0,null,"R",null,"Y-CM",2,29]
[33600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3035.59,3035.59,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3081.17,3081.17,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3453.65,3453.65,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2734.49,2734.49,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33737,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29]
[33771,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29]
[33778,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29]
[33824,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29]
[33851,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,29]
[33889,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1369.94,1369.94,0,0,0,0,0,2,1,2,2,0,null,"R",null,null,2,29]
[33895,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1361.55,1361.55,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-UR",2,29]
[33922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2460.98,2460.98,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[33930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,29]
[33952,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",744.35,744.35,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[33963,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,1,1,null,"X",null,null,2,29]
[33976,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2733.89,2733.89,0,0,0,0,0,2,2,2,0,0,null,"R",null,"Y-CM",2,29]
[33979,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3372.08,3372.08,0,0,0,0,0,2,0,2,0,0,null,"R",null,"Y-CM",2,29]
[33997,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",281.31,281.31,0,0,0,0,0,2,0,2,0,0,null,"R",null,"Y-UR",2,29]
[34051,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1759.21,1759.21,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[34520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1719.03,1719.03,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[34705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2642.72,2642.72,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[34717,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",761.15,761.15,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,29]
[34831,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3334.29,3334.29,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-CM",2,29]
[34848,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,2,0,null,"N",null,null,2,29]
[35005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1731.02,1731.02,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[35131,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2399.1999999999998,2399.1999999999998,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[35190,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1330.36,1330.36,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[35216,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3723.56,3723.56,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,null,2,29]
[35251,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3051.18,3051.18,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,null,2,29]
[35305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2128.09,2128.09,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[35355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1783.21,1783.21,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[35510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2126.89,2126.89,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[35515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2302.63,2302.63,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[35536,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2919.83,2919.83,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[35565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2277.44,2277.44,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[35631,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3209.53,3209.53,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[35634,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3053.58,3053.58,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[35663,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2111.9,2111.9,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[35685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",339.49,339.49,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM",2,29]
[35820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3529.82,3529.82,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[35905,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2903.03,2903.03,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[36013,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1470.71,221.33,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[36100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",997.47,263.31,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[36245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2327.2199999999998,412.06,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[36248,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",215.93,84.57,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,29]
[36410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",32.99,16.190000000000001,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[36450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29]
[36471,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2,29]
[36511,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2,29]
[36563,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2044.12,648.38,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[36568,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2,29]
[36590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",407.86,341.89,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[36593,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",67.180000000000007,67.180000000000007,0,0,0,0,3,0,0,0,0,0,null,"R",null,null,2,29]
[36810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",377.87,377.87,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[36831,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1082.04,1082.04,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[36903,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8007.33,551.22,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[37140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4143.42,4143.42,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,1,0,null,"R",null,"Y-CM",2,29]
[37191,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3799.13,386.87,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[37195,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,5,0,0,0,0,0,null,"N",null,"Y-CM",2,29]
[37225,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",16508.3,1035.25,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[37233,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1957.75,557.80999999999995,0,0,0,0,0,0,1,0,0,0,null,"R",null,"Y-CM",2,29]
[37242,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",13342.55,829.52,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[37252,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1787.4,154.15,0,0,0,0,0,0,0,0,1,0,null,"R",null,null,2,29]
[37617,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2353.02,2353.02,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,null,2,29]
[37722,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,1,1,1,0,null,"X",null,null,2,29]
[38101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2091.5,2091.5,90,0.11,0.73,0.16,0,2,0,2,1,0,null,"R",null,null,2,29]
[38120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1916.96,1916.96,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,null,2,29]
[38209,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,29]
[38240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,29]
[38380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1069.44,1069.44,90,0.11,0.73,0.16,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[38555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1867.18,1867.18,90,0.11,0.73,0.16,0,2,0,2,1,0,null,"R",null,null,2,29]
[38745,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1606.26,1606.26,90,0.11,0.73,0.16,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[38790,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",149.35,149.35,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[39501,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1538.49,1538.49,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,null,2,29]
[40500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[40702,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,2,2,0,0,null,"X",null,null,2,29]
[40799,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,1,1,null,"N",null,null,2,29]
[40810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[40844,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2810.66,2168.88,90,0.09,0.81,0.1,0,2,0,2,0,0,null,"R",null,"Y-CM",2,29]
[41017,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",879.31,641.79,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[41112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[41120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[41599,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,29]
[41830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,0,0,0,null,"X",null,null,2,29]
[41872,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",897.3,574.61,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[42107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[42225,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,0,0,null,"X",null,null,2,29]
[42330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[42409,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",753.95,437.85,90,0.09,0.81,0.1,0,2,0,2,0,0,null,"R",null,null,2,29]
[42600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1035.8499999999999,667.58,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[42725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1475.51,1475.51,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,29]
[42830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,0,0,0,null,"X",null,null,2,29]
[42836,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,0,0,0,null,"X",null,null,2,29]
[42892,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[43020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1037.05,1037.05,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,29]
[43118,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6347.08,6347.08,90,0.09,0.81,0.1,0,2,0,2,2,0,null,"R",null,"Y-CM",2,29]
[43180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1005.26,1005.26,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[43204,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",244.12,244.12,0,0,0,0,0,3,0,1,0,0,43200,"R",null,"Y-CM",2,29]
[43214,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",349.68,349.68,0,0,0,0,0,3,0,1,0,0,43200,"R",null,null,2,29]
[43236,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",762.35,250.72,0,0,0,0,0,3,0,1,0,0,43235,"R",null,null,2,29]
[43239,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",714.96,250.72,0,0,0,0,0,3,0,1,0,0,43235,"R",null,"Y-CM",2,29]
[43254,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",485.24,485.24,0,0,0,0,0,3,0,1,0,0,43235,"R",null,null,2,29]
[43261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",607.6,607.6,0,0,0,0,0,3,0,1,0,0,43260,"R",null,"Y-CM",2,29]
[43273,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",212.93,212.93,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[43285,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1219.99,1219.99,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[43289,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,2,1,1,null,"N",null,null,2,29]
[43320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2514.36,2514.36,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[43338,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",199.13,199.13,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM",2,29]
[43361,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4835.59,4835.59,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[43420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1871.38,1871.38,90,0.09,0.81,0.1,0,2,0,0,1,0,null,"R",null,"Y-CM",2,29]
[43520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[43631,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2608.5300000000002,2608.5300000000002,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[43652,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1392.14,1392.14,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[43770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[43810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1833.59,1833.59,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[43848,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[43880,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[44005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1964.35,1964.35,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,29]
[44121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",426.46,426.46,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM",2,29]
[44133,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,29]
[44150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3338.49,3338.49,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[44203,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",424.66,424.66,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM",2,29]
[44206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3123.16,3123.16,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[44345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1903.17,1903.17,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[44366,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",431.26,431.26,0,0,0,0,0,3,0,1,0,0,44360,"R",null,null,2,29]
[44372,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",430.06,430.06,0,0,0,0,0,3,0,1,0,0,44360,"R",null,"Y-CM",2,29]
[44388,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",595,280.70999999999998,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[44402,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,3,0,1,0,0,44388,"X",null,null,2,29]
[44615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1923.56,1923.56,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[44720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",482.24,482.24,0,0,0,0,0,2,0,2,1,0,null,"R",null,null,2,29]
[44900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1420.93,1420.93,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[45111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1970.34,1970.34,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[45121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3142.35,3142.35,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[45130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1964.35,1964.35,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[45308,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",385.67,152.94999999999999,0,0,0,0,0,3,0,1,0,0,45300,"R",null,"Y-CM",2,29]
[45335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",556.61,122.36,0,0,0,0,0,3,0,1,0,0,45330,"R",null,"Y-CM",2,29]
[45349,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,3,0,1,0,0,45330,"X",null,null,2,29]
[45382,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1257.18,464.85,0,0,0,0,0,3,0,1,0,0,45378,"R",null,"Y-CM",2,29]
[45398,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,3,0,1,0,0,45378,"X",null,null,2,29]
[45562,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2119.69,2119.69,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[45905,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",316.08999999999997,316.08999999999997,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[45990,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",191.94,191.94,0,0,0,0,0,2,0,0,1,1,null,"R",null,null,2,29]
[46220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",477.44,226.12,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[46261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",986.07,986.07,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[46604,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1234.99,120.56,0,0,0,0,0,3,0,1,0,0,46600,"R",null,"Y-CM",2,29]
[46614,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",319.69,118.16,0,0,0,0,0,3,0,1,0,0,46600,"R",null,"Y-CM",2,29]
[46740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[46910,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[46942,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",482.24,239.92,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,29]
[47015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2107.1,2107.1,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[47135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9690.3700000000008,9690.3700000000008,90,0.09,0.81,0.1,0,2,0,2,1,2,null,"R",null,"Y-CM",2,29]
[47146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",577.61,577.61,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[47382,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[47480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1597.27,1597.27,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[47541,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2177.27,590.79999999999995,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[47564,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2025.52,2025.52,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,29]
[47711,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[47712,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[48001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4122.43,4122.43,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[48102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",955.48,420.46,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[48160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,29]
[48547,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3213.73,3213.73,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,29]
[49014,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",673.58,673.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-UR",2,29]
[49203,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2161.08,2161.08,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[49324,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",699.37,699.37,10,0.1,0.8,0.1,0,3,0,2,2,0,49320,"R",null,null,2,29]
[49327,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,2,1,0,null,"X",null,null,2,29]
[49426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1220.5899999999999,1220.5899999999999,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[49429,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",826.52,826.52,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[49491,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,1,2,1,0,null,"X",null,null,2,29]
[49507,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1073.6400000000001,1073.6400000000001,90,0.09,0.81,0.1,0,2,1,2,1,0,null,"R",null,null,2,29]
[49615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1142.02,1142.02,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[49659,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,2,1,1,null,"N",null,null,2,29]
[50020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1849.18,1849.18,90,0.08,0.83,0.09,0,2,0,1,1,0,null,"R",null,null,2,29]
[50060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.08,0.83,0.09,0,2,1,2,1,0,null,"X",null,null,2,29]
[50234,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2351.2199999999998,2351.2199999999998,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,null,2,29]
[50250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.08,0.83,0.09,0,2,0,2,1,0,null,"X",null,null,2,29]
[50329,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",317.89,317.89,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[50389,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",783.94,94.77,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[50436,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",267.51,267.51,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[50541,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.08,0.83,0.09,0,2,1,2,1,0,null,"X",null,null,2,29]
[50557,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",772.54,618.39,0,0,0,0,0,3,1,0,0,0,50551,"R",null,null,2,29]
[50570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",877.51,877.51,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29]
[50660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2070.5100000000002,2070.5100000000002,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[50694,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2092.6999999999998,470.84,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[50740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2212.06,2212.06,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[50785,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2194.0700000000002,2194.0700000000002,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[50930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1994.93,1994.93,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[50953,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",737.15,584.80999999999995,0,0,0,0,0,3,1,0,0,0,50951,"R",null,"Y-CM",2,29]
[51045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",915.29,915.29,90,0.08,0.83,0.09,0,2,0,2,0,0,null,"R",null,null,2,29]
[51065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.08,0.83,0.09,0,2,0,0,0,0,null,"X",null,null,2,29]
[51585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.08,0.83,0.09,0,2,2,2,1,0,null,"X",null,null,2,29]
[51597,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.08,0.83,0.09,0,2,0,2,1,0,null,"X",null,null,2,29]
[51726,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",421.66,421.66,0,0,0,0,1,2,0,1,0,0,null,"R",null,null,2,29]
[51727,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",507.43,507.43,0,0,0,0,1,2,0,0,0,0,null,"R",null,null,2,29]
[51741,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",15,15,0,0,0,0,1,2,0,1,0,0,null,"R",null,null,2,29]
[51785,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",163.15,163.15,0,0,0,0,1,2,0,0,0,0,null,"R",null,null,2,29]
[51845,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1067.04,1067.04,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[51940,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.08,0.83,0.09,0,2,0,2,1,0,null,"X",null,null,2,29]
[52224,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1482.71,361.08,0,0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,29]
[52240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",701.17,701.17,0,0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,29]
[52301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",519.42999999999995,519.42999999999995,0,0,0,0,0,3,2,0,0,0,52000,"R",null,"Y-CM",2,29]
[52315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",878.71,491.84,0,0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,29]
[52344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",661.58,661.58,0,0,0,0,0,3,1,1,0,0,52000,"R",null,null,2,29]
[52355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,3,1,1,0,0,52351,"X",null,"Y-CM",2,29]
[52649,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1505.5,1505.5,90,0.08,0.83,0.09,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[53010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",553.62,553.62,90,0.08,0.83,0.09,0,2,0,1,0,0,null,"R",null,null,2,29]
[53265,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[53400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1459.91,1459.91,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[53450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",754.55,754.55,90,0.08,0.83,0.09,0,2,0,1,0,0,null,"R",null,null,2,29]
[53453,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,29]
[53620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",319.69,157.15,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[53665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",67.78,67.78,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[54100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",383.27,223.73,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[54125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1499.5,1499.5,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[54230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",199.73,145.75,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[54240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",200.33,200.33,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,29]
[54332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[54344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[54411,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1874.38,1874.38,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[54437,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1246.98,1246.98,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[54560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,1,2,1,0,null,"X",null,"Y-CM",2,29]
[54680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1435.92,1435.92,90,0.1,0.8,0.1,0,2,1,2,1,0,null,"R",null,null,2,29]
[54901,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1923.56,1923.56,90,0.1,0.8,0.1,0,2,2,0,0,0,null,"R",null,"Y-CM",2,29]
[55041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",942.89,942.89,90,0.1,0.8,0.1,0,2,2,1,0,0,null,"R",null,"Y-CM",2,29]
[55520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",843.32,843.32,90,0.1,0.8,0.1,0,2,1,2,1,0,null,"R",null,"Y-CM",2,29]
[55605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",965.68,965.68,90,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[55725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1095.83,1095.83,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[55865,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,2,2,1,0,null,"X",null,null,2,29]
[55980,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,29]
[56515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[56700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,29]
[56810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",505.03,505.03,10,0.1,0.8,0.1,0,2,0,2,2,0,null,"R",null,"Y-CM",2,29]
[57111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3183.14,3183.14,90,0.12,0.74,0.14000000000000001,0,2,2,2,1,0,null,"R",null,"Y-CM",2,29]
[57135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,29]
[57200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",621.99,621.99,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,null,2,29]
[57282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1275.17,1275.17,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[57305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1794,1794,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[57335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29]
[57454,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",313.7,243.52,0,0,0,0,0,3,0,1,0,0,57452,"R",null,"Y-CM",2,29]
[57500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",290.89999999999998,137.94999999999999,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[57720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",624.39,624.39,90,0.12,0.74,0.14000000000000001,0,2,0,2,0,0,null,"R",null,"Y-CM",2,29]
[58110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,29]
[58180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1758.01,1758.01,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[58290,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2100.5,2100.5,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[58350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,1,1,0,0,null,"X",null,null,2,29]
[58545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,0,2,2,0,null,"X",null,null,2,29]
[58559,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",513.42999999999995,513.42999999999995,0,0,0,0,0,3,0,1,2,0,58555,"R",null,"Y-CM",2,29]
[58571,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1670.44,1670.44,90,0.12,0.74,0.14000000000000001,0,2,0,2,2,0,null,"R",null,"Y-CM",2,29]
[58661,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,3,1,2,2,0,49320,"X",null,null,2,29]
[58671,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,3,0,1,2,0,49320,"X",null,null,2,29]
[58740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29]
[58825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,29]
[58974,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,2,1,0,null,"X",null,null,2,29]
[59020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",133.16,133.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[59076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.09,926.09,0,0,0,0,0,2,0,2,0,0,null,"R",null,"Y-CM",2,29]
[59150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1438.92,1438.92,90,0.17,0.6,0.23,0,2,0,2,0,0,null,"R",null,"Y-CM",2,29]
[59414,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",160.75,160.75,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[59430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",488.24,320.29000000000002,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[59622,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2489.17,2489.17,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[59855,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",775.54,775.54,90,0.17,0.6,0.23,0,2,0,0,0,0,null,"R",null,"Y-CM",2,29]
[60210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.82,0.09,0,2,0,2,1,0,null,"X",null,null,2,29]
[60260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.82,0.09,0,2,1,2,1,0,null,"X",null,"Y-CM",2,29]
[60522,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2423.79,2423.79,90,0.09,0.82,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[60699,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,1,1,null,"N",null,null,2,29]
[61140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2323.63,2323.63,90,0.11,0.76,0.13,0,2,0,2,0,0,null,"R",null,null,2,29]
[61150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2453.7800000000002,2453.7800000000002,90,0.11,0.76,0.13,0,2,0,1,1,0,null,"R",null,null,2,29]
[61312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3735.55,3735.55,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,29]
[61343,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3960.48,3960.48,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,29]
[61510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,0,2,1,0,null,"X",null,null,2,29]
[61530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,0,1,2,0,null,"X",null,null,2,29]
[61544,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3432.06,3432.06,90,0.11,0.76,0.13,0,2,0,2,0,0,null,"R",null,"Y-CM",2,29]
[61557,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,0,2,1,0,null,"X",null,null,2,29]
[61570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3393.07,3393.07,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,29]
[61585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5950.02,5950.02,90,0.11,0.76,0.13,0,2,1,2,1,2,null,"R",null,"Y-CM",2,29]
[61597,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5370.01,5370.01,90,0.11,0.76,0.13,0,2,1,2,1,2,null,"R",null,"Y-CM",2,29]
[61618,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2344.62,2344.62,90,0.11,0.76,0.13,0,2,0,2,1,2,null,"R",null,null,2,29]
[61640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,29]
[61697,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7558.68,7558.68,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[61737,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,1,0,0,0,null,"X",null,null,2,29]
[61790,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,1,1,0,0,null,"X",null,null,2,29]
[61868,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,2,1,0,null,"X",null,null,2,29]
[61892,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,1,1,0,0,null,"X",null,null,2]
[62010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2796.87,2796.87,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[62147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2573.7399999999998,2573.7399999999998,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,29]
[62180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2903.63,2903.63,90,0.11,0.76,0.13,0,2,0,2,0,0,null,"R",null,"Y-CM",2,29]
[62252,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",78.569999999999993,78.569999999999993,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,29]
[62270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",274.11,113.36,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,29]
[62302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",478.04,214.13,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[62328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",419.86,152.94999999999999,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[62362,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",710.16,710.16,10,0.1,0.8,0.1,0,2,0,0,1,0,null,"R",null,"Y-UR",2,29]
[62368,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",82.17,61.78,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-UR",2,29]
[63020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2015.33,2015.33,90,0.11,0.76,0.13,0,2,1,2,2,0,null,"R",null,"Y-UR",2,29]
[63045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2352.42,2352.42,90,0.11,0.76,0.13,0,2,2,2,2,0,null,"R",null,"Y-UR",2,29]
[63075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2465.7800000000002,2465.7800000000002,90,0.11,0.76,0.13,0,2,0,2,2,0,null,"R",null,"Y-UR",2,29]
[63101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4211.8,4211.8,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[63190,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2273.2399999999998,2273.2399999999998,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[63271,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3749.35,3749.35,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[63280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3836.92,3836.92,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[63283,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3456.05,3456.05,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[63620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2050.7199999999998,2050.7199999999998,90,0.11,0.76,0.13,0,0,0,2,0,0,null,"R",null,"Y-CM",2,29]
[63655,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,0,2,1,0,null,"X",null,"Y-UR",2,29]
[63709,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2041.12,2041.12,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,29]
[64405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",139.15,94.77,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[64446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",134.96,134.96,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[64480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",254.32,110.36,0,0,0,0,0,0,1,1,0,0,null,"R",null,"Y-UR",2,29]
[64490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",364.08,192.54,0,0,0,0,0,2,1,2,0,0,null,"R",null,"Y-UR",2,29]
[64494,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",170.94,91.77,0,0,0,0,0,0,1,2,0,0,null,"R",null,"Y-UR",2,29]
[64569,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1408.33,1408.33,90,0.11,0.76,0.13,0,2,1,0,1,1,null,"R",null,"Y-UR",2,29]
[64584,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,1,0,1,1,null,"X",null,null,2,29]
[64615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",281.91000000000003,220.73,10,0.1,0.8,0.1,0,2,2,1,0,0,null,"R",null,"Y-CM",2,29]
[64629,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2,29]
[64646,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",299.3,209.93,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[64716,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",953.68,953.68,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,29]
[64726,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",502.03,502.03,90,0.11,0.76,0.13,0,2,0,1,0,0,null,"R",null,"Y-CM",2,29]
[64740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",855.91,855.91,90,0.11,0.76,0.13,0,2,1,2,0,0,null,"R",null,"Y-CM",2,29]
[64786,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1819.19,1819.19,90,0.11,0.76,0.13,0,2,1,2,0,0,null,"R",null,null,2,29]
[64790,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1563.08,1563.08,90,0.11,0.76,0.13,0,2,0,0,1,0,null,"R",null,"Y-CM",2,29]
[64832,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",597.4,597.4,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,29]
[64857,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1930.16,1930.16,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,29]
[64885,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1971.54,1971.54,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,29]
[64893,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2051.3200000000002,2051.3200000000002,90,0.11,0.76,0.13,0,2,0,2,0,0,null,"R",null,null,2,29]
[65093,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1388.54,1388.54,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,29]
[65105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1794,1794,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,29]
[65260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1819.79,1819.79,90,0.1,0.7,0.2,0,2,1,2,0,0,null,"R",null,null,2,29]
[65272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",996.27,653.78,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29]
[65435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",154.15,128.96,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,29]
[65755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2322.4299999999998,2322.4299999999998,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,29]
[65779,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2232.46,216.53,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,29]
[65875,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1180.4100000000001,1180.4100000000001,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,29]
[66130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1317.76,1042.45,90,0.1,0.7,0.2,0,2,1,0,0,0,null,"R",null,null,2,29]
[66160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1831.79,1831.79,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,29]
