{"text_format":"1","workbook":"xlsx","n_sheets":9,"sheets":["Lookup Tool","Field Keys","2025 Professional Fee Schedule","Updates and Corrections","Chapters Inclusion","Table","Parameters","MARFS_URL's","Lookup Results"],"not_rendered":{"charts":0,"images":2,"macros":1,"external_links":0,"defined_names":10,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Lookup Tool","index":0,"n_rows":30,"n_cols":11,"rows_kept":30,"cut":false,"hidden":false,"merged":[[0,0,0,10],[7,2,7,10],[9,2,9,10],[10,2,10,10],[11,2,11,10],[12,2,12,10],[21,0,21,4],[8,2,8,10],[5,2,6,10],[5,0,11,1]]}
["Code Lookup Tool (Professional Services Fee Schedule)"]
[null,null,{"$f":"CodeLookup[[#Headers],[Modifiers]]","v":"Modifiers"},{"$f":"CodeLookup[[#Headers],[Short Description (HCPCS and Local Only)]]","v":"Short Description (HCPCS and Local Only)"},{"$f":"CodeLookup[[#Headers],[NON-FACILITY SETTING]]","v":"NON-FACILITY SETTING"},{"$f":"CodeLookup[[#Headers],[FACILITY SETTING]]","v":"FACILITY SETTING"},{"$f":"CodeLookup[[#Headers],[FOL UP]]","v":"FOL UP"},{"$f":"CodeLookup[[#Headers],[PRE OP\n(-56)]]","v":"PRE OP\n(-56)"},{"$f":"CodeLookup[[#Headers],[INTRA OP\n(-54)]]","v":"INTRA OP\n(-54)"},{"$f":"CodeLookup[[#Headers],[POST OP\n(-55)]]","v":"POST OP\n(-55)"},{"$f":"CodeLookup[[#Headers],[PCTC\n(26/TC)]]","v":"PCTC\n(26/TC)"}]
["Enter code --> ","01953",{"$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":58.65},{"$f":"CodeLookup[FACILITY SETTING]","v":58.65},{"$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":""},"RR",{"$f":"CodeLookup[MSI\n(-51)]","v":0},{"$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 12: Injections and Medication Administration"}]
[null,null,{"$f":"IFERROR(HYPERLINK(C25,C26),\"\")","v":""}]
[null,null,"Link to Prior Authorization Details (if applicable)"]
[null,null,{"$f":"IFERROR(HYPERLINK(D25,D26),\"\")","v":""}]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[{"$f":"CodeLookup[MARFS Chapters]","v":2},{"$f":"CodeLookup[MARFS Chapters2]","v":12},{"$f":"CodeLookup[MARFS Chapters3]","v":0}]
[{"$f":"IFERROR(VLOOKUP(A24,'MARFS_URL''s'!$B$2:$D$29,2,),\"\")","v":"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter2.pdf"},{"$f":"IFERROR(VLOOKUP(B24,'MARFS_URL''s'!$B$2:$D$29,2,),\"\")","v":"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter12.pdf"},{"$f":"IFERROR(VLOOKUP(C24,'MARFS_URL''s'!$B$2:$D$29,2,),\"\")","v":""},{"$f":"VLOOKUP(K5,'MARFS_URL''s'!$B$32:$D$35,2,)","v":{"$error":"#N/A"}}]
[{"$f":"IFERROR(VLOOKUP(A24,'MARFS_URL''s'!$B$2:$D$29,3,),\"\")","v":"Chapter 2: Information for All Providers"},{"$f":"IFERROR(VLOOKUP(B24,'MARFS_URL''s'!$B$2:$D$29,3,),\"\")","v":"Chapter 12: Injections and Medication Administration"},{"$f":"IFERROR(VLOOKUP(C24,'MARFS_URL''s'!$B$2:$D$29,3,),\"\")","v":""},{"$f":"VLOOKUP(K5,'MARFS_URL''s'!$B$32:$D$35,3,)","v":{"$error":"#N/A"}}]
[]
[]
[{"$f":"CodeLookup[[#Headers],[CODE]]","v":"CODE"}]
[{"$f":"CodeLookup[CODE]","v":"01953"}]

{"sheet":"Field Keys","index":1,"n_rows":401,"n_cols":11,"rows_kept":401,"cut":false,"hidden":false,"merged":[[394,0,394,17],[395,0,395,1],[395,2,395,6],[395,7,395,8],[395,9,395,17],[400,7,400,8],[400,9,400,17],[396,0,400,1],[396,2,400,6],[396,7,396,8],[396,9,396,17],[397,7,397,8],[397,9,397,17],[398,7,398,8],[398,9,398,17],[399,7,399,8],[399,9,399,17],[389,0,392,1],[389,2,392,6],[389,7,389,8],[389,9,389,17],[390,7,390,8],[390,9,390,17],[391,7,391,8],[391,9,391,17],[392,7,392,8],[392,9,392,17],[384,0,384,1],[384,2,384,6],[384,7,384,8],[384,9,384,17],[385,0,388,1],[385,2,388,6],[385,7,385,8],[385,9,385,17],[386,7,386,8],[386,9,386,17],[387,7,387,8],[387,9,387,17],[388,7,388,8],[388,9,388,17],[381,0,381,17],[382,0,382,1],[382,2,382,6],[382,7,382,8],[382,9,382,17],[383,0,383,1],[383,2,383,6],[383,7,383,8],[383,9,383,17],[377,7,377,8],[377,9,377,17],[378,7,378,8],[378,9,378,17],[379,0,379,1],[379,2,379,6],[379,7,379,8],[379,9,379,17],[374,7,374,8],[374,9,374,17],[375,7,375,8],[375,9,375,17],[376,7,376,8],[376,9,376,17],[363,7,363,8],[363,9,363,17],[364,7,364,8],[364,9,364,17],[371,7,371,8],[371,9,371,17],[372,7,372,8],[372,9,372,17],[373,7,373,8],[373,9,373,17],[368,7,368,8],[368,9,368,17],[369,7,369,8],[369,9,369,17],[370,7,370,8],[370,9,370,17],[359,7,359,8],[359,9,359,17],[360,7,360,8],[360,9,360,16],[361,7,361,8],[361,9,361,17],[355,0,378,1],[355,2,378,6],[355,7,355,8],[355,9,355,17],[356,7,356,8],[356,9,356,17],[357,7,357,8],[357,9,357,17],[358,7,358,8],[358,9,358,17],[365,7,365,8],[365,9,365,17],[366,7,366,8],[366,9,366,17],[367,7,367,8],[367,9,367,17],[362,7,362,8],[362,9,362,17],[344,0,344,17],[345,0,345,1],[345,2,345,6],[345,7,345,8],[345,9,345,17],[350,7,350,8],[350,9,350,17],[353,0,353,11],[354,0,354,1],[354,2,354,6],[354,7,354,8],[354,9,354,17],[346,0,350,1],[346,2,350,6],[346,7,346,8],[346,9,346,17],[347,7,347,8],[347,9,347,17],[348,7,348,8],[348,9,348,17],[349,7,349,8],[349,9,349,17],[339,0,342,1],[339,2,342,6],[339,7,339,8],[339,9,339,17],[340,7,340,8],[340,9,340,17],[341,7,341,8],[341,9,341,17],[342,7,342,8],[342,9,342,17],[334,0,334,1],[334,2,334,6],[334,7,334,8],[334,9,334,17],[335,0,338,1],[335,2,338,6],[335,7,335,8],[335,9,335,17],[336,7,336,8],[336,9,336,17],[337,7,337,8],[337,9,337,17],[338,7,338,8],[338,9,338,17],[331,0,331,11],[332,0,332,1],[332,2,332,6],[332,7,332,8],[332,9,332,17],[333,0,333,1],[333,2,333,6],[333,7,333,8],[333,9,333,17],[318,0,321,1],[318,2,321,7],[318,8,319,9],[318,10,319,17],[320,8,321,9],[320,10,321,17],[325,8,325,9],[324,8,324,9],[328,8,328,9],[322,8,322,9],[322,10,322,17],[328,10,328,17],[325,10,325,17],[324,10,324,17],[326,8,326,9],[326,10,326,17],[323,8,323,9],[327,8,327,9],[323,10,323,17],[327,10,327,17],[322,0,328,1],[322,2,328,7],[316,0,316,17],[317,0,317,1],[317,2,317,7],[317,8,317,9],[317,10,317,17],[311,8,311,9],[311,10,311,17],[312,8,312,9],[312,10,312,17],[313,8,313,9],[313,10,313,17],[308,8,308,9],[308,10,308,17],[309,8,309,9],[309,10,309,17],[310,8,310,9],[310,10,310,17],[298,0,314,1],[298,2,314,7],[298,8,298,9],[298,10,298,17],[299,8,302,9],[299,10,302,17],[303,8,306,9],[303,10,306,17],[307,8,307,9],[307,10,307,17],[314,8,314,9],[314,10,314,17],[288,8,289,9],[288,10,289,17],[290,8,292,9],[290,10,292,17],[293,0,297,1],[293,2,297,7],[293,8,297,9],[293,10,297,17],[279,0,279,1],[279,2,279,7],[279,8,279,9],[279,10,279,17],[280,0,292,1],[280,2,292,7],[280,8,282,9],[280,10,282,17],[283,8,287,9],[283,10,287,17],[265,10,269,17],[270,8,273,9],[270,10,273,17],[274,8,276,9],[274,10,276,17],[278,0,278,17],[252,10,255,17],[256,8,258,9],[256,10,258,17],[259,8,261,9],[259,10,261,17],[262,0,276,1],[262,2,276,7],[262,8,264,9],[262,10,264,17],[265,8,269,9],[244,0,244,17],[245,0,245,1],[245,2,245,7],[245,8,245,9],[245,10,245,17],[246,0,261,1],[246,2,261,7],[246,8,251,9],[246,10,251,17],[252,8,255,9],[219,0,242,1],[219,2,242,7],[219,8,221,9],[219,10,221,17],[222,8,225,9],[222,10,225,17],[205,10,205,17],[206,8,209,9],[206,10,209,17],[210,8,213,9],[210,10,213,17],[214,8,214,9],[214,10,214,17],[226,8,234,9],[226,10,234,17],[235,8,239,9],[235,10,239,17],[240,8,242,9],[240,10,242,17],[215,8,215,9],[215,10,215,17],[216,8,218,9],[216,10,218,17],[200,0,200,17],[201,0,201,1],[201,2,201,7],[201,8,201,9],[201,10,201,17],[202,0,218,1],[202,2,218,7],[202,8,204,9],[202,10,204,17],[205,8,205,9],[144,0,198,1],[144,2,198,7],[144,8,148,9],[144,10,148,17],[149,8,153,9],[149,10,153,17],[154,8,159,9],[154,10,159,17],[160,8,166,9],[160,10,166,17],[186,8,186,9],[186,10,186,17],[187,8,194,9],[187,10,194,17],[195,8,198,9],[195,10,198,17],[167,8,172,9],[167,10,172,17],[173,8,179,9],[173,10,179,17],[180,8,185,9],[180,10,185,17],[137,0,139,1],[137,2,139,7],[137,8,139,9],[137,10,139,17],[142,0,142,17],[143,0,143,1],[143,2,143,7],[143,8,143,9],[143,10,143,17],[131,0,133,1],[131,2,133,7],[131,8,133,9],[131,10,133,17],[134,0,136,1],[134,2,136,7],[134,8,136,9],[134,10,136,17],[125,0,125,17],[126,0,126,1],[126,2,126,7],[126,8,126,9],[126,10,126,17],[127,0,130,1],[127,2,130,7],[127,8,130,9],[127,10,130,17],[115,8,119,9],[115,10,119,17],[120,8,120,9],[120,10,120,17],[121,8,121,9],[121,10,121,17],[111,8,111,9],[111,10,111,17],[112,0,121,1],[112,2,121,7],[112,8,112,9],[112,10,112,17],[113,8,113,9],[113,10,113,17],[114,8,114,9],[114,10,114,17],[96,0,97,1],[96,2,97,7],[96,8,97,9],[96,10,97,17],[104,8,104,9],[104,10,104,17],[105,8,109,9],[105,10,109,17],[110,8,110,9],[110,10,110,17],[98,0,101,1],[98,2,101,7],[98,8,101,9],[98,10,101,17],[102,0,111,1],[102,2,111,7],[102,8,102,9],[102,10,102,17],[103,8,103,9],[103,10,103,17],[84,7,84,15],[94,0,94,11],[86,5,86,6],[85,7,85,15],[85,5,85,6],[87,5,87,6],[91,5,91,6],[95,0,95,1],[95,2,95,7],[95,8,95,9],[95,10,95,17],[77,0,79,1],[77,2,79,4],[77,5,77,6],[77,7,77,15],[78,5,78,6],[78,7,78,15],[85,0,91,1],[85,2,91,4],[88,5,88,6],[79,5,79,6],[79,7,79,15],[80,0,84,1],[80,2,84,4],[80,5,80,6],[80,7,80,15],[81,5,81,6],[81,7,81,15],[82,5,82,6],[82,7,82,15],[89,5,89,6],[90,5,90,6],[83,5,83,6],[83,7,83,15],[84,5,84,6],[73,0,76,1],[73,2,76,4],[73,5,73,6],[73,7,73,15],[74,5,74,6],[74,7,74,15],[75,5,75,6],[75,7,75,15],[76,5,76,6],[76,7,76,15],[12,0,13,16],[14,0,14,16],[18,0,18,16],[20,0,20,16],[66,0,66,11],[67,0,67,1],[67,2,67,4],[67,5,67,6],[67,7,67,15],[68,0,68,1],[68,2,68,4],[68,5,68,6],[68,7,68,15],[69,0,72,1],[69,2,72,4],[69,5,69,6],[69,7,69,15],[70,5,70,6],[70,7,70,15],[71,5,71,6],[71,7,71,15],[72,5,72,6],[72,7,72,15]]}
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["Professional Services Fee Schedule"]
[]
["CPT® Through Local Codes"]
[]
[]
[]
["Effective for Dates of Service on or After"]
[]
["2025-07-01"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["ANESTHESIA SERVICES FEE SCHEDULE                   "]
["FIELD KEY:  "]
["Column Title",null,"Column Description",null,null,"Column Values",null,"Value Definitions"]
["CPTÒ CODE",null,"2024 CPT® anesthesia code.",null,null,null,null,"2024 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,"2024 CPT® or HCPCS code",null,null,null,null,null,null,null,"2024 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 2024 CPT® or HCPCS code book for complete code descriptions."]