[66625,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",797.73,797.73,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29]
[66680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",969.88,969.88,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,29]
[66840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1282.3699999999999,1282.3699999999999,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29]
[66982,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1375.94,1375.94,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29]
[67010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1013.06,1013.06,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,29]
[67036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1654.85,1654.85,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,29]
[67115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",927.89,927.89,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29]
[67141,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",508.63,403.67,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[67314,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",845.12,845.12,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[67346,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",353.28,353.28,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[67413,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1804.8,1804.8,90,0.1,0.7,0.2,0,2,1,2,0,0,null,"R",null,null,2,29]
[67450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2604.33,2604.33,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,29]
[67800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",242.32,188.94,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,29]
[67830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",511.63,254.92,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[67906,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",932.09,932.09,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29]
[67911,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1034.6600000000001,1034.6600000000001,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29]
[67935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1123.43,805.53,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29]
[67999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,29]
[68328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1300.97,1300.97,90,0.1,0.7,0.2,0,2,1,0,0,0,null,"R",null,null,2,29]
[68399,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,29]
[68700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1115.6300000000001,1115.6300000000001,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,29]
[68770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1160.01,1160.01,90,0.1,0.7,0.2,0,2,1,0,0,0,null,"R",null,null,2,29]
[69020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",443.25,272.31,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,29]
[69209,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",30.59,30.59,0,0,0,0,5,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[69420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",364.08,227.92,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[69433,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",385.07,249.52,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[69603,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2408.1999999999998,2408.1999999999998,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[69620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1408.33,928.49,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R",null,null,2,29]
[69646,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2937.82,2937.82,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,null,"R",null,"Y-CM",2,29]
[69670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1765.81,1765.81,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,0,0,null,"R",null,"Y-CM",2,29]
[69716,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1149.82,1149.82,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R",null,"Y-CM",2,29]
[69729,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"X",null,null,2,29]
[69970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,1,0,null,"X",null,null,2,26]
[70010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",104.37,104.37,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,26]
[70130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",118.16,118.16,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26]
[70134,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",118.76,118.76,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[70170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26]
[70210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",61.78,61.78,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[70250,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",16.190000000000001,16.190000000000001,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[70310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",77.97,77.97,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[70332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",157.75,157.75,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26]
[70336,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",519.42999999999995,519.42999999999995,0,0,0,0,1,4,2,0,0,0,null,"R",null,null,2,26]
[70371,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",132.56,132.56,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[70450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",206.33,206.33,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26]
[70470,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",109.76,109.76,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26]
[70482,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",413.26,413.26,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[70490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",291.5,291.5,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[70492,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",293.3,293.3,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[70542,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",388.07,388.07,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[70543,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",480.44,480.44,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[70546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",650.78,650.78,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[70551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",383.87,383.87,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26]
[70555,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,3,0,0,0,null,"X",null,null,2,26]
[70558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26]
[71047,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",56.98,56.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[71100,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",19.190000000000001,19.190000000000001,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[71120,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",17.39,17.39,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[71260,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",100.17,100.17,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[71550,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",541.02,541.02,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[71551,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",587.79999999999995,587.79999999999995,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[71555,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",153.55000000000001,153.55000000000001,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[72052,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",26.39,26.39,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[72080,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",18.59,18.59,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[72083,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",152.94999999999999,152.94999999999999,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[72084,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",35.99,35.99,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[72120,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",58.18,58.18,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[72129,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",104.97,104.97,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[72130,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",109.76,109.76,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[72133,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",387.47,387.47,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[72147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",535.62,535.62,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26]
[72157,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",627.99,627.99,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26]
[72159,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",680.17,680.17,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[72192,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",93.57,93.57,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[72193,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",99.57,99.57,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[72200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",63.58,63.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[72202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",74.98,74.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[72240,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",133.76,133.76,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[72295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",211.73,211.73,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR",2,26]
[73020,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",13.2,13.2,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26]
[73050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",55.18,55.18,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2,26]
[73085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",191.34,191.34,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26]
[73092,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,3,0,0,0,null,"X",null,null,2,26]
[73120,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",45.58,45.58,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26]
[73130,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",55.78,55.78,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26]
[73206,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",428.26,428.26,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[73219,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",653.17999999999995,653.17999999999995,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR",2,26]
[73223,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",761.75,761.75,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR",2,26]
[73501,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",46.18,46.18,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[73522,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",77.37,77.37,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[73525,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",51.58,51.58,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26]
[73562,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",16.79,16.79,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26]
[73565,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",15,15,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2,26]
[73590,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",46.18,46.18,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26]
[73615,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",195.53,195.53,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26]
[73630,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",14.4,14.4,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,26]
[73701,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",99.57,99.57,0,0,0,0,1,4,3,0,0,0,null,"R",null,null,2,26]
[73719,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",139.15,139.15,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR",2,26]
[73722,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",617.79,617.79,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR",2,26]
[74019,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",69.58,69.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[74021,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",58.78,58.78,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[74150,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",102.57,102.57,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[74175,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",155.35,155.35,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[74178,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",667.58,667.58,0,0,0,0,1,4,0,9,0,0,null,"R",null,null,2,26]
[74185,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",662.78,662.78,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[74221,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",209.33,209.33,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[74230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",239.32,239.32,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[74250,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",68.98,68.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[74251,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",100.17,100.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[74263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1297.3699999999999,1297.3699999999999,0,0,0,0,1,9,9,9,9,9,null,"R",null,"Y-CM",2,26]
[74290,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",163.15,163.15,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[74301,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26]
[74340,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26]
[74400,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",41.99,41.99,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[74420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",148.75,148.75,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[74445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26]
[74455,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",171.54,171.54,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[74470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26]
[74740,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26]
[75559,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",484.04,484.04,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM",2,26]
[75565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",89.37,89.37,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[75600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",350.28,350.28,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[75625,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",116.36,116.36,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[75710,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",146.35,146.35,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[75726,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",150.55000000000001,150.55000000000001,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[75731,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",97.77,97.77,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[75743,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",137.35,137.35,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,26]
[75774,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",98.97,98.97,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[75807,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,2,0,0,0,null,"N",null,null,2,26]
[75810,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",85.77,85.77,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[75827,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",95.37,95.37,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[75842,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",128.36000000000001,128.36000000000001,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,26]
[75872,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",242.92,242.92,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[75887,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",258.51,258.51,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[75891,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",140.94999999999999,140.94999999999999,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[75894,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",126.56,126.56,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[75956,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",581.21,581.21,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[75959,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26]
[76000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",80.97,80.97,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",170.34,170.34,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1744.22,1744.22,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,26]
[76376,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",47.38,47.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76391,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",395.27,395.27,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26]
[76497,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26]
[76510,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",71.38,71.38,0,0,0,0,1,7,3,0,0,0,null,"R",null,null,2,26]
[76512,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",34.79,34.79,0,0,0,0,1,7,3,0,0,0,null,"R",null,null,2,26]
[76519,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",55.18,55.18,0,0,0,0,1,7,3,0,0,0,null,"R",null,null,2,26]
[76641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",195.53,195.53,0,0,0,0,1,0,1,0,0,0,null,"R",null,"Y-CM",2,26]
[76705,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",115.76,115.76,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,26]
[76706,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",157.15,157.15,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[76801,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",85.17,85.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76802,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",40.79,40.79,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76812,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",154.75,154.75,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76815,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",154.15,154.15,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[76820,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",43.19,43.19,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76826,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",228.52,228.52,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76828,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",43.79,43.79,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76830,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",59.38,59.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76873,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,"Y-CM",2,26]
[76881,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",99.57,99.57,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76885,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26]
[76937,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",47.38,47.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[76945,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26]
[76975,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26]
[76978,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",139.75,139.75,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM",2,26]
[76979,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",73.180000000000007,73.180000000000007,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[76998,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26]
[77001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",188.94,188.94,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[77011,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",311.3,311.3,0,0,0,0,1,0,0,9,0,0,null,"R",null,"Y-CM",2,26]
[77013,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",327.49,327.49,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[77046,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",124.16,124.16,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,26]
[77049,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",671.78,671.78,0,0,0,0,1,4,2,0,0,0,null,"R",null,"Y-UR",2,26]
[77062,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,9,0,0,null,"X",null,"Y-CM",2,26]
[77063,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,2,9,0,0,null,"X",null,"Y-CM",2,26]
[77073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",86.37,86.37,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[77074,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",86.37,86.37,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[77078,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",177.54,177.54,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[77081,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",17.39,17.39,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77091,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",53.98,53.98,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77280,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",68.98,68.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77295,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",413.26,413.26,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3536.42,3536.42,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77317,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",442.05,442.05,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77318,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",597.4,597.4,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77334,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",110.96,110.96,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77338,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",473.84,473.84,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77401,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",80.37,80.37,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,26]
[77522,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,3,0,0,0,0,0,null,"N",null,"Y-CM",2,26]
[77600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1049.6500000000001,1049.6500000000001,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77750,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",482.24,482.24,90,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77761,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",427.66,427.66,90,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[77770,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26]
[77771,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26]
[77790,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",34.79,34.79,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",155.94999999999999,155.94999999999999,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78018,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",476.24,476.24,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78020,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",101.37,101.37,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78099,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26]
[78102,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",44.99,44.99,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",146.94999999999999,146.94999999999999,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",187.14,187.14,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78191,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",193.14,193.14,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78199,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26]
[78216,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",46.78,46.78,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",314.89999999999998,314.89999999999998,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",355.08,355.08,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78262,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",434.86,434.86,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78268,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,26]
[78290,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",578.21,578.21,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[78305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",479.24,479.24,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[78315,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",521.83000000000004,521.83000000000004,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[78428,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",332.89,332.89,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78430,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-UR",2,26]
[78434,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-UR",2,26]
[78445,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",43.79,43.79,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78457,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",293.89999999999998,293.89999999999998,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78458,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",368.88,368.88,0,0,0,0,1,6,2,0,0,0,null,"R",null,"Y-CM",2,26]
[78469,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",393.47,393.47,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-UR",2,26]
[78473,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",389.27,389.27,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78492,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",3194.8,3194.8,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-UR",2,26]
[78496,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",36.590000000000003,36.590000000000003,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR",2,26]
[78582,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",582.41,582.41,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78598,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",529.62,529.62,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78606,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",526.62,526.62,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[78608,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",124.16,124.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78610,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",25.19,25.19,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[78650,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",43.79,43.79,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[78701,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",41.99,41.99,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[78725,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",154.75,154.75,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[78761,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",316.69,316.69,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[78799,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26]
[78804,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",84.57,84.57,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[78811,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26]
[78813,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26]
[78816,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26]
[79005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",250.72,250.72,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[79200,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",142.15,142.15,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[79445,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,23]
[80050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",48.63,48.63,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[80151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.38,26.38,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[80157,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.75,18.75,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[80169,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.43,19.43,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[80181,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.38,26.38,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[80195,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.43,19.43,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[80203,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.75,18.75,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[80320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[80327,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[80339,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[80340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[80350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[80362,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[80374,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[80408,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",177.58,177.58,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[80428,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[80439,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4.92,4.92,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[81105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81171,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81178,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81190,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81207,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81218,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81233,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81252,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81259,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81271,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81279,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81294,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81316,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81348,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81364,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81376,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",172.94,172.94,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[81404,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81412,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81437,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81458,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
[81500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[81551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[82024,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",54.65,54.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",42.45,42.45,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82128,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.63,19.63,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.17,9.17,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82239,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",24.22,24.22,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",41.88,41.88,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[82340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8.5299999999999994,8.5299999999999994,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82374,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6.91,6.91,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.93,17.93,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82482,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",13.88,13.88,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.95,18.95,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82595,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.16,9.16,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82652,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",54.48,54.48,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[82664,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",87.02,87.02,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82728,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.29,19.29,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82746,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.8,20.8,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82803,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",36.89,36.89,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82943,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.22,20.22,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[82965,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.61,18.61,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[83003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",23.59,23.59,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[83021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.55,25.55,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[83080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[83500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[83518,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",13.64,13.64,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[83625,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.100000000000001,18.100000000000001,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[83632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",28.61,28.61,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[83718,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",11.59,11.59,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[83775,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[83880,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",55.55,55.55,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[83950,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[84035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5.63,5.63,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[84075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7.33,7.33,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[84134,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.64,20.64,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[84154,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.02,26.02,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[84163,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[84182,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",41.33,41.33,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[84238,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",51.75,51.75,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[84285,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",35.67,35.67,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[84379,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[84403,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",36.520000000000003,36.520000000000003,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[84443,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",23.77,23.77,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[84480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.059999999999999,20.059999999999999,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[84545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",10.19,10.19,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[84585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[84704,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",21.64,21.64,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[85009,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7.17,7.17,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[85049,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6.34,6.34,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[85245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",32.46,32.46,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[85291,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",12.89,12.89,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[85300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",16.77,16.77,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[85360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",11.9,11.9,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[85384,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",13.75,13.75,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[85445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[85536,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.74,9.74,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[85597,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.44,25.44,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[85652,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3.82,3.82,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86022,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.99,25.99,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86037,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[86146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",36.01,36.01,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[86152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[86226,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.14,17.14,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",11.59,11.59,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86318,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.6,25.6,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86325,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",31.79,31.79,0,0,0,0,6,0,0,0,0,0,null,"R",null,null,2,23]