[]
[]
[]
["DOLLAR VALUE\nNON-FACILITY SETTING",null,"This column indicates the:\n• Maximum dollar amount for covered services provided in a non-facility setting, or\n• Pricing method for the procedure code, or\n• Coverage status for the procedure code.\n",null,null,null,null,null,"Dollar Value",null,"Maximum dollar amount payable for covered services."]
[null,null,null,null,null,null,null,null,"Bundled",null,"Bundled code, not separately payable."]
[null,null,null,null,null,null,null,null,"By Report",null,"Service paid on a “by report” basis."]
[null,null,null,null,null,null,null,null,"Contracted",null,"Contracted service. Payable only to department’s contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured workers."]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,"Facility Only",null,"Procedure code for facility outpatient use only."]
[null,null,null,null,null,null,null,null,"Not Covered",null,"Procedure code is not covered."]
["DOLLAR VALUE\nFACILITY SETTING",null,"This column indicates the:\n• Maximum dollar amount for covered services provided in a facility setting, or\n• Pricing method for the procedure code, or\n• Coverage status for the procedure code.\n",null,null,null,null,null,"Dollar Value",null,"Maximum dollar amount payable for covered services."]
[null,null,null,null,null,null,null,null,"Bundled",null,"Bundled code, not separately payable."]
[null,null,null,null,null,null,null,null,"By Report",null,"Service paid on a “by report” basis."]
[null,null,null,null,null,null,null,null,"Contracted",null,"Contracted service. Payable only to department’s contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured workers."]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,"Hosp. Only",null,"Procedure code for hospital outpatient use only."]
[null,null,null,null,null,null,null,null,"Not Covered",null,"Procedure code is not covered."]
[]
[]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["FOL UP",null,"Follow-up Days for Global Surgery",null,null,null,null,null,"Number",null,"The number of days following surgery during which charges for normal postoperative care are bundled in the global surgery fee."]
[]
[]
[]
["PRE OP \n(-56)",null,"Preoperative Percentage\n(Modifier –56)",null,null,null,null,null,"Percent",null,"The percent of the total global surgery dollar value that is allowed when modifier –56 is billed."]
[]
[]
["INTRA OP  (-54)",null,"Intraoperative Percentage\n(Modifier –54)",null,null,null,null,null,"Percent",null,"The percent of the total global surgery dollar value that is allowed when modifier -54 is billed."]
[]
[]
["POST OP \n(-55)",null,"Postoperative Percentage\n(Modifier –55)",null,null,null,null,null,"Percent ",null,"The percent of the total global surgery dollar value that is allowed when modifier -55 is billed."]
[]
[]
[]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["PCTC\n(26/TC)",null,"Professional and Technical Component (Modifiers –26 and –TC)\nThis field identifies whether professional and technical component modifiers (-26/-TC) are valid with the procedure code.",null,null,null,null,null,0,null,"Modifiers -26 and -TC are not valid. The procedure is for physician services only; the concept of PC/TC does not apply"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"Modifiers -26 and -TC are valid. Diagnostic test or radiology service which has both a professional and technical component. "]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,2,null,"Modifiers -26 and -TC are not valid. Stand alone code for the professional component of a diagnostic test. An associated code describes the technical component of the diagnostic test or the global procedure (professional and technical components)."]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,3,null,"Modifiers -26 and -TC are not valid. Stand alone code for the technical component of a diagnostic test. An associated code describes the professional component of the diagnostic test or the global procedure (professional and technical components). "]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,4,null,"Modifiers -26 and -TC are not valid. Stand alone code for the global procedure for a diagnostic test. Associated codes describe the professional and technical components of the diagnostic test. "]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,5,null,"Modifiers -26 and -TC are not valid. Covered service incident to a physician’s service when provided by auxiliary personnel employed by and working under the direct supervision of the physician. This service not payable when provided to hospital inpatients or outpatients."]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,6,null,"Modifier -TC is not valid; modifier -26 may be valid. Clinical laboratory or other service for which separate payment for interpretations by laboratory physicians or other physicians may be made."]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,7,null,"This indicator is not currently in use."]
[null,null,null,null,null,null,null,null,8,null,"Professional component of a clinical laboratory code; payable only if the physician interprets an abnormal smear for a hospital inpatient. No -TC modifier billing is recognized; payment for the underlying clinical laboratory test is made to the hospital. Not payable when furnished to hospital outpatients or non-hospital patients."]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,9,null,"Modifiers -26 and -TC are not valid. Concept of a professional/technical component split does not apply."]