[86343,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.63,17.63,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86353,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",69.38,69.38,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86386,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[86480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",87.7,87.7,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86592,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6.04,6.04,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86611,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",14.4,14.4,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86638,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.149999999999999,17.149999999999999,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86653,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.66,18.66,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86684,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",22.41,22.41,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86689,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",27.38,27.38,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86703,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.399999999999999,19.399999999999999,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86723,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.66,18.66,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86759,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.8,25.8,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86777,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.36,20.36,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86804,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",21.92,21.92,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86816,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",42.69,42.69,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86835,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",456.99,456.99,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[86891,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,23]
[86922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,23]
[86930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,23]
[86975,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,23]
[87015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.4499999999999993,9.4499999999999993,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",11.42,11.42,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87109,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",21.78,21.78,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87143,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.72,17.72,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87168,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6.04,6.04,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87207,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8.48,8.48,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6.04,6.04,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.420000000000002,20.420000000000002,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87279,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",23.25,23.25,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87327,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.989999999999998,18.989999999999998,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",16.95,16.95,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49.99,49.99,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[87430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",23.79,23.79,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",28.37,28.37,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",32.19,32.19,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[87498,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49.65,49.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87521,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49.65,49.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87533,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",59.09,59.09,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",28.37,28.37,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87563,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[87582,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",428.21,428.21,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",28.37,28.37,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87653,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49.65,49.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87809,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",30.79,30.79,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[87899,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",22.74,22.74,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,23]
[88005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,23]
[88027,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,23]
[88106,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",102.57,102.57,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[88112,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",49.18,49.18,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[88141,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",45.58,45.58,0,0,0,0,2,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[88152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",39.11,39.11,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[88160,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",45.58,45.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[88172,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",62.98,62.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[88182,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",68.38,68.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[88199,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,23]
[88261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",374.04,374.04,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[88272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",57.59,57.59,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,23]
[88300,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",7.8,7.8,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[88304,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",82.17,82.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[88307,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",404.87,404.87,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[88313,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",137.94999999999999,137.94999999999999,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[88319,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",47.98,47.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[88332,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",48.58,48.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[88342,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",62.38,62.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[88344,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",68.38,68.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[88358,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,23]
[88360,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,23]
[88362,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",199.13,199.13,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[88367,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,23]
[88369,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,23]
[88377,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,23]
[88388,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",41.99,41.99,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[88740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[89220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",31.79,31.79,0,0,0,0,3,0,0,0,0,0,null,"R",null,null,2,23]
[89250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[89259,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[89320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.420000000000002,17.420000000000002,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,16]
[89346,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
[90284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,16]
[90386,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,16]
[90471,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",38.99,38.99,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,16]
[90622,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,16]
[90636,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,16]
[90648,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,16]
[90662,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",73.400000000000006,73.400000000000006,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
[90673,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,16]
[90690,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,17]
[90716,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,17]
[90738,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,17]
[90791,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",317.29000000000002,269.91000000000003,0,0,0,0,0,0,0,9,0,0,null,"R",null,"Y-CM",2,17]
[90838,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",221.93,196.13,0,0,0,0,0,0,0,9,0,0,null,"R",null,"Y-CM",2,17]
[90865,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",300.5,221.93,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,17]
[90880,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",189.54,156.55000000000001,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,17]
[90912,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",152.35,77.37,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,6]
[90956,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
[90968,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",31.19,31.19,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[91010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",422.26,422.26,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[91030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",277.70999999999998,277.70999999999998,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[91037,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",234.52,234.52,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[91037,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",88.17,88.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[91110,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",203.33,203.33,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[91113,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",219.53,219.53,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[91133,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",828.92,828.92,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[91299,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2]
[92002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",160.75,82.77,0,0,0,0,0,0,2,0,0,0,null,"R",null,null,2]
[92025,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",33.590000000000003,33.590000000000003,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92081,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",28.79,28.79,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92082,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",37.79,37.79,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92134,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",44.99,44.99,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92145,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",15,15,0,0,0,0,1,7,2,0,0,0,null,"R",null,"Y-CM",2]
[92240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",359.88,359.88,0,0,0,0,1,7,2,0,0,0,null,"R",null,"Y-CM",2]
[92250,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",32.39,32.39,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92285,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",38.99,38.99,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",186.54,77.97,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[92340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",65.38,32.39,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2]
[92352,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
[92516,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",137.94999999999999,41.39,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[92519,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",241.72,116.36,0,0,0,0,0,0,2,0,0,0,null,"R",null,"Y-CM",2]
[92533,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
[92541,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",46.78,46.78,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[92546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",255.51,255.51,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[92552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",73.78,73.78,0,0,0,0,3,0,2,0,0,0,null,"R",null,null,2,29]
[92563,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",67.180000000000007,67.180000000000007,0,0,0,0,3,0,2,0,0,0,null,"R",null,null,2]
[92568,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",27.59,26.99,0,0,0,0,7,0,2,0,0,0,null,"R",null,null,2,29]
[92588,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",9.6,9.6,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2,26]
[92595,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,26]
[92608,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",91.17,91.17,0,0,0,0,7,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[92615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,0,0,0,0,0,0,null,"B",null,"Y-CM",2,26]
[92633,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,26]
[92929,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,26]
[92944,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,26]
[92960,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",286.10000000000002,194.94,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[92987,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2413,2413,0,0.09,0.84,7.0000000000000007E-2,0,2,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.99,26.99,0,0,0,0,4,6,0,0,0,0,null,"R",null,null,2,26]
[93025,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",67.180000000000007,67.180000000000007,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",295.7,170.34,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[93245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",524.23,524.23,0,0,0,0,4,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",131.36000000000001,131.36000000000001,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93279,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",55.78,55.78,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93281,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",83.37,83.37,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",85.77,85.77,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93287,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",98.97,98.97,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93291,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",92.37,92.37,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93293,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",58.18,58.18,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93304,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",64.180000000000007,64.180000000000007,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93308,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",188.34,188.34,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[93316,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",46.18,46.18,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,26]
[93317,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",157.15,157.15,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,26]
[93350,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",124.16,124.16,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[93351,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",148.75,148.75,0,0,0,0,1,6,0,9,9,9,null,"R",null,null,2,26]
[93455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1887.57,1887.57,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93456,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2107.6999999999998,2107.6999999999998,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93460,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2321.23,2321.23,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93461,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",1839.59,1839.59,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93568,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",81.569999999999993,81.569999999999993,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,26]
[93571,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26]
[93588,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
[93592,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",687.37,687.37,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,26]
[93598,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,26]
[93600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26]
[93610,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26]
[93615,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26]
[93620,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26]
[93621,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,26]
[93640,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",308.3,308.3,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93641,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",538.62,538.62,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",305.3,305.3,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93701,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",52.18,52.18,0,0,0,0,3,6,0,0,0,0,null,"R",null,"Y-CM",2,26]
[93786,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",43.79,43.79,0,0,0,0,3,6,0,0,0,0,null,"R",null,null,2,26]
[93799,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,26]
[93888,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",307.10000000000002,307.10000000000002,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[93892,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",521.83000000000004,521.83000000000004,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[93923,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",211.13,211.13,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,26]
[93924,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",41.99,41.99,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,26]
[93971,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",227.92,227.92,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[93975,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",506.23,506.23,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[93980,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",220.73,220.73,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,26]
[93985,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",407.86,407.86,0,0,0,0,1,6,2,0,0,0,null,"R",null,"Y-CM",2,26]
[94005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",167.34,167.34,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2]
[94014,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",106.16,106.16,0,0,0,0,4,0,0,0,0,0,null,"R",null,null,2]
[94150,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Bundled","Bundled",0,0,0,0,1,9,9,9,9,9,null,"B",null,null,2]
[94375,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",48.58,48.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[94621,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",170.94,170.94,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[94626,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",152.94999999999999,49.18,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2]
[94680,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",80.37,80.37,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[94690,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",6.6,6.6,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[94729,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",16.190000000000001,16.190000000000001,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[94780,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2]
[95024,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",15.59,1.8,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[95044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.6,9.6,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2]
[95134,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
[95146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",130.76,5.4,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2]
[95199,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2]
[95709,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2]
[95725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",537.41999999999996,523.63,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2]
[95783,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2]
[95805,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",103.17,103.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[95806,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",79.17,79.17,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[95813,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",851.72,851.72,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95816,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",759.95,759.95,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95824,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2]
[95860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",213.53,213.53,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95865,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",281.31,281.31,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2]
[95867,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",127.16,127.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95872,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",268.11,268.11,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95874,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",35.39,35.39,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95887,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",66.58,66.58,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2]
[95905,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2]
[95909,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",143.35,143.35,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95913,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",335.89,335.89,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95924,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",284.31,284.31,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95926,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",253.72,253.72,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2]
[95930,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",95.37,95.37,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2]
[95937,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",62.38,62.38,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95940,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",58.18,58.18,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[95957,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",374.88,374.88,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95961,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",328.69,328.69,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[95967,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",308.89999999999998,308.89999999999998,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[95990,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",174.54,174.54,0,0,0,0,5,0,0,0,0,0,null,"R",null,"Y-UR",2]
[96003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",29.99,29.99,0,0,0,0,0,0,2,0,0,0,null,"R",null,"Y-CM",2]
[96125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",190.74,190.74,0,0,0,0,7,5,0,0,0,0,null,"R",null,"Y-CM",2,25]
[96138,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",66.58,66.58,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-ONC",2,25]
[96170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,17]
[96203,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,17]
[96369,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",272.91000000000003,272.91000000000003,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,25]
[96405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",158.35,52.18,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,25]
[96417,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",121.76,121.76,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,25]
[96547,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
[96900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",48.58,48.58,0,0,0,0,5,0,0,0,0,0,null,"R",null,"Y-CM",2,25]
[96934,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",224.93,224.93,0,0,0,0,4,0,0,0,0,0,null,"R",null,"Y-CM",2,10]
[97028,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",15.59,15.59,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,23]
[97034,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.39,26.39,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,23]
[97113,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",68.98,68.98,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,23]
[97155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,25]
[97164,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",130.76,130.76,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,25]
[97542,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",59.38,59.38,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,10]
[97608,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",695.77,44.39,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,10]
[97799,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,7,0,0,0,0,0,null,"N",null,null,2,10]
[98929,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",156.55000000000001,126.56,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10]
[98962,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.99,20.99,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2,10]
[98968,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",60.58,56.38,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10]
[99051,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,10]
[99058,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,10]
[99135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,10]
[99175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",58.18,58.18,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,10]
[99192,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,10]
[99221,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",149.35,149.35,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10]
[99235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",289.10000000000002,289.10000000000002,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10]
[99242,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",139.75,101.97,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2,10]
[99285,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",313.10000000000002,313.10000000000002,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10]
[99307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",73.78,73.78,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10]
[99349,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",232.72,232.72,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,10]
[99379,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,10]
[99386,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,10]
[99404,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
[99411,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
[99421,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
[99443,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",238.72,176.94,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[99452,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
[99464,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
[99472,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
[99486,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
[99492,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",287.89999999999998,170.94,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-ONC",2]
[99507,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
[99511,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0004A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",40,40,0,0,0,0,0,0,0,0,0,0,null,"D",null,"Y-CM",2]
["0010U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",604.57000000000005,604.57000000000005,0,0,0,0,0,0,0,0,0,0,null,"L",null,null,2]
["0015M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1847.1,1847.1,0,0,0,0,0,0,0,0,0,0,null,"L",null,"Y-ONC",2]
["0020U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2]
["0054T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2]
["0084U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0092U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3520.52,3520.52,0,0,0,0,0,0,0,0,0,0,null,"L",null,null,2]
["0094U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0102T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0107U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0118U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0124A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",40,40,0,0,0,0,0,0,0,0,0,0,null,"D",null,"Y-CM",2]
["0134U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0145U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0152U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0154U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0184T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0207U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0210U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0214T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,1,0,0,0,null,"N",null,"Y-UR",2]
["0220T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-UR",2]
["0229U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0234U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0236T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2]
["0264T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0273T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0293U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0300U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0329T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0339T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0356U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0378R",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",10.45,10.45,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,30]
["0391R",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5.76,5.76,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,18]
["0394T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0407A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","State Rate","State Rate",0,0,0,0,0,0,0,0,0,0,null,"S",null,null,2]
["0411T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0419T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,21]
["0422U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0429U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0437T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0450T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["0473T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0494T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,2,2,1,0,null,"X",null,null,2]
["0503F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["0516F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["0520T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,0,1,0,0,null,"N",null,"Y-CM",2]
["0528F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["0529T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,9,9,9,9,9,null,"X",null,null,2]
["0546T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0551F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["0564T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0571T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0578T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,25]
["0582T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0592T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0621T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2]
["0637T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,3,0,0,0,null,"X",null,null,2]
["0671T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2]
["0679T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,0,1,0,0,null,"N",null,"Y-UR",2]
["0691T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2]
["0705T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,9,2,9,9,9,null,"X",null,null,2]
["0712T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,9,9,9,9,9,null,"X",null,null,2]
["0748T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2]
["0751T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["0767T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0779T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2]
["0790T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,2,0,0,null,"X",null,null,2]
["0813T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,3,0,1,0,0,null,"X",null,null,2]
["0825T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2]
["0832T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["0844T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["0851T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["0856T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["0800V",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",10.55,10.55,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,30]
["0841V",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8.99,8.99,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,30]
["0844V",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",10.55,10.55,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,30]
["1001M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Work hardening eval, per hour",142.31,142.31,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,25]
["1008F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1027M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lep form by a/p at insurer's request",23.01,23.01,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,27]
["1034F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1055F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1061F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1076M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Opioid req for subacute pain w/o doc",36.81,36.81,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,27]
["1083M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"SHSC Initial Surgical Intake",162.83000000000001,162.83000000000001,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,22]
["1097M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Review of FCE Report/Summary",59.81,59.81,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,27]
["1119F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1127F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1135F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1150F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1152F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1180F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1183F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1223M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nurse case management travel / wait",6.52,6.52,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,20]
["1230M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ur contract:  retrospective outpatient review","Contracted","Contracted",0,0,0,0,0,0,0,0,0,0,null,"C",null,null,2]
["1256M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"UR, work conditioning - questionnaire","Contracted","Contracted",0,0,0,0,0,0,0,0,0,0,null,"C",null,null,2]
["1278M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"CCM, VALUE BASE-INITIAL PHASE","Contracted","Contracted",0,0,0,0,0,0,0,0,0,0,null,"C",null,null,2]
["1402W",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",42.78,42.78,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,22]
["1460F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1728M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"PGAP Coach Travel Time",8.56,8.5500000000000007,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,22]
["2010F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["2015F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["2027F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["2052A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",78.19,78.19,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,7]
["3016F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3037F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3049F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3074F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3079F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3089F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3117F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3160F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3220F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3273F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3279F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3319F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3322F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3340F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3372F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3386F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3475F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3503F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3517F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3751F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3754F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3761F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4011F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4035F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4046F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4060F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4069F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4115F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,18]
["4130F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4140F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4159F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4172F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4187F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4210F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4248F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4271F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4300F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,28]
["4450F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,28]
["4526F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4554F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["5010F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,18]
["5200F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["5939M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lodging provider reimbursement - dinner","State Rate","State Rate",0,0,0,0,0,0,0,0,0,0,null,"S",null,null,2,22]
["6110F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["8885H",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",588.91999999999996,588.91999999999996,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2]
["8886H",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",557.92999999999995,557.92999999999995,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2]
["8916H",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-ONC",2]
["8971H",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",10.75,10.75,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,11]
["9940M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"L&I Mexico Medical Coordinator","Contracted","Contracted",0,0,0,0,0,0,0,0,0,0,null,"C",null,null,2]
["A0090",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Interest escort in non er","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28]
["A0170",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transport parking fees/tolls","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28]
["A0392",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Als defibrillation supplies",64.739999999999995,64.739999999999995,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,28]
["A0428",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bls",421.07,421.07,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,3]
["A0431",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rotary wing air transport",7992.76,7992.76,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,3]
["A2004",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Xcellistem, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["A2011",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Supra sdrm, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["A2023",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Innovamatrix pd, 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["A4208",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"3 cc sterile syringe&needle",9.9600000000000009,9.9600000000000009,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4226",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Weekly supply maint cgs pump","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28]
["A4239",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-adju cgm supply allow","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["A4252",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Blood ketone test or strip",11.32,11.32,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4256",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Calibrator solution/chips",3.43,3.43,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4269",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spermicide","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["A4284",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Replcmnt breast pump shield","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["A4310",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Insert tray w/o bag/cath",10.7,10.7,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4327",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fem urinary collect dev cup",58.54,58.54,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4341",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Iduc valve pat inst repl",337.93,337.93,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["A4358",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urinary leg or abdomen bag",8.94,8.94,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4367",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ostomy belt",9.43,9.43,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4371",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Skin barrier powder per oz",4.97,4.97,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4389",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Drainable pch w st wear barr",8.6,8.6,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4395",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ostomy pouch solid deodorant",0.05,0.05,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4408",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ext wear ost skn barr >4sq\"",13.67,13.67,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4415",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ost skn barr w/o conv >4 sqi",8.3000000000000007,8.3000000000000007,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4427",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ost pch drain/barr lk flng/f",3.87,3.87,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4450",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-waterproof tape",0.1,0.1,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4459",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Manual pump enema, reusable",4034.81,4034.81,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["A4465",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-elastic extremity binder",34.86,34.86,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4553",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nondisp underpads, all sizes","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["A4557",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lead wires, pair",19.16,19.16,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A4580",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast supplies (plaster)","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["A4601",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lith ion non prosth recharge",74.84,74.84,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["A4617",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mouth piece",4.29,4.29,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["A4633",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Uvl replacement bulb","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["A4640",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alternating pressure pad",96.23,96.23,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["A4652",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Microcapillary tube sealant",9.9600000000000009,9.9600000000000009,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["A4707",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bicarbonate conc pow per pac","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28]
["A4714",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Treated water per gallon",37.68,37.68,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["A4737",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj anesthetic per 10 ml","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28]
["A4770",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Blood collection tube/vacuum",13.63,13.63,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["A4927",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-sterile gloves",18.010000000000002,18.010000000000002,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["A5052",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Clsd ostomy pouch w/o barr",2.06,2.06,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A5082",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Continent stoma catheter",14.06,14.06,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A5102",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bedside drain btl w/wo tube",31.25,31.25,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A5506",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diabetic shoe w/off set heel",44.91,44.91,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,28]
["A5510",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Compression form shoe insert",88.63,88.63,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,28]
["A6154",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Wound pouch each",19.89,19.89,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6205",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Composite drsg > 48 sq in",14.94,14.94,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6217",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-sterile gauze>16<=48 sq",0.43,0.43,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6221",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gauze > 48 sq in w/border",9.11,9.11,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6240",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hydrocolld drg filler paste",16.96,16.96,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6243",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hydrogel drg >16<=48 w/o bdr",17.07,17.07,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Wound cleanser any type/size",0.52,0.52,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6266",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Impreg gauze no h20/sal/yard",2.65,2.65,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6444",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Conform band n/s w>=5\"/yd",0.77,0.77,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6451",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mod compres band w>=3\"<5\"/yd",2.4300000000000002,2.4300000000000002,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6505",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cmprsburngarment glove-elbow",323.68,323.68,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["A6512",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Compres burn garment, noc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,9]
["A6530",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Compression stocking bk18-30",37.479999999999997,37.479999999999997,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9]
["A6533",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gc stocking thighlngth 18-30",52.64,52.64,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9]
["A6555",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"G com stcking bk 40+ custm",217.22,217.22,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6558",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"G com stcking thgh 40+ cust",307.20999999999998,307.20999999999998,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6571",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"G com garment genital custm",653.28,653.28,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6578",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gradient comp sleeve",76.33,76.33,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6590",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urinary cath disp suc pump","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,9]
["A6598",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"G comp bandage med stretch",0.72,0.72,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A6610",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"G com stcking bk 18-30 custm",217.22,217.22,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,9]
["A7002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tubing used w suction pump",7.34,7.34,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9]
["A7020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Interface, cough stim device",35.22,35.22,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9]
["A7027",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Combination oral/nasal mask",221.67,221.67,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9]
["A7045",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Repl exhalation port for pap",4.9800000000000004,4.9800000000000004,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9]
["A7048",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vacuum drain bottle/tube kit",57.21,57.21,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9]
["A7521",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Trach/laryn tube cuffed",65.150000000000006,65.150000000000006,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9]
["A8000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Soft protect helmet prefab",258.14999999999998,258.14999999999998,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,9]
["A9269",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Programable ingest capsule","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["A9277",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"External transmitter, cgm",936.94,936.94,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,9]
["A9291",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pres digital behav thera fda","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,9]
["A9502",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tc99m tetrofosmin",176.77,176.77,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["A9526",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nitrogen n-13 ammonia",1436.03,1436.03,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["A9529",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"I131 iodide sol, dx",1.96,1.96,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["A9546",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Co57/58",26.13,26.13,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["A9554",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"I125 iothalamate, dx",1273.78,1273.78,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["A9567",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Technetium tc-99m aerosol",176.37,176.37,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["A9578",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj multihance multipack",1.77,1.77,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,9]
["A9587",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gallium ga-68","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,9]
["A9590",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Iodine i-131 iobenguane 1mci",346.21,346.21,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2,9]
["A9608",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flotufolastat f18 diag 1 mci","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["A9698",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-rad contrast materialnoc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,9]
["B4083",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Enteral stomach tube levine",2.68,2.68,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2]
["B4102",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ef adult fluids and electro",4.7,4.7,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2]
["B4162",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ef ped specmetabolic inherit","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,"Y-CM",2]
["B4185",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pn soln nos 10 grams lipids",16.149999999999999,16.149999999999999,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2]
["B5200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Parenteral sol hepatic fream",8.61,8.61,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2]
["B9004","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Parenteral infus pump portab",3628.64,3628.64,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2]
["C1716",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brachytx, non-str, gold-198","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["C1721",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Aicd, dual chamber","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C1732",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cath, ep, diag/abl, 3d/vect","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C1754",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Catheter, intradiscal","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C1766",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intro/sheath,strble,non-peel","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C1773",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ret dev, insertable","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C1787",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Patient progr, neurostim","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C1813",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prosthesis, penile, inflatab","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C1831",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Personalized interbody cage","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2]
["C1832",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"AUTO CELL PROCESS SYS","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["C1881",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dialysis access system","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C1894",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intro/sheath, non-laser","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C2616",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brachytx, non-str,yttrium-90","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C2623",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cath, translumin, drug-coat","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["C2637",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brachy,non-str,ytterbium-169","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["C2644",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brachytx cesium-131 chloride","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-CM",2]
["C5274",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Low cost skin substitute app","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["C7504",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Perq cvt&ls inj vert bodies","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,"Y-CM",2]
["C7511",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bronch/bpsy(s) w/ navigation","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR",2]
["C7523",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"L hrt angio w/ ivus or oct","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR",2]
["C7535",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fem/pop revasc w/stent & us","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR",2]
["C7543",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ercp w/otomy, pancreatoscopy","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C7555",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rmvl thyrd w/autotran parath","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-UR",2]
["C7903",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hopd mntl hlt, grp","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["C8913",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mra w/o cont, lwr ext","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C8919",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mra w/o cont, pelvis","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C8926",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tee w or w/o fol w/cont,cong","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["C8957",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prolonged iv inf, req pump","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C9063",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, eptinezumab-jjmr",10.050000000000001,10.050000000000001,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2]
["C9144",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, bupivacaine (posimir)","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2]
["C9254",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, lacosamide","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2]
["C9360",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surgimend, neonatal","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["C9487",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ustekinumab iv inj, 1 mg","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2]
["C9600",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Perc drug-el cor stent sing","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["C9607",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Perc d-e cor revasc chro sin","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["C9754",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Perc av fistula, direct","Facility Only",10516.88,0,0,0,0,0,0,0,0,0,0,null,"O",null,"Y-ONC",2]
["C9761",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cysto, litho, vacuum kidney","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-ONC",2]
["C9776",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fluo bile duct imaging w/icg","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-ONC",2]
["C9789",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Instill pharm renal pelvis","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-UR",2]
["C9898",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inpnt stay radiolabeled item","Facility Only","Facility Only",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2]
["D0210",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intraor complete film series",168,168,0,0,0,0,1,0,0,0,0,0,null,"F",null,null,2,8]
["D0240",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intraoral occlusal film",51.2,51.2,0,0,0,0,1,0,0,0,0,0,null,"F",null,null,2,8]
["D0277",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vert bitewings 7 to 8 images",120.8,120.8,0,0,0,0,1,0,0,0,0,0,null,"F",null,null,2,8]
["D0373",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tomo bitewing image","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,8]
["D0381",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cone beam ct capt mandible",413.6,413.6,0,0,0,0,1,4,0,0,0,0,null,"F",null,null,2,8]
["D0395",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fusion 2 or more 3d images",386.4,386.4,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D0431",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diag tst detect mucos abnorm","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8]
["D0476",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spec stains for microorganis","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8]
["D0600",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-ionizing diag proc",95.2,95.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,8]
["D0603",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Caries risk assess high risk",97.6,97.6,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D0706",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intraoral occlus radio image",61.6,61.6,0,0,0,0,1,0,0,0,0,0,null,"F",null,null,2,8]
["D1208",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Topical app fluorid ex vrnsh","Not Covered","Not Covered",0,0,0,0,5,0,0,0,0,0,null,"X",null,null,2,8]
["D1352",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prev resin rest, perm tooth",133.6,133.6,0,0,0,0,5,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D1553",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Recement unilat space maint","Not Covered","Not Covered",0,0,0,0,5,0,0,0,0,0,null,"X",null,null,2,8]
["D1781",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Janssen Covid-19 vaccine administration","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8]
["D2161",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amalgam 4 or > surfaces perm",344.8,344.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8]
["D2430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental gold foil three surfa","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8]
["D2543",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental onlay metallic 3 surf","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8]
["D2643",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental onlay porcelin 3 surf","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8]
["D2722",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crown resin w/ noble metal",1267.2,1267.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D2781",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crown 3/4 cast base metal",1291.2,1291.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D2928",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prefab porc/cer crown perm",644.79999999999995,644.79999999999995,0,0,0,0,5,0,0,0,0,0,null,"F",null,"Y-ONC",2,8]
["D2952",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Post and core cast + crown",518.4,518.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D2962",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lab labial veneer porcelain",1496,1496,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D2981",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inlay repair","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8]
["D3320",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"End thxpy, premolar tooth",1097.5999999999999,1097.5999999999999,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8]
["D3332",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Incomplete endodontic tx",550.4,550.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8]
["D3421",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Root surgery premolar",1045.5999999999999,1045.5999999999999,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8]
["D3432",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Guided tissue regeneration",802.4,802.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D3920",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tooth splitting",602.4,602.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D4230",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ana crown exp 4 or> per quad",1152,1152,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8]
["D4266",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Guided tiss regen resorble",860.8,860.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D4323",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Splint extra-coronal",581.6,581.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D4920",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Unscheduled dressing change",133.6,133.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D5110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dentures complete maxillary",2258.4,2258.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D5225",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Maxillary part denture flex",1972.8,1972.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D5286",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rem unilat dent 1 pc resin",1464,1464,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,8]
["D5650",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Add tooth to partial denture",301.60000000000002,301.60000000000002,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D5720",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dentures rebase part maxill",711.2,711.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D5810",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Denture interm cmplt maxill",1172,1172,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D5875",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prosthesis modification",565.6,565.6,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D5915",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Orbital prosthesis",8264.7999999999993,8264.7999999999993,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D5922",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nasal septal prosthesis",6434.4,6434.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D5935",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mandibular denture prosth","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,8]
["D5986",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fluoride applicator","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8]
["D5993",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Main/clean max prosthesis",212.8,212.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D6013",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surgical place mini implant",1640,1640,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D6063",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Abutment supported mtl crown",1610.4,1610.4,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D6075",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant supported retainer",1808,1808,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D6085",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Provisional implant crown",677.6,677.6,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D6088",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Imp crown titanium alloys",1854.4,1854.4,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-ONC",2,8]
["D6099",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Imp retainer for fpd",1840.8,1840.8,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-ONC",2,8]
["D6110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implnt/abut remov dent max",4108.8,4108.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,8]
["D6122",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Retain metal fpd noble alloy",1906.4,1906.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,8]
["D6197",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Replace material prosthesis",251.2,251.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D6245",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bridge porcelain/ceramic",1377.6,1377.6,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D6604",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cst bse mtl inlay 2 surfaces","Not Covered","Not Covered",0,0,0,0,0,9,9,9,9,9,null,"X",null,null,2,8]
["D6611",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onlay cst hgh nbl mtl >=3srf","Not Covered","Not Covered",0,0,0,0,0,9,9,9,9,9,null,"X",null,null,2,8]
["D6750",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crown porcelain high noble",1422.4,1422.4,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D6784",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Retainer crown 3/4 titanium",1417.6,1417.6,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-ONC",2,8]
["D6792",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crown full noble metal cast",1358.4,1358.4,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D7210",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rem imp tooth w mucoper flp",363.2,363.2,0,0,0,0,0,9,9,9,9,9,null,"F",null,null,2,8]
["D7260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oral antral fistula closure",1671.2,1671.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8]
["D7290",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Repositioning of teeth",594.4,594.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8]
["D7297",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Corticotomy, 4 or more teeth",1604,1604,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D7340",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vestibuloplasty ridge extens",1658.4,1658.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D7440",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Malig tumor exc to 1.25 cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8]
["D7521",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Incision/drain abscess extra",853.6,853.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D7550",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Removal of sloughed off bone",687.2,687.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D7720",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Clsd reduct compd maxilla fx",4047.2,4047.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D7780",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reduct compnd facial bone fx",10086.4,10086.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D7870",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tmj aspiration joint fluid",764,764,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D7881",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Occ orthotic device adjust",236.8,236.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,8]
["D7943",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cutting ramus open w/graft",9815.2000000000007,9815.2000000000007,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D7946",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reconstruction maxilla total",11280,11280,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,8]
["D7972",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surg redct fibrous tuberosit",903.2,903.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
["D7981",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Excision of salivary gland","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8]
["D8010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Limited dental tx primary","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,8]
["D8681",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Removable retainer adjust",260.8,260.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,8]
["D8703",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Replace broken retainer max",362.4,362.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,8]
["D9211",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Regional block anesthesia","Bundled","Bundled",0,0,0,0,0,0,0,0,0,0,null,"B",null,null,2,8]
["D9410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental house call",298.39999999999998,298.39999999999998,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,8]
["D9440",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Office visit after hours",227.2,227.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,8]
["D9939",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Placemnt removable appliance","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,8]
["D9943",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Occlusal guard adjustment",162.4,162.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,8]
["D9951",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Limited occlusal adjustment",240,240,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,8]
["D9975",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"External bleaching home app","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8]
["D9999",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adjunctive procedure","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,8]
["E0114","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Crutch underarm pair no wood",61.62,61.62,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0143","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Walker folding wheeled w/o s",102.85,102.85,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0144","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Enclosed walker w rear seat",35.5,35.5,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0157","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Walker crutch attachment",82.84,82.84,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0163","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Commode chair with fixed arm",110.96,110.96,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0182","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Replace pump, alt press pad",317.7,317.7,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0183","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Press underlay alter w/pump",28.24,28.24,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0191","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Protector heel or elbow",11.76,11.76,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0198","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Water pressure pad for mattr",260.86,260.86,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0225",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hydrocollator unit","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["E0232","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Warming card for nwt","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,9]