[]
[]
[]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["MSI",null,"Multiple Surgery Indicator\n(Modifier –51)\nThis field indicates whether multiple surgery payment rules apply to the service.\n",null,null,null,null,null,0,null,"Modifier -51 is not valid. Payment adjustment rules for multiple surgeries do not apply."]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"This indicator is not currently in use."]
[null,null,null,null,null,null,null,null,2,null,"Modifier -51 is valid. Standard multiple surgery payment policy applies (100%, 50%, 50%, 50%, 50%). "]
[]
[]
[]
[null,null,null,null,null,null,null,null,3,null,"Modifier -51 may be valid. Multiple endoscopic procedures payment policy applies if this service is billed with another endoscopy in the same family. "]
[]
[]
[]
[null,null,null,null,null,null,null,null,4,null,"This indicator is not currently in use."]
[null,null,null,null,null,null,null,null,5,null,"This indicator is not currently in use."]
[null,null,null,null,null,null,null,null,9,null,"Modifier -51 is not valid. Concept of multiple surgery does not apply."]
[]
[]
["BSI",null,"Bilateral Surgery Indicator\n(Modifier –50)\nThis field indicates whether the procedure is subject to a payment adjustment for bilateral surgery.\n",null,null,null,null,null,0,null,"Modifier -50 is not valid. Payment adjustment rule for bilateral surgery does not apply. "]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"Modifier -50 is valid. Payment adjustment for bilateral procedures (150%) applies to this procedure."]
[]
[]
[]
[null,null,null,null,null,null,null,null,2,null,"Modifier -50 is not valid. Payment adjustment for bilateral procedures does not apply. Procedures in this category include services for which the code descriptor specifically states that the procedure is bilateral; procedures that are usually performed as bilateral procedures; or procedures for which the code descriptor indicates the procedures may be performed either unilaterally or bilaterally. "]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,3,null,"Modifier -50 is not valid. Payment adjustment for bilateral procedure does not apply. This is a radiology procedure which is not subject to payment rules for bilateral surgeries. "]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,9,null,"Modifier -50 is not valid. Concept of bilateral surgery does not apply. "]
[]
[]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["ASI",null,"Assistant Surgeon Indicator\n(Modifiers –80, -81, -82)\nThis field indicates whether or not an assistant surgeon may be paid for the procedure.\n",null,null,null,null,null,0,null,"Modifiers -80, -81 and -82 are not valid under normal situations. Assistant at surgery is not usually paid for this procedure. Supporting documentation is necessary to establish medical necessity. "]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"Modifiers -80, -81 and -82 are not valid. Assistant at surgery may not be paid for this procedure. "]
[]
[]
[]
[null,null,null,null,null,null,null,null,2,null,"Modifiers -80, -81 and -82 are valid. Assistant at surgery may be paid."]
[]
[]
[null,null,null,null,null,null,null,null,9,null,"Modifiers -80, -81 and -82 are not valid. Concept does not apply."]
[]
[]
["CSI",null,"Co-surgeons Indicator\n(Modifier –62)\nThis field indicates whether or not co-surgeons may be paid for the procedure.\n",null,null,null,null,null,0,null,"Modifier -62 is not valid. Co-surgeons not permitted."]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"Modifier -62 is not valid under normal situations. Supporting documentation is required to establish medical necessity of two surgeons."]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,2,null,"Modifier -62 is valid. Co-surgeons may be paid for this procedure. Supporting documentation is not required if two specialty requirement is met."]
[]
[]
[]
[null,null,null,null,null,null,null,null,9,null,"Modifier -62 is not valid with this procedure. Concept of co-surgeons does not apply."]
[]
[]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["TSI",null,"Team Surgeons Indicator\n(Modifier -66)\nThis field indicates whether or not team surgeons may be paid for the procedure.\n",null,null,null,null,null,0,null,"Modifier -66 is not valid. Team surgeons not permitted."]
[]
[]
[null,null,null,null,null,null,null,null,1,null,"Modifier -66 is not valid under normal situations. Team surgeons may be payable. Supporting documentation is required to establish medical necessity of a team."]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,2,null,"Modifier -66 is valid. Team surgeons permitted."]
[]
[null,null,null,null,null,null,null,null,9,null,"Modifier -66 is not valid. Concept of team surgery does not apply."]
[]
[]
["ENDO BASE",null,"Endoscopy Base Code",null,null,null,null,null,"Code number",null,"This column contains the endoscopic base code for procedure codes that are part of an endoscopy family. The Multiple Surgery Indicator for procedures in an endoscopy family is 3."]
[]
[]
[]
[]
["FSI",null,"Fee Schedule Indicator\nThis column indicates the payment status for the procedure code.",null,null,null,null,null,"B",null,"Bundled code, not separately payable."]
[null,null,null,null,null,null,null,null,"C",null,"Contracted service. Payable only to department’s contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured workers. "]
[]
[]
[]
[null,null,null,null,null,null,null,null,"D",null,"Drug fee based on Average Wholesale Price (AWP) or Average Average Wholesale Price (AAWP)."]
[]
[]
[]
[null,null,null,null,null,null,null,null,"F",null,"Flat fee developed by the department"]
[null,null,null,null,null,null,null,null,"L",null,"Clinical lab fee"]
[null,null,null,null,null,null,null,null,"N",null,"No fee or RVUs available, code paid by report."]
[null,null,null,null,null,null,null,null,"O",null,"For hospital outpatient use only."]
[null,null,null,null,null,null,null,null,"R",null,"RBRVS fee"]
[null,null,null,null,null,null,null,null,"S",null,"State Rate"]
[null,null,null,null,null,null,null,null,"T",null,"Tracking code"]
[null,null,null,null,null,null,null,null,"X",null,"Non-covered code"]
[]
["Field Key: Evaluation & Management through HCPCS (continued)"]
["Column Title",null,"Column Description",null,null,null,null,null,"Column Values",null,"Value Definitions"]
["LIC\nREQ",null,"Licensure Required",null,null,null,null,null,"Y",null,"Appropriate professional licensure is required to bill the department for these codes."]
[]
[null,null,null,null,null,null,null,null,"blank",null,"No special professional licensure is required to bill the department."]