["E0244","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Toilet seat raised",59.71,59.71,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0255","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hospital bed var ht w/ mattr",110.26,110.26,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E0272","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Mattress foam rubber",20.65,20.65,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0275","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Bed pan standard",19.75,19.75,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0293","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hosp bed var ht no sr no mat",78.91,78.91,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["E0297","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hosp bed total elect w/o mat",1447.39,1447.39,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["E0305","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Rails bed side half length",17.68,17.68,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["E0316","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Bed safety enclosure",242.41,242.41,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0373","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Nonpowered pressure mattress",492.92,492.92,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oxygen system gas portable","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["E0457","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Chest shell",1742.24,1742.24,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0459","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Chest wrap",25.82,25.82,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["E0471","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Rad w/backup non inv intrfc",561.1,561.1,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E0483","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hi freq chest wall oscil sys",14723.59,14723.59,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0550","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Humidif extens supple w ippb",59.02,59.02,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["E0565","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Compressor air power source",63.62,63.62,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0600","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Suction pump portab hom modl",634.07000000000005,634.07000000000005,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0601","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Cont airway pressure device",93.94,93.94,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E0620","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Cap bld skin piercing laser",1210.79,1210.79,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0621","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Patient lift sling or seat",11.89,11.89,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0638","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Standing frame sys",464.67,464.67,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0641","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Multi-position stnd fram sys","By Report ","By Report ",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9]
["E0656","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Segmental pneumatic trunk",800.33,800.33,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0665","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pneumatic appliance full arm",19.48,19.48,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0671","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pressure pneum appl full leg",57.56,57.56,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0673","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pressure pneum appl half leg",371.38,371.38,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0705","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Transfer device",62.75,62.75,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0731",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Conductive garment for tens/","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["E0736",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transcut tibial nerv stimula","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["E0749","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Elec osteogen stim implanted",384.79,384.79,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,9]
["E0770","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Functional electric stim nos",408.91,408.91,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["E0781","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"External ambulatory infus pu",331.81,331.81,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,9]
["E0791","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Parenteral infusion pump sta",395.26,395.26,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0840","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Tract frame attach headboard",101.47,101.47,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0890","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Traction frame attach pelvic",45.47,45.47,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0910","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Trapeze bar attached to bed",18.41,18.41,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0930","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Fracture frame free standing",632.54999999999995,632.54999999999995,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0948","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Fracture frame attachmnts ce",81.209999999999994,81.209999999999994,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0956","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"W/c lateral trunk/hip suppor",10.82,10.82,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0960","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"W/c shoulder harness/straps",101.09,101.09,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0970","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair no. 2 footplates",154.88999999999999,154.88999999999999,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["E0971","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair anti-tipping devi",4.96,4.96,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0985","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"W/c seat lift mechanism",279.63,279.63,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E0986","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Man w/c push-rim powr system",673.68,673.68,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E0994","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair arm rest",2.25,2.25,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E1006","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwr seat combo w/o shear",770.57,770.57,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E1015","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Shock absorber for man w/c",156.29,156.29,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E1028","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"W/c manual swingaway",21.01,21.01,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E1039","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Transport chair pt wt >300lb",44.96,44.96,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E1083","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hemi-wheelchair fixed arms",1090.4100000000001,1090.4100000000001,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E1089","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair lightwt fixed arm",154.88999999999999,154.88999999999999,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E1090","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair lightweight det a",351.09,351.09,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E1110","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair semi-recl detach",1243.27,1243.27,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E1170","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Whlchr ampu fxd arm leg rest",1051.54,1051.54,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["E1180","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair amputee w/ foot r",1192.93,1192.93,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["E1223","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair spec size w foot",102.5,102.5,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["E1230","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Power operated vehicle",3132.41,3132.41,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E1237",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rgd ped wc adjstabl w/o seat","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["E1280","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Whchr h-duty det arm leg res",179.8,179.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E1290","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair hvy duty detach a",797.17,797.17,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["E1297","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair special seat dept",16.100000000000001,16.100000000000001,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E1358","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Dc power adapter, port conc","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-PHL",2,9]
["E1405","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"O2/water vapor enrich w/heat",210.8,210.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,9]
["E1590","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hemodialysis machine","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9]
["E1635","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Compact travel hemodialyzer","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9]
["E1701","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Repl cushions for jaw motion",13.35,13.35,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E1818","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sps forearm device",192.62,192.62,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E1825","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Adjust finger ext/flex devc",174.99,174.99,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2104","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Glucose monitor w cartridge",52.98,52.98,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2203","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Frame depth less than 22 in",60.11,60.11,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2207","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Crutch and cane holder",59.26,59.26,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2216","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Foam filled propulsion tire",62.06,62.06,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2228","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Mwc acc, wheelchair brake",1257.48,1257.48,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2292",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Planar seat for ped size wc","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["E2312","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Mini-prop remote joystick",279.27999999999997,279.27999999999997,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2324","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Chin cup interface",5.21,5.21,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2325","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sip and puff interface",1602.69,1602.69,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2331","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Attendant control","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,9]
["E2342","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"W/c dpth 20-21 in seat frame",62.04,62.04,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2362","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Gr24 nonsealed leadacid",12.74,12.74,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2368","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwr wc drivewheel motor repl",57.08,57.08,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2373","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hand/chin ctrl spec joystick",961,961,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2378","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pw actuator replacement",786.65,786.65,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2385","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Tube, pneumatic caster tire",5.59,5.59,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2387","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Foam filled caster tire",71.849999999999994,71.849999999999994,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2394","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Drive wheel excludes tire",83.18,83.18,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2397","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc acc, lith-based battery",57.25,57.25,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2508","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sgd spelling phys contact",4953.29,4953.29,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2603","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Skin protect wc cus wd <22in",156.57,156.57,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2614","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Position back cush wd>=22in",617.6,617.6,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2624","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Adj skin pro/pos cus<22in",388.98,388.98,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E2631","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Elevat proximal arm support",335.82,335.82,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["E3000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Speech volume modulation sys","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0019",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Comm hlth intg svs sdoh 60mn","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0031",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pall serv during meas","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt phys/occ therapy","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0051",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt hospice mnth","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0064",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cert nurse midwife ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0080",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Care manag h vst new pt 75 m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0087",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Care man home care plan 60 m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0090",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adm iv chemo 1st home visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0117",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glaucoma scrn hgh risk direc","Bundled","Bundled",0,0,0,0,0,0,0,0,0,0,null,"B",null,null,2]
["G0123",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Screen cerv/vag thin layer",28.67,28.67,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2]
["G0138",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Iv cipaglucosidase alfa-atga","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0147",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scr c/v cyto, automated sys",25.13,25.13,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2]
["G0166",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Extrnl counterpulse, per tx",198.53,198.53,0,0,0,0,5,9,9,9,9,9,null,"R",null,null,2]
["G0202","TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Scr mammo bi incl cad","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0219",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pet img wholbod melano nonco","Not Covered","Not Covered",0,0,0,0,1,9,9,9,9,9,null,"X",null,null,2]
["G0235",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pet not otherwise specified","Not Covered","Not Covered",0,0,0,0,1,9,9,9,9,9,null,"X",null,null,2]
["G0255",26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Current percep threshold tst","Not Covered","Not Covered",0,0,0,0,1,9,9,9,9,9,null,"X",null,null,2]
["G0260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj for sacroiliac jt anesth","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["G0282",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Elect stim wound care not pd","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["G0299",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hhs/hospice of rn ea 15 min",47.06,47.06,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,11]
["G0321",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Audio-only hhs","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0342",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Laparoscopy islet cell trans","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2]
["G0381",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lev 2 hosp type b ed visit","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["G0398",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home sleep test/type 2 porta","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2]
["G0412",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Open tx iliac spine uni/bil",1339.35,1339.35,0,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2]
["G0415",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Open tx post pelvic fxcture",2502.9699999999998,2502.9699999999998,0,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2]
["G0429",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dermal filler injection(s)","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2]
["G0439",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ppps, subseq visit","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0455",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fecal microbiota prep instil","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0471",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ven blood coll snf/hha","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0483",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Drug test def 22+ classes",349.39,349.39,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-ONC",2]
["G0493",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rn care ea 15 min hh/hospice","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0513",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prolong prev svcs, first 30m",116.36,107.96,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
["G0517",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Remove drug implant",413.26,200.93,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-ONC",2]
["G1007",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cdsm aim","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G1015",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cdsm reliant","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G1027",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt hemo < 3mo","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Post-d/c h vst new pt 45 m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G2067",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med assist tx meth wk","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2070",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med assist tx implant","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2088",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Off base opioid tx, add30","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G2092",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ace arb arni","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2112",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pred<=5 mg ra glu <6m","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2125",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt 81+ frailty","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2144",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fs odi 6-20wk postop > 22","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2151",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dx degen neuro","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2179",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med doc rsn no low ex","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2182",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt 1st biolog antirheum","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2199",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Not scrn etoh no rsn","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2204",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt 50-85 w/ scope","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G3003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brief chkin by md/qhp, 11-22","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G4002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ep cardio ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G4014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nephrology ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G4021",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Orthopedic surgery ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G4033",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Skilled nursing facility ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G4036",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urgent care ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G6010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Radiation treatment delivery",334.69,334.69,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM",2]
["G6014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Radiation treatment delivery",443.85,443.85,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM",2]
["G8417",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Calc bmi abv up param f/u","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8420",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Calc bmi norm parameters","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8473",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ace/arb thxpy rx'd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8483",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flu imm no admin doc rea","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8560",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt hx act drain prev 90 days","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8563",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt no ref oto reas no spec","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8600",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tpa initi w/in 3 hrs","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8648",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rafscrs ki scor < 0","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8668",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rafscrs ewh scor < 0","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8696",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Antithromb thx presc","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G8734",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc neg elder mal no plan","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8756",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No bp measure doc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8833",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt not disch home day#2 evar","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8849",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc reas no pos air press","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8864",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pneumococcal vaccine admin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8867",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No pneumococcal admin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8914",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt trans to hosp post d/c","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8917",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt w iv ab not given on time","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8952",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pre-htn/htn, no f/u, not gvn","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8961",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Csit lowrisk surg pts preop","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9009",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mccd, risk adj, level 3","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["G9050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oncology work-up evaluation","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9062",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc prac guide differs nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9065",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx nsclc stg3a no progre","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9084",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx colon t1-3,n1-2,no pr","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9087",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx colon metas evid dx","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9101",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx gastric p r1-r2noprog","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9107",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx pancreatic unresectab","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9124",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx cml acceler phase","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9132",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx prostate mets no cast","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9157",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transesoph doppl cardiac mon","Not Covered","Not Covered",0,0,0,0,2,9,9,9,0,0,null,"X",null,null,2]
["G9189",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Beta pres or already taking","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9254",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc pt dischg >2d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9255",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc pt dischg <=2d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9282",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc medrsn no histo type","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9294",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt cat and thck on report","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9311",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No surg site infection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9318",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Image std nomenclature","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9354",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"1 or no ct sinus w/in 90d dx","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9357",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pp eval/edu perf","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9386",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scrn hcv infec not recd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9406",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc reas no 7d f/u","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9413",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No admit req surg rev","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9425",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spec rpt no doc class histo","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9457",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt no abd img no doc rsn","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9473",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Chap services at hospice","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9502",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med reas no perf foot exam","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9505",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Abx pres w/in 10 dys of symp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9530",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt mbht hd ct ord ec prov","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9537",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc sysm rsn img hd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9547",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cys ren les or adren","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9582",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Door to punc time >2hr, nrg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9608",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intraop cyst eval not done","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9625",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt bl srg 30 day pst srg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9642",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Current smoker","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9659",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},">85y no hx colo ca/rsn scope","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9688",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt w/hosp anytime msmt per","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9691",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt hosp dur msmt period","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9699",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Long inhal bronchdil no pres","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9712",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc med rsn presc anbx","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9726",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Refused to participate","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9735",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt unbl cmplt shld fs prom","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9755",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc med rsn no fllw up","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9763",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt not have 2-3 hpv vaccines","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9776",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc med rsn no proph antiem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9780",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pts dx w/rhabdomyolysis","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9788",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Most rct bp </= 140/90","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9820",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc chlam scr test w/follow","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9823",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Endo smpl/hyst bx res doc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9845",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt recd anti-egfr ther","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9877",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"2 em core ms mo 10-12 no wl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9885",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"2 em ongoing ms mo 22-24 wl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9898",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt 66+ snp or ltc pos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9901",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt 66+ snp or ltc pos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9912",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hbv status assesed and int","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9925",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No scrn prov rsn nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9939",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Same path/derm perf biopsy","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9960",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med rsn sys antimi nt rx","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9977",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"DIL MAC EXAM NO PERF RSN NOS ","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G9993",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pall serv during meas","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H0007",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol and/or drug services","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["H0016",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol and/or drug services","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H0018",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol and/or drug services","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["H0030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol and/or drug hotline","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H0037",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Comm psy sup tx pgm per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H0049",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol/drug screening","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,17]
["H2001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rehabilitation program 1/2 d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H2016",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Comp comm supp svc, per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H2021",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Com wrap-around sv, 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H2036",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"A/d tx program, per diem","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,17]
["H2040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Coord specialty care, month","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC",2]
["J0136",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, acetaminophen (b braun)",0.06,0.06,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J0177",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, aflibercept hd, 1 mg","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["J0208",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj sodium thiosulfate 100mg","Facility Only",100.12,0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-CM",2,16]
["J0224",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj. lumasiran, 0.5 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J0275",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alprostadil urethral suppos",65.12,65.12,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J0348",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Anidulafungin injection",0.46,0.46,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J0390",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Chloroquine injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J0400",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Aripiprazole injection",0.76,0.76,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J0491",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj anifrolumab-fnia 1mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J0565",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, bezlotoxumab, 10 mg",39.86,39.86,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J0587",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, rimabotulinumtoxinb",13.03,13.03,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J0594",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Busulfan injection",1.41,1.41,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J0630",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Calcitonin salmon injection",1069.5,1069.5,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J0688",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj cefazolin sodium, hikma","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,16]
["J0696",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ceftriaxone sodium injection",0.49,0.49,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J0699",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, cefiderocol, 10 mg",2.17,2.17,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J0720",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Chloramphenicol sodium injec",40.270000000000003,40.270000000000003,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J0775",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Collagenase, clost hist inj","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J0801",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj. acthar gel to 40 units",4151.4399999999996,4151.4399999999996,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,16]
["J0874",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, daptomycin (baxter)","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,16]
["J0889",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Daprodustat oral 1mg esrd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["J1000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Depo-estradiol cypionate inj","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J1100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dexamethasone sodium phos",0.12,0.12,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J1120",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Acetazolamid sodium injectio",28.12,28.12,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J1240",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dimenhydrinate injection",8.9499999999999993,8.9499999999999993,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J1267",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doripenem injection",0.79,0.79,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J1323",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, elranatamab-bcmm, 1 mg","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["J1380",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Estradiol valerate 10 mg inj","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J1436",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Etidronate disodium inj","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J1450",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fluconazole",2.8,2.8,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J1457",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gallium nitrate injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J1561",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gamunex-c/gammaked",49.79,49.79,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J1573",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hepagam b intravenous, inj",84.84,84.84,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J1576",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, panzyga, 500 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["J1628",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj., guselkumab, 1 mg",119.38,119.38,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J1644",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj heparin sodium per 1000u",0.27,0.27,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J1730",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diazoxide injection",112.16,112.16,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J1786",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Imuglucerase injection",44.02,44.02,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J1805",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, esmolol hcl, 10mg",0.25,0.25,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,16]
["J1817",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Insulin for insulin pump use",7.96,7.96,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J1941",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, furoscix, 20 mg","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,16]
["J1945",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lepirudin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J2010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lincomycin injection",9.84,9.84,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J2175",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Meperidine hydrochl /100 mg",7.3,7.3,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J2260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj milrinone lactate / 5 mg",1.56,1.56,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J2315",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Naltrexone, depot form",3.96,3.96,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J2350",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, ocrelizumab, 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J2355",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oprelvekin injection",426.92,426.92,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J2425",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Palifermin injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J2430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pamidronate disodium /30 mg",8.8699999999999992,8.8699999999999992,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J2513",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pentastarch 10% solution","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J2598",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, vasopressin, 1 unit","Facility Only",2.96,0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2,16]
["J2700",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oxacillin sodium injeciton",1.05,1.05,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J2760",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Phentolaine mesylate inj",446.8,446.8,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J2788",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rho d immune globulin 50 mcg",23.8,23.8,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J2792",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rho(d) immune globulin h, sd",32.96,32.96,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J2860",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, siltuximab","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J2919",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, methylpred sod succ 5mg",0.27,0.27,0,0,0,0,0,0,0,0,0,0,null,"D",null,null,2,16]
["J3032",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj. eptinezumab-jjmr 1 mg",18.059999999999999,18.059999999999999,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2,16]
["J3110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Teriparatide injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J3260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tobramycin sulfate injection",2.66,2.66,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J3301",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Triamcinolone acet inj nos",0.95,0.95,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J3358",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ustekinumab, iv inject, 1 mg",12.62,12.62,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J3365",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urokinase 250,000 iu inj","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J3424",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj hydroxocobalamin iv 25mg","Facility Only","By Report",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2,16]
["J3480",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj potassium chloride",0.12,0.12,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J7030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Normal saline solution infus",2.69,2.69,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J7050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Normal saline solution infus",0.67,0.67,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J7175",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, factor x, (human), 1iu",9.11,9.11,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J7183",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Wilate injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J7196",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Antithrombin recombinant","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,16]
["J7199",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hemophilia clot factor noc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,16]
["J7209",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Factor viii nuwiq recomb 1iu",1.28,1.28,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J7300",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intraut copper contraceptive","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J7321",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hyalgan supartz visco-3 dose","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,16]
["J7324",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Orthovisc inj per dose","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,16]
["J7345",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Aminolevulinic acid, 10% gel","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J7501",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Azathioprine parenteral","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J7515",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cyclosporine oral 25 mg",0.84,0.84,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J7605",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Arformoterol non-comp unit",2.3199999999999998,2.3199999999999998,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J7615",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Levalbuterol comp unit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J7624",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Betamethasone comp unit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J7642",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glycopyrrolate comp con","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J7645",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ipratropium bromide comp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J7669",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Metaproterenol non-comp unit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J7684",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Triamcinolone comp unit",0.56000000000000005,0.56000000000000005,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,16]
["J8520",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Capecitabine, oral, 150 mg",0.25,0.25,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J8597",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Antiemetic drug oral nos","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,16]
["J9019",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Erwinaze injection",427.27,427.27,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J9022",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, atezolizumab,10 mg",85.01,85.01,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J9045",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Carboplatin injection",3.6,3.6,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J9048",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, bortezomib freseniuskab",2.68,2.68,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J9059",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj bendamustine, baxter 1mg",24.32,24.32,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,16]
["J9098",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cytarabine liposome inj",628.37,628.37,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J9165",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diethylstilbestrol injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,16]
["J9179",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eribulin mesylate injection",134.02000000000001,134.02000000000001,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J9206",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Irinotecan injection",1.95,1.95,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J9209",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mesna injection",1.37,1.37,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J9229",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj inotuzumab ozogam 0.1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J9249",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, melphalan (apotex) 1 mg","Facility Only","By Report",0,0,0,0,0,0,0,0,0,0,null,"O",null,null,2,16]
["J9260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Methotrexate sodium inj",3.03,3.03,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J9273",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj tisotu vedotin-tftv, 1mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J9301",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Obinutuzumab inj","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J9308",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, ramucirumab",70.239999999999995,70.239999999999995,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J9322",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj pemetrexed (bluepoint)","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC",2,16]
["J9325",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj talimogene laherparepvec",66.59,66.59,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["J9354",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, ado-trastuzumab emt 1mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J9358",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj fam-trastu deru-nxki 1mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["J9381",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj teplizumab mzwv 5 mcg",36.81,36.81,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,16]
["K0003","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Lightweight wheelchair",846.1,846.1,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0008","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Cstm manual wheelchair/base","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9]
["K0012","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Ltwt portbl power whlchr",4499.8,4499.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0018","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Detach adjust armrst upper",3.3,3.3,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["K0038","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Leg strap each",28.63,28.63,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["K0044","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Ftrst upr hanger brac rep ea",2,2,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["K0046","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Elev lgrst lwr exten repl ea",23.23,23.23,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["K0051","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Cam rel asm ft/legrst rep ea",6.16,6.16,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["K0073","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Caster pin lock each",46.95,46.95,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["K0552","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sup/ext non-ins inf pump syr",2.95,2.95,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["K0607",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Repl batt for aed","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["K0745","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Absorp drg >16<=48 suc pump","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,9]
["K0808","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pov group 2 vhd 451-600 lbs",4201.34,4201.34,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0821","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 2 std port cap chair",4770.3999999999996,4770.3999999999996,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0822","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 2 std seat/back",552.44000000000005,552.44000000000005,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0826","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 2 vhd seat/back",10337.469999999999,10337.469999999999,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0835","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp2 std sing pow opt s/b",5788.14,5788.14,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0838","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 2 hd sing pow opt cap",6329.13,6329.13,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0849","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 3 std cap chair",9096.84,9096.84,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0855","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 3 xhd cap chair",16302.32,16302.32,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0858","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp3 hd sing pow opt s/b",1260.07,1260.07,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0864","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp3 xhd mult pow opt s/b",2142.21,2142.21,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["K0869","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 4 std cap chair","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,9]
["K0877","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp4 std sing pow opt s/b","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,9]
["K0886","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp4 hd mult pow s/b","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,9]
["K1035",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mol diag reader self-admn","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["L0140",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cervical semi-rigid adjustab",114.1,114.1,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L0454",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tlso trnk sj-t9 pre cst",483.92,483.92,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L0464",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tlso 4mod sacro-scap pre",2074.0500000000002,2074.0500000000002,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L0490",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tlso rigid plastic pre one",394.73,394.73,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L0621",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sio flex pelvic/sacr pre ots",124.71,124.71,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L0634",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lso flexion control custom",984.02,984.02,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L0641",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lo rig pos pnl l1-l5 pre ots",89.14,89.14,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L0700",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ctlso a-p-l control molded",2702.46,2702.46,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L0980",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Peroneal straps pair pre ots",24.82,24.82,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L1050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sternal pad",137,137,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L1110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ring flange plas/leather mol",399.54,399.54,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L1300",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Body jacket mold to patient",2258.09,2258.09,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L1600",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ho flex frejka w/cov pre cst",172.25,172.25,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L1660",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ho abduction static plastic",247.91,247.91,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L1812",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ko elastic w/joints pre ots",125.42,125.42,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L1836",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ko rigid w/o joints pre ots",155.81,155.81,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L1900",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Afo sprng wir drsflx calf bd",397.6,397.6,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L1951",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Afo spiral prefabricated",1171.83,1171.83,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L2005",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Kafo sng/dbl mechanical act",5717.66,5717.66,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L2040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hkafo torsion bil rot straps",305.43,305.43,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L2116",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Afo tibial fracture rigid",951.61,951.61,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L2132",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Kafo femoral fx cast soft",1078.32,1078.32,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L2220",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dorsi & plantar flex ass/res",129.36000000000001,129.36000000000001,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L2270",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Varus/valgus strap padded/li",95.72,95.72,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L2375",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Torsion ank & half solid sti",151.04,151.04,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L2500",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Thi/glut/ischia wgt bearing",452.76,452.76,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L2610",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hip clevis/thrust bearing lo",383.24,383.24,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L2660",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Thoracic control thoracic ba",249.14,249.14,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L2780",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-corrosive finish",120.63,120.63,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L2800",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Knee cap medial or lateral p",163.44,163.44,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Foot longitudinal arch suppo",243.17,243.17,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3070",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Arch suprt att to sho longit",44.32,44.32,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3201",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oxford w supinat/pronat inf","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["L3221",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Orthopedic mens shoes dpth i",165.42,165.42,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3252",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoe molded plastazote cust",434.12,434.12,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3334",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoe lifts elevation heel /i",53.25,53.25,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3400",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoe metatarsal bar wedge ro",56.8,56.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sho heel count plast reinfor",223.6,223.6,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3530",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ortho shoe add half sole",44.32,44.32,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3620",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Trans shoe solid stirrup exi",106.49,106.49,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3677",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"So hard plas stabili pre cst",194.24,194.24,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L3760",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eo adj jt prefab custom fit",635.03,635.03,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3900",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hinge extension/flex wrist/f",1904.95,1904.95,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L3919",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ho w/o joints cf",343.93,343.93,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L3930",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hfo nontorsion jnts pre ots",123.88,123.88,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L3935",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fo nontorsion joint cf",280.52,280.52,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L3977",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sewhfo cap desgn w/jnt(s) cf",2391.12,2391.12,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L4010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Replace trilateral socket br",1069.8699999999999,1069.8699999999999,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L4110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Repl leath cuff kafo-afo cal",151.15,151.15,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L4370",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pneum full leg splnt pre ots",336.47,336.47,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L5050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ank symes mold sckt sach ft",3996.86,3996.86,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5280",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hemipelvect canad sing axis",10066.040000000001,10066.040000000001,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Postop dsg bk ea add cast ch",762.21,762.21,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5510",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prep bk ptb plaster molded",2339.0700000000002,2339.0700000000002,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5590",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prep ak ischial laminated",3747.02,3747.02,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5615",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ak 4 bar link hydl swg/stanc",7998.18,7998.18,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,16]
["L5632",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Symes type ptb brim design s",438.97,438.97,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5642",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Above knee leather socket",1224.8599999999999,1224.8599999999999,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5654",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Socket insert symes",574.45000000000005,574.45000000000005,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5676",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bk knee joints single axis p",625.92999999999995,625.92999999999995,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5684",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bk fork strap",95.15,95.15,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5688",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bk waist belt webbing",103.46,103.46,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5707",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom shape cvr hip disart",2091.41,2091.41,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L5712",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Knee-shin exo frict swg & st",819.9,819.9,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5785",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Exoskeletal bk ultralt mater",920.26,920.26,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5816",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Endo knee-shin polyc mch sta",1260.98,1260.98,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L5855",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mech hip extension assist",610.54999999999995,610.54999999999995,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L5926",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Endoskel posit rotat unit",1071.1300000000001,1071.1300000000001,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,16]
["L5971",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sach foot, replacement",363.7,363.7,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L5974",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Foot single axis ankle/foot",460.69,460.69,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L6000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Part hand thumb rem",2626.77,2626.77,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L6026",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Part hand myo exclu term dev",6475.13,6475.13,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L6320",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoulder passive restor cap",2533.87,2533.87,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L6386",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Postop ea cast chg & realign",684.45,684.45,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L6600",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Polycentric hinge pair",301.36,301.36,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L6621",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flex/ext wrist w/wo friction",3329.37,3329.37,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L6641",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Excursion amplifier pulley t",254.63,254.63,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L6646",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Multipo locking shoulder jnt",4590.91,4590.91,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L6687",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Frame typ socket bel elbow/w",855.25,855.25,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L6690",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Frame typ sock interscap-tho",1359.39,1359.39,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L6713",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped term dev, hand, vol open","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["L6721",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hook/hand, hvy dty, vol open",3423.46,3423.46,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L6900",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hand restorat thumb/1 finger",2879.04,2879.04,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L6935",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Below elbow myoelectronic ct",13229.9,13229.9,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L7040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prehensile actuator",4465.9799999999996,4465.9799999999996,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L7180",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Electronic elbow sequential",54323.46,54323.46,0,0,0,0,0,0,0,0,0,0,null,"F","Y","Y-CM",2,9]
["L7403",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Add ue prost b/e acrylic",536.02,536.02,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L7510",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prosthetic device repair rep",112.08,112.08,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L8030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Breast prosthes w/o adhesive",467.77,467.77,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L8041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Midfacial prosthesis",4386.7299999999996,4386.7299999999996,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L8330",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Truss add to std pad scrotal",73.19,73.19,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L8435",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pros sock multi ply upper lm",41.57,41.57,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,9]
["L8509",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Trach-esoph voice pros md in",158.94999999999999,158.94999999999999,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,9]
["L8512",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gel cap for trach voice pros",3.14,3.14,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,9]
["L8613",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ossicular implant",446.29,446.29,0,0,0,0,0,0,0,0,0,0,null,"F","Y",null,2,9]
["L8619",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Coch imp ext proc/contr rplc",11957.61,11957.61,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["L8678",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ext sply implt neurostim","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["L8681",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt prgrm for implt neurostim",1599.55,1599.55,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,9]
["L8693",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Aud osseo dev, abutment","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,9]
["L8702",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pow ue rom dev ewhf uprt cus",83327.75,83327.75,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,9]
["M0222",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bebteleovimab injection","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["M0244",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bamlan and estesv infus",799.77,799.77,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2]
["M1009",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dc eoc doc med rec","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1012",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dc eoc doc med rec","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1038",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt dx lum sp reg fract","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt cr ft inf lm or pt id sl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1059",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt no prm nurs hm res in pp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1069",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt scr ft fall rsk","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1120",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oc ni pt selfdc 1-2 vis","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1127",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Docu dx degen neuro","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1145",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mfn drug add-on, per dose","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["M1148",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt self dschg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1167",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1170",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1184",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1190",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1202",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1209",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1221",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dre w/o rtnopthy","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1224",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Iop dec <20% from base","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1240",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt no resp best int","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1241",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt no resp seen as person","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1256",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prior history of known cvd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1263",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pts hosp dialysis dt","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1275",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pts hosp exl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1282",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt scrn tbco id as non user","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1294",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bp scrn perf rec interval","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1297",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bmi not doc medrsn ptref","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1308",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flu immunize no admin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1317",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pts counsl cpt opt out","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1324",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pts intravitreal/pci","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1336",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pts eval ini xm 2 wks","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1348",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt pam incr 6 pt 6-12 mo","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1355",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Suicd based cln eval","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1367",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Qual care ent disorder mvp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1369",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Qualcare mental hlth/sud mvp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["P9022",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Washed red blood cells unit","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["P9026",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cryo fib comp path redu each","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["P9037",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Plate pheres leukoredu irrad","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["P9051",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Blood, l/r, cmv-neg","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["P9073",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Platelets pheresis path redu","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q0035",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cardiokymography","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2]
["Q0092",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Set up port xray equipment",50.38,50.38,0,0,0,0,3,0,0,0,0,0,null,"R",null,null,2]
["Q0144",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Azithromycin dihydrate, oral","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q0240",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"CASIRIVI AND IMDEVI 600MG",0.01,0.01,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,16]
["Q0245",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bamlanivimab and etesevima","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,16]
["Q0481",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Microprcsr cu elec vad, rep","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,16]
["Q0493",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Emr pwr cbl combo vad, rep","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q0504",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pwr adpt pneum vad, rep veh","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q0514",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disp fee inhal drugs/90 days","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q2035",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Afluria vacc, 3 yrs & >, im","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q2049",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Imported lipodox inj",484.5,484.5,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2]
["Q4001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup body cast plaster",60.61,60.61,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["Q4004",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup shoulder cast fbrgl",150.66,150.66,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,28]
["Q4011",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup sht arm ped plaster","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["Q4028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup hip spica ped fbrgl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["Q4036",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup lngleg cylndr ped f","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["Q4043",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup lng leg splnt ped p","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,28]
["Q4100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Skin substitute, nos","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28]
["Q4107",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Graftjacket","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,28]