[]
["PRIOR           AUTH",null,"Prior authorization indicator \nThis column indicates whether prior authorization and utilization review is required.",null,null,null,null,null,"Y",null,"Prior authorization required"]
[null,null,null,null,null,null,null,null,"Y-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":"2025 Professional Fee Schedule","index":2,"n_rows":21171,"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,58.65,null,58.65,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["01996",null,"See CPT",null,78.06,null,78.06,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,95.08,null,76.41,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[10005,null,"See CPT",null,242.65,null,128.33000000000001,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[10006,null,"See CPT",null,107.91,null,87.5,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[10007,null,"See CPT",null,560.54999999999995,null,156.32,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[10008,null,"See CPT",null,260.14999999999998,null,90.41,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[10009,null,"See CPT",null,776.37,null,189.57,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[10010,null,"See CPT",null,432.81,null,125.41,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,1151.43,null,235.65,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,213.49,null,92.74,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[10060,null,"See CPT",null,234.49,null,197.16,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10061,null,"See CPT",null,390.81,null,335.4,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10080,null,"See CPT",null,455.56,null,192.49,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[10081,null,"See CPT",null,620.63,null,307.98,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[10120,null,"See CPT",null,278.82,null,194.24,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10121,null,"See CPT",null,482.97,null,331.9,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10140,null,"See CPT",null,310.32,null,216.99,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10160,null,"See CPT",null,238.57,null,176.74,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[10180,null,"See CPT",null,480.06,null,324.31,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11000,null,"See CPT",null,107.91,null,47.25,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11001,null,"See CPT",null,49,null,26.25,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11004,null,"See CPT",null,986.94,null,986.94,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11005,null,"See CPT",null,1335.76,null,1335.76,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[11006,null,"See CPT",null,1216.76,null,1216.76,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11008,null,"See CPT",null,470.14,null,470.14,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[11010,null,"See CPT",null,806.7,null,495.22,null,10,0.1,0.8,0.1,0,2,2,1,0,0,null,"R"]
[11011,null,"See CPT",null,905.28,null,528.47,null,0,0,0,0,0,2,2,1,0,0,null,"R"]
[11012,null,"See CPT",null,1169.52,null,735.54,null,0,0,0,0,0,2,2,1,0,0,null,"R"]
[11042,null,"See CPT",null,237.4,null,108.49,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11043,null,"See CPT",null,421.14,null,272.98,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11044,null,"See CPT",null,558.79999999999995,null,396.64,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11045,null,"See CPT",null,71.75,null,43.16,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[11046,null,"See CPT",null,130.08000000000001,null,95.08,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[11047,null,"See CPT",null,215.24,null,169.16,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[11055,null,"See CPT",null,130.08000000000001,null,26.83,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11056,null,"See CPT",null,151.07,null,39.08,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11057,null,"See CPT",null,163.91,null,49.58,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11102,null,"See CPT",null,182.57,null,67.08,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11103,null,"See CPT",null,90.99,null,38.5,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11104,null,"See CPT",null,226.9,null,83.41,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11105,null,"See CPT",null,109.08,null,44.91,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11106,null,"See CPT",null,282.32,null,100.33,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11107,null,"See CPT",null,128.91,null,54.25,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11200,null,"See CPT",null,170.91,null,142.33000000000001,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11201,null,"See CPT",null,33.25,null,28.58,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[11300,null,"See CPT",null,181.99,null,60.08,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11301,null,"See CPT",null,220.49,null,91.58,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11302,null,"See CPT",null,249.65,null,106.74,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11303,null,"See CPT",null,277.07,null,127.16,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11305,null,"See CPT",null,190.74,null,65.91,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11306,null,"See CPT",null,222.24,null,86.33,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11307,null,"See CPT",null,250.24,null,109.08,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11308,null,"See CPT",null,262.49,null,121.91,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11310,null,"See CPT",null,209.99,null,80.5,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11311,null,"See CPT",null,249.65,null,111.99,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11312,null,"See CPT",null,283.48,null,132.99,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11313,null,"See CPT",null,329.56,null,170.32,null,0,0,0,0,0,2,9,0,0,0,null,"R"]
[11400,null,"See CPT",null,235.65,null,155.74,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11401,null,"See CPT",null,285.82,null,194.24,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11402,null,"See CPT",null,316.14999999999998,null,212.32,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11403,null,"See CPT",null,363.4,null,275.32,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11404,null,"See CPT",null,411.81,null,302.14999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11406,null,"See CPT",null,582.13,null,450.31,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11420,null,"See CPT",null,232.74,null,151.66,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11421,null,"See CPT",null,292.23,null,200.07,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11422,null,"See CPT",null,328.98,null,250.82,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11423,null,"See CPT",null,377.98,null,289.89999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11424,null,"See CPT",null,436.89,null,331.9,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11426,null,"See CPT",null,599.04999999999995,null,487.06,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11440,null,"See CPT",null,262.49,null,198.91,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11441,null,"See CPT",null,317.89999999999998,null,244.99,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11442,null,"See CPT",null,354.65,null,270.64999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11443,null,"See CPT",null,418.23,null,328.4,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11444,null,"See CPT",null,518.54999999999995,null,412.98,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11446,null,"See CPT",null,701.71,null,576.88,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11450,null,"See CPT",null,783.96,null,479.47,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R"]
[11451,null,"See CPT",null,960.11,null,604.29999999999995,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R"]
[11462,null,"See CPT",null,771.71,null,460.81,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R"]
[11463,null,"See CPT",null,960.7,null,601.97,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R"]
[11470,null,"See CPT",null,828.87,null,523.22,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[11471,null,"See CPT",null,989.28,null,638.13,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[11600,null,"See CPT",null,361.65,null,222.24,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11601,null,"See CPT",null,418.81,null,269.48,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11602,null,"See CPT",null,449.14,null,293.39999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11603,null,"See CPT",null,510.39,null,349.4,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11604,null,"See CPT",null,568.72,null,383.81,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11606,null,"See CPT",null,814.29,null,564.04999999999995,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11620,null,"See CPT",null,362.81,null,223.99,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11621,null,"See CPT",null,420.56,null,271.82,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11622,null,"See CPT",null,463.14,null,306.82,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11623,null,"See CPT",null,540.14,null,377.4,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11624,null,"See CPT",null,613.63,null,426.98,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11626,null,"See CPT",null,737.29,null,519.72,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11640,null,"See CPT",null,372.73,null,230.99,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11641,null,"See CPT",null,433.98,null,282.32,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11642,null,"See CPT",null,490.56,null,328.98,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11643,null,"See CPT",null,575.72,null,410.06,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11644,null,"See CPT",null,708.13,null,505.14,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11646,null,"See CPT",null,914.03,null,692.96,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11719,null,"See CPT",null,26.25,null,12.83,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11720,null,"See CPT",null,60.66,null,25.08,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11721,null,"See CPT",null,82.25,null,42,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11730,null,"See CPT",null,209.99,null,95.66,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11732,null,"See CPT",null,59.5,null,29.75,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[11740,null,"See CPT",null,106.74,null,60.08,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11750,null,"See CPT",null,293.39999999999998,null,184.91,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11755,null,"See CPT",null,222.24,null,107.33,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[11760,null,"See CPT",null,338.31,null,198.32,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11762,null,"See CPT",null,529.04999999999995,null,340.65,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11765,null,"See CPT",null,304.48,null,170.91,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[11770,null,"See CPT",null,635.21,null,331.9,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11771,null,"See CPT",null,1139.77,null,814.29,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11772,null,"See CPT",null,1399.92,null,1049.94,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[11900,null,"See CPT",null,105.58,null,52.5,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11901,null,"See CPT",null,127.74,null,80.5,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[11920,null,"See CPT",null,366.9,null,205.32,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11921,null,"See CPT",null,401.89,null,234.49,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11922,null,"See CPT",null,112.58,null,50.16,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[11950,null,"See CPT",null,150.49,null,92.74,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11951,null,"See CPT",null,199.49,null,128.91,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11952,null,"See CPT",null,265.39999999999998,null,180.82,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11954,null,"See CPT",null,293.39999999999998,null,198.91,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[11960,null,"See CPT",null,1868.31,null,1868.31,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[11970,null,"See CPT",null,1024.27,null,1024.27,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R"]
[11971,null,"See CPT",null,1011.44,null,1011.44,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,182.57,null,110.83,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[11982,null,"See CPT",null,198.91,null,128.33000000000001,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[11983,null,"See CPT",null,254.32,null,181.99,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[12001,null,"See CPT",null,171.49,null,78.16,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12002,null,"See CPT",null,207.65,null,102.66,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12004,null,"See CPT",null,240.9,null,127.74,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12005,null,"See CPT",null,319.64999999999998,null,163.32,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12006,null,"See CPT",null,370.4,null,201.82,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12007,null,"See CPT",null,411.81,null,251.4,null,0,0,0,0,0,2,0,1,1,0,null,"R"]
[12011,null,"See CPT",null,204.16,null,97.41,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12013,null,"See CPT",null,211.74,null,100.33,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12014,null,"See CPT",null,256.64999999999998,null,128.33000000000001,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12015,null,"See CPT",null,312.07,null,162.16,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12016,null,"See CPT",null,397.23,null,219.9,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[12017,null,"See CPT",null,265.98,null,265.98,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[12018,null,"See CPT",null,300.98,null,300.98,null,0,0,0,0,0,2,0,2,0,0,null,"R"]
[12020,null,"See CPT",null,547.14,null,342.4,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12021,null,"See CPT",null,320.82,null,254.9,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12031,null,"See CPT",null,480.06,null,275.89999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12032,null,"See CPT",null,557.04999999999995,null,347.06,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12034,null,"See CPT",null,610.13,null,371.56,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12035,null,"See CPT",null,710.46,null,435.14,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12036,null,"See CPT",null,790.95,null,506.3,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12037,null,"See CPT",null,884.87,null,585.04999999999995,null,10,0.1,0.8,0.1,0,2,0,0,1,0,null,"R"]
[12041,null,"See CPT",null,481.81,null,264.23,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12042,null,"See CPT",null,565.79999999999995,null,355.23,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12044,null,"See CPT",null,699.96,null,387.89,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12045,null,"See CPT",null,753.04,null,491.72,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12046,null,"See CPT",null,909.95,null,571.04999999999995,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[12047,null,"See CPT",null,995.69,null,631.13,null,10,0.1,0.8,0.1,0,2,0,2,1,0,null,"R"]
[12051,null,"See CPT",null,516.22,null,306.82,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12052,null,"See CPT",null,575.72,null,361.65,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12053,null,"See CPT",null,662.05,null,389.64,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12054,null,"See CPT",null,694.71,null,394.89,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12055,null,"See CPT",null,912.86,null,540.72,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[12056,null,"See CPT",null,1055.77,null,695.29,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[12057,null,"See CPT",null,1098.3499999999999,null,757.12,null,10,0.1,0.8,0.1,0,2,0,2,1,0,null,"R"]
[13100,null,"See CPT",null,620.04999999999995,null,361.65,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13101,null,"See CPT",null,720.96,null,444.47,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13102,null,"See CPT",null,209.99,null,126.58,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[13120,null,"See CPT",null,645.71,null,416.48,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13121,null,"See CPT",null,772.29,null,463.72,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13122,null,"See CPT",null,228.07,null,145.24,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[13131,null,"See CPT",null,705.79,null,435.14,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13132,null,"See CPT",null,853.95,null,541.89,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13133,null,"See CPT",null,303.32,null,221.65,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[13151,null,"See CPT",null,767.62,null,499.3,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13152,null,"See CPT",null,898.87,null,599.63,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[13153,null,"See CPT",null,334.23,null,242.07,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[13160,null,"See CPT",null,1436.08,null,1436.08,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14000,null,"See CPT",null,1169.52,null,922.2,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14001,null,"See CPT",null,1483.33,null,1184.68,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14020,null,"See CPT",null,1294.3399999999999,null,1037.1099999999999,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14021,null,"See CPT",null,1594.16,null,1290.26,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14040,null,"See CPT",null,1395.84,null,1136.8499999999999,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14041,null,"See CPT",null,1695.07,null,1385.92,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14060,null,"See CPT",null,1406.92,null,1210.93,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14061,null,"See CPT",null,1829.23,null,1486.83,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[14301,null,"See CPT",null,1969.8,null,1567.33,null,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R"]
[14302,null,"See CPT",null,379.15,null,379.15,null,0,0,0,0,0,0,0,2,0,0,null,"R"]
[14350,null,"See CPT",null,1205.68,null,1205.68,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15002,null,"See CPT",null,618.88,null,390.23,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[15003,null,"See CPT",null,123.66,null,77.58,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[15004,null,"See CPT",null,710.46,null,463.14,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[15005,null,"See CPT",null,208.24,null,156.91,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[15011,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,2,0,1,0,0,null,"N"]
[15012,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,1,0,0,null,"N"]
[15013,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,2,0,1,0,0,null,"N"]