["Q4122",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dermacell, awm, porous sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4125",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Arthroflex","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4135",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mediskin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4148",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Neox neox rt or clarix cord","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4155",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Neoxflo or clarixflo 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4167",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Truskin, per sq centimeter","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4180",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Revita, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4206",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fluid flow or fluid gf 1 cc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4219",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surgigraft dual per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4230",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cogenex flow amnion 0.5 cc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4232",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Corplex, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4247",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amniotext patch, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4254",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Novafix dl per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4266",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Neostim per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4278",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Epieffect, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4285",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nudyn dl or dl mesh pr sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4290",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Membrane wrap hydr per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4301",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Activate matrix, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4308",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sanopellis, per sq cm","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["Q5010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice home care in hospice","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["Q5113",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj herzuma 10 mg",40.31,40.31,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2]
["Q5125",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, releuko 1 mcg",0.54,0.54,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2]
["Q9003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Va chaplain counsel group","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q9955",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj perflexane lip micros,ml",13.25,13.25,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["Q9969",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-heu tc-99m add-on/dose","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["R0075","UR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Transport port x-ray multipl",40.090000000000003,40.090000000000003,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,26]
["R0076",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transport portable ekg","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["S0013",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Esketamine, nasal spray",11.58,11.58,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2]
["S0034",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, ofloxacin, 400 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0108",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mercaptopurine 50 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0139",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Minoxidil, 10 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0157",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Becaplermin gel 1%, 0.5 gm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0182",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Procarbazine, oral",104.08,104.08,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["S0197",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prenatal vitamins 30 day","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0207",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Paramedicintercep nonhospals","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0271",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home hospice case 30 days","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0353",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cancer treatmentplan initial","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0500",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dispos cont lens","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0515",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scleral lens liquid bandage","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0613",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ann breast exam","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S1016",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-pvc intravenous administ","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S1040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cranial remolding orthosis","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S2054",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transplantation of multivisc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S2107",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adoptive immunotherapy","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S2120",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Low density lipoprotein(ldl)","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S2230",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant semi-imp hear","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S2325",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hip core decompression","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S2405",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fetal surg sacrococ teratoma","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S3652",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Saliva test, hormone level;","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S3842",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gene test hippel-lindau","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S3900",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surface emg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S4011",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ivf package","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S4020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ivf canc a aspir case rate","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S4040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Monit store cryo embryo 30 d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S4993",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contraceptive pills for bc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S5102",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult day care per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S5130",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Homaker service nos per 15m","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S5136",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult companioncare per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S5161",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Emer rspns sys serv permonth","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["S5520",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit picc insert kit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S5523",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hip midline cath insert kit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8032",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Low dose ct lung screening","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["S8085",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fluorine-18 fluorodeoxygluco","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8185",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flutter device","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8301",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Infect control supplies nos","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["S8415",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Supplies for home delivery","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8420",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom gradient sleev/glov","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8421",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ready gradient sleev/glov","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8422",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom grad sleeve med","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8423",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom grad sleeve heavy","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8424",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ready gradient sleeve","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8425",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom grad glove med","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8426",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom grad glove heavy","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8427",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ready gradient glove","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8428",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ready gradient gauntlet","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8429",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gradient pressure wrap","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Padding for comprssn bdg","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8431",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Compression bandage","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S8450",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Splint digit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8451",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Splint wrist or ankle","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8452",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Splint elbow","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8460",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Camisole post-mast","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8490",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"100 insulin syringes","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8930",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Auricular electrostimulation","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8940",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hippotherapy per session","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8948",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Low-level laser trmt 15 min","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["S8950",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Complex lymphedema therapy,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8990",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt or manip for maint","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8999",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Resuscitation bag","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home uterine monitor with or","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intra-vag motion sens biofk","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["S9007",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ultrafiltration monitor","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9024",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Paranasal sinus ultrasound","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9025",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Omnicardiogram/cardiointegra","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9034",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eswl for gallstones","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9055",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Procuren or other growth fac","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9056",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Coma stimulation per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9061",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Medical supplies and equipme","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9083",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urgent care center global","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9088",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Services provided in urgent","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9090",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vertebral axial decompressio","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9097",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home visit wound care","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9098",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home phototherapy visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Telemonitoring/home per mnth","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9117",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Back school visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9122",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home health aide or certifie",43,43,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2]
["S9123",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nursing care in home rn",86.43,86.43,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2]
["S9124",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nursing care, in the home; b",62.44,62.44,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2]
["S9125",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Respite care, in the home, p","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9126",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice care, in the home, p","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9127",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Social work visit, in the ho","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9128",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Speech therapy, in the home,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9129",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Occupational therapy, in the","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9131",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt in the home per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9140",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diabetic management program,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9141",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diabetic management program,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9145",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Insulin pump initiation","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9150",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Evaluation by ocularist","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9152",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Speech therapy, re-eval","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9208",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home mgmt preterm labor","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9209",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home mgmt pprom","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9211",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home mgmt gest hypertension","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9212",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hm postpar hyper per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9213",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hm preeclamp per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9214",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hm gest dm per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9325",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit pain mgmt per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9326",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit cont pain per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9327",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit int pain per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9328",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit pain imp pump diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9329",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit chemo per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9330",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit cont chem diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9331",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit intermit chemo diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9335",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht hemodialysis diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9336",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit cont anticoag diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9338",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit immunotherapy diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9339",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit periton dialysis diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9340",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit enteral per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9341",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit enteral grav diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9342",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit enteral pump diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9343",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit enteral bolus nurs","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9345",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit anti-hemophil diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9346",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit alpha-1-proteinas diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9347",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit longterm infusion diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9348",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit sympathomim diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9349",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tocolysis diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9351",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit cont antiemetic diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9353",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit cont insulin diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9355",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit chelation diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9357",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit enzyme replace diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9359",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit anti-tnf per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9361",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit diuretic infus diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9363",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit anti-spasmotic diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9364",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tpn total diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9365",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tpn 1 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9366",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tpn 2 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9367",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tpn 3 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9368",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit tpn over 3l diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9370",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj antiemetic diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9372",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj anticoag diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9373",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit hydra total diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9374",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit hydra 1 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9375",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit hydra 2 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9376",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit hydra 3 liter diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9377",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit hydra over 3l diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9379",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit noc per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9381",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit high risk/escort","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9401",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Anticoag clinic per session","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pharmacy comp/disp serv","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9432",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med food non inborn err meta","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9433",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Medical food oral 100% nutr","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9434",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mod solid food suppl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9435",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Medical foods for inborn err","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9436",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lamaze class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9437",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Childbirth refresher class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9438",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cesarean birth class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9439",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vbac class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9441",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Asthma education","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9442",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Birthing class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9443",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lactation class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9444",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Parenting class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9445",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt education noc individ",46.23,46.23,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2]
["S9446",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt education noc group","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9447",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Infant safety class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9449",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Weight mgmt class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9451",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Exercise class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9452",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nutrition class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9453",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Smoking cessation class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9454",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Stress mgmt class","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9455",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diabetic management program,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9460",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diabetic management program,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9465",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diabetic management program,","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9470",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nutritional counseling, diet","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9472",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cardiac rehabilitation progr","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9473",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pulmonary rehabilitation pro","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9474",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Enterostomal therapy by a re","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9475",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ambulatory setting substance","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9476",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vestibular rehab per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9480",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intensive outpatient psychia","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,17]
["S9482",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Family stabilization 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9484",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crisis intervention per hour","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9485",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crisis intervention mental h","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9490",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit corticosteroid/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9494",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic total diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9497",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q3h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9500",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q24h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9501",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q12h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9502",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q8h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9503",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q6h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9504",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit antibiotic q4h diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9529",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Venipuncture home/snf","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9537",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht hem horm inj diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9538",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit blood products diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9542",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj noc per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9558",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj growth horm diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9559",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit inj interferon diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9560",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj hormone diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9562",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj palivizumab diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9563",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht inj immuno diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9590",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht irrigation diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9810",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ht pharm per hour","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9900",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Christian sci pract visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9901",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Christian sci nurse visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9960",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Air ambulanc nonemerg fixed","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9961",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Air ambulan nonemerg rotary","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9970",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Health club membership yr","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9975",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transplant related per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9976",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lodging per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9977",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Meals per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9981",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med record copy admin",29.93,29.93,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2]
["S9982",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med record copy per page",0.59,0.59,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2]
["S9986",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Not medically necessary svc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9988",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Serv part of phase i trial","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9989",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Services outside us","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9990",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Services provided as part of","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9991",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Services provided as part of","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9992",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transportation costs to and","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9994",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lodging costs (e.g. hotel ch","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9996",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Meals for clinical trial par","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9999",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sales tax","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Private duty/independent nsg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nursing assessment/evaluatn","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rn services up to 15 minutes","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lpn/lvn services up to 15min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1004",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nsg aide service up to 15min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1005",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Respite care service 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1006",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Family/couple counseling","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1007",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Treatment plan development","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1009",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Child sitting services","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Meals when receive services","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1012",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol/substance abuse skil","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1013",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sign lang/oral interpreter","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Telehealth transmit, per min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1015",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Clinic service","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["T1016",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Case management","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1017",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Targeted case management","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1018",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"School-based iep ser bundled","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1019",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Personal care ser per 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Personal care ser per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1021",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hh aide or cn aide per visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1022",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contracted services per day","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1023",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Program intake assessment","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1024",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Team evaluation & management","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1025",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped compr care pkg, per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1026",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped compr care pkg, per hour","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1027",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Family training & counseling","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Home environment assessment","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1029",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dwelling lead investigation","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rn home care per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1031",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lpn home care per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1032",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sv doula brth wrk per 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1033",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sv doula brth wrk per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Comm bh clinic svc per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Comm bh clinic svc per month","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1502",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Medication admin visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1503",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med admin, not oral/inject","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1505",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Elec med comp dev, noc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T1999",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Noc retail items andsupplies","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; patient attend/escort","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; encounter/trip","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2004",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; commerc carrier pass","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2005",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; stretcher van","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2007",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-emer transport wait time","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pasrr level i","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2011",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pasrr level ii","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2012",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil ed waiver, per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2013",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil ed waiver per hour","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil prevoc waiver, per d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2015",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil prevoc waiver per hr","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2016",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil res waiver per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2017",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil res waiver 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2018",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil sup empl waiver/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2019",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Habil sup empl waiver 15min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Day habil waiver per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2021",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Day habil waiver per 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2022",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Case management, per month","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2023",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Targeted case mgmt per month","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2024",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Serv asmnt/care plan waiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2025",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Waiver service, nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2026",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Special childcare waiver/d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2027",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spec childcare waiver 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Special supply, nos waiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2029",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Special med equip, noswaiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Assist living waiver/month","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2031",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Assist living waiver/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2032",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Res