[15014,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,1,0,0,null,"N"]
[15015,null,"See CPT",null,"By Report",null,"By Report",null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"N"]
[15016,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,1,0,0,null,"N"]
[15017,null,"See CPT",null,"By Report",null,"By Report",null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"N"]
[15018,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,1,0,0,null,"N"]
[15040,null,"See CPT",null,477.72,null,225.15,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15050,null,"See CPT",null,1072.69,null,839.37,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15100,null,"See CPT",null,1574.33,null,1292.5899999999999,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15101,null,"See CPT",null,333.65,null,194.82,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15110,null,"See CPT",null,1493.83,null,1279.18,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15111,null,"See CPT",null,201.24,null,177.32,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15115,null,"See CPT",null,1468.17,null,1258.76,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15116,null,"See CPT",null,271.23,null,240.9,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15120,null,"See CPT",null,1535.83,null,1246.51,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15121,null,"See CPT",null,372.15,null,232.15,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15130,null,"See CPT",null,1311.84,null,1089.02,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15131,null,"See CPT",null,174.99,null,158.66,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15135,null,"See CPT",null,1581.91,null,1370.76,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15136,null,"See CPT",null,172.66,null,158.66,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15150,null,"See CPT",null,1260.51,null,1141.52,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15151,null,"See CPT",null,208.24,null,188.41,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15152,null,"See CPT",null,272.39999999999998,null,253.74,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15155,null,"See CPT",null,1440.17,null,1318.84,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15156,null,"See CPT",null,279.39999999999998,null,260.14999999999998,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15157,null,"See CPT",null,311.48,null,283.48,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15200,null,"See CPT",null,1531.16,null,1219.68,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15201,null,"See CPT",null,251.4,null,134.16,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15220,null,"See CPT",null,1409.84,null,1110.02,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15221,null,"See CPT",null,231.57,null,121.33,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15240,null,"See CPT",null,1701.49,null,1451.25,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15241,null,"See CPT",null,313.82,null,188.41,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15260,null,"See CPT",null,1833.31,null,1540.5,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15261,null,"See CPT",null,369.81,null,239.15,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15271,null,"See CPT",null,279.39999999999998,null,149.32,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[15272,null,"See CPT",null,43.75,null,29.75,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15273,null,"See CPT",null,549.47,null,340.06,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[15274,null,"See CPT",null,144.08000000000001,null,76.41,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15275,null,"See CPT",null,289.32,null,166.24,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[15276,null,"See CPT",null,58.91,null,43.75,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[15277,null,"See CPT",null,614.21,null,391.98,null,0,0,0,0,0,2,0,1,1,0,null,"R"]
[15278,null,"See CPT",null,169.74,null,97.41,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[15570,null,"See CPT",null,1647.82,null,1314.17,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15572,null,"See CPT",null,1609.91,null,1335.76,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15574,null,"See CPT",null,1564.99,null,1307.76,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15576,null,"See CPT",null,1432,null,1179.43,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15600,null,"See CPT",null,620.63,null,390.81,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15610,null,"See CPT",null,682.46,null,453.22,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15620,null,"See CPT",null,824.2,null,602.54999999999995,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15630,null,"See CPT",null,853.95,null,633.46,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15650,null,"See CPT",null,999.19,null,741.96,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15730,null,"See CPT",null,2564.77,null,1648.99,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15731,null,"See CPT",null,2037.47,null,1800.65,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15733,null,"See CPT",null,1847.89,null,1847.89,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15734,null,"See CPT",null,2678.51,null,2678.51,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15736,null,"See CPT",null,2191.46,null,2191.46,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15738,null,"See CPT",null,2262.62,null,2262.62,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15740,null,"See CPT",null,1854.89,null,1528.25,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15750,null,"See CPT",null,1684.57,null,1684.57,null,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R"]
[15756,null,"See CPT",null,4062.1,null,4062.1,null,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R"]
[15757,null,"See CPT",null,4037.02,null,4037.02,null,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R"]
[15758,null,"See CPT",null,4021.85,null,4021.85,null,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R"]
[15760,null,"See CPT",null,1545.16,null,1267.51,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15769,null,"See CPT",null,870.87,null,870.87,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[15770,null,"See CPT",null,1227.26,null,1227.26,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,683.04,null,456.14,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[15776,null,"See CPT",null,922.2,null,622.96,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[15777,null,"See CPT",null,377.98,null,377.98,null,0,0,0,0,0,0,1,1,0,0,null,"R"]
[15778,null,"See CPT",null,683.63,null,683.63,null,0,0,0,0,0,2,0,2,1,0,null,"R"]
[15780,null,"See CPT",null,1553.33,null,1214.43,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15781,null,"See CPT",null,962.45,null,768.79,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15782,null,"See CPT",null,895.95,null,682.46,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15783,null,"See CPT",null,832.37,null,656.8,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15786,null,"See CPT",null,418.23,null,244.99,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[15787,null,"See CPT",null,54.83,null,30.33,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"]
[15820,null,"See CPT",null,1057.52,null,938.53,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15821,null,"See CPT",null,1131.02,null,999.78,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15822,null,"See CPT",null,841.7,null,725.04,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[15823,null,"See CPT",null,1132.77,null,1000.36,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[15824,null,"See CPT",null,1648.46,null,1648.46,null,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM"]
[15825,null,"See CPT",null,1417.39,null,1417.39,null,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM"]
[15826,null,"See CPT",null,1340.35,null,1340.35,null,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM"]
[15828,null,"See CPT",null,4591.07,null,4591.07,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,2115.63,null,2115.63,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[15832,null,"See CPT",null,1681.65,null,1681.65,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[15833,null,"See CPT",null,1593.58,null,1593.58,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15834,null,"See CPT",null,1622.74,null,1622.74,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15835,null,"See CPT",null,1688.65,null,1688.65,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15836,null,"See CPT",null,1450.67,null,1450.67,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[15837,null,"See CPT",null,1588.33,null,1305.43,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15838,null,"See CPT",null,1187.02,null,1187.02,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15839,null,"See CPT",null,1627.41,null,1338.67,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[15840,null,"See CPT",null,1815.23,null,1815.23,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15841,null,"See CPT",null,3200.57,null,3200.57,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15842,null,"See CPT",null,4826.22,null,4826.22,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15845,null,"See CPT",null,1928.39,null,1928.39,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,100.91,null,117.24,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[15852,null,"See CPT",null,78.16,null,78.16,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[15853,null,"See CPT",null,21,null,21,null,0,0,0,0,5,0,0,1,0,0,null,"R"]
[15854,null,"See CPT",null,26.83,null,26.83,null,0,0,0,0,5,0,0,1,0,0,null,"R"]