care, nos waiver/month","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2033",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Res, nos waiver per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2034",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crisis interven waiver/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2035",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Utility services waiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2036",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Camp overnite waiver/session","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2037",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Camp day waiver/session","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2038",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Comm trans waiver/service","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2039",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vehicle mod waiver/service","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Financial mgt waiver/15min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Support broker waiver/15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2042",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice routine home care","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2043",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice continuous home care","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2044",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice respite care","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2045",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice general care","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2046",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice long term care, r&b","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2047",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hab prevo waiver per 15","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2048",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bh ltc res r&b, per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2049",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"N-et; stretcher van, mileage","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Financial mgt waiver/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2051",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Support broker waiver/diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T2101",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Breast milk proc/store/dist","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T4521",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size brief/diaper sm","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4522",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size brief/diaper med","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4523",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size brief/diaper lg","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4524",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size brief/diaper xl","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4525",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size pull-on sm","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4526",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size pull-on med","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4527",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size pull-on lg","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4528",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult size pull-on xl","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4529",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped size brief/diaper sm/med","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T4530",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped size brief/diaper lg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T4531",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped size pull-on sm/med","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T4532",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped size pull-on lg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T4533",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Youth size brief/diaper","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4534",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Youth size pull-on","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4535",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disposable liner/shield/pad","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4536",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reusable pull-on any size","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4537",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reusable underpad bed size","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4538",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diaper serv reusable diaper","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T4539",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reuse diaper/brief any size","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4540",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reusable underpad chair size","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4541",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Large disposable underpad","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4542",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Small disposable underpad","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4543",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult disp brief/diap abv xl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T4544",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adlt disp und/pull on abv xl","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T4545",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Incon disposable penile wrap","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["T5001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Position seat spec orth need","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["T5999",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Supply, nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["U0001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"2019-ncov diagnostic p",50.83,50.83,0,0,0,0,0,0,0,0,0,0,null,"L",null,"Y-CM",2]
["U0002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Covid-19 lab test non-cdc",72.599999999999994,72.599999999999994,0,0,0,0,0,0,0,0,0,0,null,"L",null,"Y-CM",2]
["V0028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Travel, vocational services, claimant","State Rate","State Rate",0,0,0,0,0,0,0,0,0,0,null,"S",null,null,2,30]
["V2020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vision svcs frames purchases","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2025",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eyeglasses delux frames","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens spher single plano 4.00","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2101",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Single visn sphere 4.12-7.00","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2102",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Singl visn sphere 7.12-20.00","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2103",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylindr 4.00d/12-2.00d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2104",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylindr 4.00d/2.12-4d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2105",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.00d/4.25-6d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2106",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.00d/>6.00d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2107",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.25d/12-2d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2108",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.25d/2.12-4d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2109",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.25d/4.25-6d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder 4.25d/over 6d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2111",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylindr 7.25d/.25-2.25","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2112",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylindr 7.25d/2.25-4d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2113",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylindr 7.25d/4.25-6d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2114",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spherocylinder over 12.00d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2115",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens lenticular bifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2118",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens aniseikonic single","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2121",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lenticular lens, single","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2199",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens single vision not oth c","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens spher bifoc plano 4.00d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2201",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphere bifocal 4.12-7.0","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2202",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphere bifocal 7.12-20.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2203",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl bifocal 4.00d/.1","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2204",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.00d/2.1","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2205",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.00d/4.2","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2206",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.00d/ove","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2207",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.25-7d/.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2208",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.25-7/2.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2209",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.25-7/4.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2210",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifocal 4.25-7/ov","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2211",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy bifo 7.25-12/.25-","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2212",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl bifo 7.25-12/2.2","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2213",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl bifo 7.25-12/4.2","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2214",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl bifocal over 12.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2215",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens lenticular bifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2218",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens aniseikonic bifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2219",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens bifocal seg width over","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2220",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens bifocal add over 3.25d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2221",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lenticular lens, bifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2299",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens bifocal speciality","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2300",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphere trifocal 4.00d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2301",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphere trifocal 4.12-7.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2302",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphere trifocal 7.12-20","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2303",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy trifocal 4.0/.12-","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2304",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy trifocal 4.0/2.25","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2305",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy trifocal 4.0/4.25","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2306",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl trifocal 4.00/>6","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2307",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcy trifocal 4.25-7/.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2308",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifocal 4.25-7/2.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2309",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifocal 4.25-7/4.","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2310",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifocal 4.25-7/>6","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2311",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifo 7.25-12/.25-","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2312",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifo 7.25-12/2.25","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2313",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphc trifo 7.25-12/4.25","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2314",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens sphcyl trifocal over 12","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2315",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens lenticular trifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2318",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens aniseikonic trifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2319",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens trifocal seg width > 28","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2320",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens trifocal add over 3.25d","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2321",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lenticular lens, trifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2399",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens trifocal speciality","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens variab asphericity sing","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens variable asphericity bi","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2499",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Variable asphericity lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2500",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens pmma spherical","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2501",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens pmma-toric/prism","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2502",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens pmma bifocal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2503",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens pmma color vision","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2510",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct gas permeable sphericl","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2511",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct toric prism ballast","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2512",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens gas permbl bifocl","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2513",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens extended wear","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2520",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens hydrophilic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2521",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens hydrophilic toric","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2522",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens hydrophil bifocl","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2523",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens hydrophil extend","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2524",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens hydrophil photoch","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2525",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cl, hydrophilic, dual focus","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["V2526",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cntct lens blue violet","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["V2530",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens gas impermeable","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2531",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens gas permeable","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2599",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Contact lens/es other type","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2600",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hand held low vision aids","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2610",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Single lens spectacle mount","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2615",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Telescop/othr compound lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2623",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Plastic eye prosth custom","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2624",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Polishing artifical eye","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2625",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Enlargemnt of eye prosthesis","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2626",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reduction of eye prosthesis","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2627",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scleral cover shell","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2628",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fabrication & fitting","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2629",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prosthetic eye other type","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2630",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Anter chamber intraocul lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2631",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Iris support intraoclr lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2632",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Post chmbr intraocular lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2700",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Balance lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2702",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Deluxe lens feature","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2710",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glass/plastic slab off prism","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2715",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prism lens/es","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2718",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fresnell prism press-on lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2730",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Special base curve","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2744",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tint photochromatic lens/es","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2745",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tint, any color/solid/grad","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2750",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Anti-reflective coating","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2755",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Uv lens/es","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2756",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eye glass case","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2760",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scratch resistant coating","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2761",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mirror coating","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2762",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Polarization, any lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2770",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Occluder lens/es","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2780",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oversize lens/es","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2781",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Progressive lens per lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2782",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens, 1.54-1.65 p/1.60-1.79g","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2783",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens, >= 1.66 p/>=1.80 g","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2784",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lens polycarb or equal","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2785",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Corneal tissue processing","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2786",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Occupational multifocal lens","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2787",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Astigmatism-correct function","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V2788",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Presbyopia-correct function","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["V2790",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amniotic membrane","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2797",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vis item/svc in other code","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V2799",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Misc vision item or service","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["V5008",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing screening",93.09,93.09,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["V5010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Assessment for hearing aid","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,5]
["V5011",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid fitting/checking","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,5]
["V5014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid repair/modifying",62.07,62.07,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["V5020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Conformity evaluation","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,5]
["V5030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Body-worn hearing aid air","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Body-worn hearing aid bone","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural in ear","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5060",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Behind ear hearing aid","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5070",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glasses air conduction","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5080",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glasses bone conduction","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5090",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid dispensing fee","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5095",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant mid ear hearing pros","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Body-worn bilat hearing aid","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid dispensing fee","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5120",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Body-worn binaur hearing aid","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5130",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"In ear binaural hearing aid","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5140",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Behind ear binaur hearing ai","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5150",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glasses binaural hearing aid","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5160",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dispensing fee binaural",1762.64,1762.64,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["V5171",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5172",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5181",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5190",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural glasses","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disp fee contralateral monau",1056.48,1056.48,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["V5211",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural ite/ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5212",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural ite/itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5213",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural ite/bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5214",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural itc/itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5215",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural itc/bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5221",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural bte/bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5230",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural glasses","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5240",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disp fee contralateral binau",1056.48,1056.48,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["V5241",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dispensing fee, monaural",881.32,881.32,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,5]
["V5242",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, monaural, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5243",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, monaural, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5244",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, mon, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5245",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, mon, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5246",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, mon, ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5247",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, mon, bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5248",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, binaural, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5249",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, binaural, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5250",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, bin, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5251",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, bin, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5252",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, bin, ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5253",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, bin, bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5254",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing id, digit, mon, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5255",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, mon, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5256",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, mon, ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5257",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, mon, bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5258",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, bin, cic","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5259",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, bin, itc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, bin, ite","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5261",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, bin, bte","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,5]
["V5262",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, disp, monaural","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5263",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, disp, binaural","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5264",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ear mold/insert","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL",2,5]
["V5265",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ear mold/insert, disp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5266",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Battery for hearing device",1.0900000000000001,1.0900000000000001,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,5]
["V5267",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid sup/access/dev","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL",2,5]
["V5268",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald telephone amplifier","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5269",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alerting device, any type","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5270",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald, tv amplifier, any type","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5271",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald, tv caption decoder","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5272",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tdd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5273",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald for cochlear implant","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5274",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald unspecified","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5275",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ear impression","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5281",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm system, monaural","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5282",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm system binaural","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5283",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald neck, loop ind receiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5284",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm ear level receiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5285",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm aud input receiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5286",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald blu tooth fm/dm receiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5287",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm receiver, nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5288",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm transmitter ald","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5289",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm adapt/boot couplin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5290",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald transmitter microphone","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5298",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid noc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["V5299",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing service","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,5]
["V5336",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Repair communication device","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V5362",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Speech screening","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V5363",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Language screening","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["V5364",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dysphagia screening","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]

{"sheet":"Parameters","index":6,"n_rows":14,"n_cols":5,"rows_kept":14,"cut":false,"hidden":true,"merged":[]}
["parameters","value",null,"Parameter","Value"]
[26,"Yes",null,"mod",{"$f":"'Lookup Tool'!B5","v":53}]
["TC","No",null,"mod1",""]
[53,null,null,"mod2",{"$f":"IF('Lookup Tool'!B4=\"No\",\"N\",\"Y\")","v":"N"}]
["NU",null,null,"mod3"]
["RR",null,null,"code1",{"$f":"UPPER('Lookup Tool'!B3)","v":"01953"}]
["TC",null,null,"mod4",{"$f":"E2","v":53}]
["TF",null,null,"mod5","TC"]
["TG",null,null,"code2",{"$f":"up","v":{"$error":"#NAME?"}}]
["UN"]
["UP"]
["UQ"]
["UR"]
["US"]

{"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/2024/2024MARFSChapter1.pdf","Chapter 1: Introduction"]
[null,2,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter2.pdf","Chapter 2: Information for All Providers"]
[null,3,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter3.pdf","Chapter 3: Ambulance Services"]
[null,4,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter4.pdf","Chapter 4: Anesthesia Services"]
[null,5,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter5.pdf","Chapter 5: Audiology and Hearing Services"]
[null,6,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter6.pdf","Chapter 6: Biofeedback, Electrocardiograms (EKG), Electrodiagnostic services, & Extracorporeal Shockwave Therapy (ESWT)"]
[null,7,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter7.pdf","Chapter 7: Chiropractic Services"]
[null,8,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter8.pdf","Chapter 8: Dental Services"]
[null,9,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter9.pdf","Chapter 9: Durable Medical Equipment (DME)"]
[null,10,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter10.pdf","Chapter 10: Evaluation and Management (E/M) Services"]
[null,11,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter11.pdf","Chapter 11: Home Health Services"]
[null,12,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter12.pdf","Chapter 12: Impairment Rating Services"]
[null,13,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter13.pdf","Chapter 13: Independent Medical Exams (IME)"]
[null,14,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter14.pdf","Chapter 14: Language Access Services"]
[null,15,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter15.pdf","Chapter 15: Medical Testimony"]
[null,16,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter16.pdf","Chapter 16: Medication Administration and Injections"]
[null,17,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter17.pdf","Chapter 17: Mental Health Services"]
[null,18,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter18.pdf","Chapter 18: Modifications to Home and Vehicle"]
[null,19,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MARFSChapter19.pdf","Chapter 19: Naturopathic Physicians and Acupuncture Services"]
[null,20,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter20.pdf","Chapter 20: Nurse Case Management"]
[null,21,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter21.pdf","Chapter 21: Obesity Treatment"]
[null,22,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter22.pdf","Chapter 22: Other Services"]
[null,23,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter23.pdf","Chapter 23: Pathology and Laboratory Services"]
[null,24,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter24.pdf","Chapter 24: Pharmacy Services"]
[null,25,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter25.pdf","Chapter 25: Physical Medicine Services"]
[null,26,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter26.pdf","Chapter 26: Radiology Services"]
[null,27,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter27.pdf","Chapter 27: Reports and Forms"]
[null,28,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter28.pdf","Chapter 28: Supplies, Materials, and Bundled Services"]
[null,29,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter29.pdf","Chapter 29: Surgery Services"]
[null,30,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter30.pdf","Chapter 30: Vocational Services"]
[null,31,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter31.pdf","Chapter 31: Washington RBRVS Payment System"]
[null,32,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter32.pdf","Chapter 32: Ambulatory Surgery Centers (ASCs)"]
[null,33,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter33.pdf","Chapter 33: Brain Injury Rehabilitation Services"]
[null,34,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter34.pdf","Chapter 34: Chronic Pain Management"]
[null,35,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter35.pdf","Chapter 35: Hospitals"]
[null,36,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2024/2024MarfsChapter36.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"]

{"sheet":"Lookup Results","index":8,"n_rows":2,"n_cols":23,"rows_kept":2,"cut":false,"hidden":true,"merged":[]}
["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"]
["01953",null,"N","See CPT",58.35,58.35,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,4]