[15860,null,"See CPT",null,186.66,null,186.66,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,1149.0999999999999,null,1149.0999999999999,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15922,null,"See CPT",null,1452.42,null,1452.42,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15931,null,"See CPT",null,1268.0899999999999,null,1268.0899999999999,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15933,null,"See CPT",null,1574.91,null,1574.91,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15934,null,"See CPT",null,1783.15,null,1783.15,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15935,null,"See CPT",null,2094.0500000000002,null,2094.0500000000002,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15936,null,"See CPT",null,1595.33,null,1595.33,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15937,null,"See CPT",null,1766.82,null,1766.82,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15940,null,"See CPT",null,1280.3399999999999,null,1280.3399999999999,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15941,null,"See CPT",null,1722.48,null,1722.48,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15944,null,"See CPT",null,1697.99,null,1697.99,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15945,null,"See CPT",null,1851.39,null,1851.39,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R"]
[15946,null,"See CPT",null,2871,null,2871,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15950,null,"See CPT",null,1162.52,null,1162.52,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R"]
[15951,null,"See CPT",null,1634.99,null,1634.99,null,90,0.1,0.71,0.19,0,2,0,0,1,0,null,"R"]
[15952,null,"See CPT",null,1664.74,null,1664.74,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[15953,null,"See CPT",null,1832.15,null,1832.15,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15956,null,"See CPT",null,2094.63,null,2094.63,null,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R"]
[15958,null,"See CPT",null,2094.63,null,2094.63,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,146.41,null,80.5,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[16020,null,"See CPT",null,157.49,null,101.49,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[16025,null,"See CPT",null,284.07,null,198.32,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[16030,null,"See CPT",null,360.48,null,235.65,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[16035,null,"See CPT",null,343.56,null,343.56,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[16036,null,"See CPT",null,144.08000000000001,null,144.08000000000001,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[17000,null,"See CPT",null,125.99,null,101.49,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17003,null,"See CPT",null,12.25,null,3.5,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17004,null,"See CPT",null,306.23,null,179.66,null,10,0.1,0.8,0.1,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17106,null,"See CPT",null,635.21,null,506.3,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17107,null,"See CPT",null,825.95,null,660.88,null,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17108,null,"See CPT",null,1164.8499999999999,null,960.11,null,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[17110,null,"See CPT",null,209.99,null,127.74,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17111,null,"See CPT",null,245.57,null,155.16,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17250,null,"See CPT",null,156.91,null,68.25,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[17260,null,"See CPT",null,183.16,null,129.49,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17261,null,"See CPT",null,273.57,null,160.41,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17262,null,"See CPT",null,327.23,null,201.24,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17263,null,"See CPT",null,354.65,null,222.24,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17264,null,"See CPT",null,380.89,null,237.99,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17266,null,"See CPT",null,431.64,null,277.64999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17270,null,"See CPT",null,276.48,null,175.57,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17271,null,"See CPT",null,306.23,null,191.91,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17272,null,"See CPT",null,345.9,null,219.9,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17273,null,"See CPT",null,383.81,null,248.49,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17274,null,"See CPT",null,448.56,null,303.89999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17276,null,"See CPT",null,518.54999999999995,null,364.56,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17280,null,"See CPT",null,259.57,null,159.82,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17281,null,"See CPT",null,330.15,null,215.24,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17282,null,"See CPT",null,376.81,null,247.32,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17283,null,"See CPT",null,445.06,null,307.98,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17284,null,"See CPT",null,505.14,null,359.31,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17286,null,"See CPT",null,650.38,null,489.39,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17311,null,"See CPT",null,1250.5999999999999,null,632.29999999999995,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17312,null,"See CPT",null,758.29,null,336.56,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17313,null,"See CPT",null,1176.52,null,567.54999999999995,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[17314,null,"See CPT",null,726.79,null,310.89999999999998,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[17315,null,"See CPT",null,147.57,null,88.66,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,177.91,null,74.66,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[19001,null,"See CPT",null,46.66,null,36.159999999999997,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[19020,null,"See CPT",null,839.95,null,571.04999999999995,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R"]
[19030,null,"See CPT",null,296.32,null,132.41,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19081,null,"See CPT",null,897.7,null,285.23,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19082,null,"See CPT",null,687.71,null,142.33000000000001,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19083,null,"See CPT",null,888.37,null,267.73,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19084,null,"See CPT",null,674.88,null,134.74,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19085,null,"See CPT",null,1364.34,null,313.82,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19086,null,"See CPT",null,1055.19,null,156.32,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19100,null,"See CPT",null,265.39999999999998,null,118.99,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19101,null,"See CPT",null,576.88,null,401.31,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,873.2,null,642.21,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19112,null,"See CPT",null,827.7,null,592.63,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19120,null,"See CPT",null,944.95,null,754.79,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19125,null,"See CPT",null,1040.02,null,832.95,null,90,0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[19126,null,"See CPT",null,277.07,null,277.07,null,0,0,0,0,0,0,0,1,1,0,null,"R",null,"Y-CM"]
[19281,null,"See CPT",null,440.39,null,172.07,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19282,null,"See CPT",null,310.89999999999998,null,85.75,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19283,null,"See CPT",null,469.56,null,173.24,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19284,null,"See CPT",null,340.06,null,86.33,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19285,null,"See CPT",null,657.38,null,146.99,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19286,null,"See CPT",null,536.04999999999995,null,73.5,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19287,null,"See CPT",null,1133.94,null,219.32,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19288,null,"See CPT",null,872.62,null,110.83,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[19294,null,"See CPT",null,285.23,null,285.23,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,1434.33,null,1434.33,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19318,null,"See CPT",null,1972.72,null,1972.72,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19325,null,"See CPT",null,1122.8499999999999,null,1122.8499999999999,null,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[19328,null,"See CPT",null,1010.28,null,1010.28,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19330,null,"See CPT",null,1172.43,null,1172.43,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19340,null,"See CPT",null,1377.17,null,1377.17,null,90,0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[19342,null,"See CPT",null,1383,null,1383,null,90,0.1,0.71,0.19,0,2,1,0,1,0,null,"R",null,"Y-CM"]
[19350,null,"See CPT",null,1519.5,null,1225.51,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,2113.88,null,2113.88,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19361,null,"See CPT",null,2799.26,null,2799.26,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19364,null,"See CPT",null,4850.1400000000003,null,4850.1400000000003,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19367,null,"See CPT",null,3177.24,null,3177.24,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19368,null,"See CPT",null,3874.28,null,3874.28,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19369,null,"See CPT",null,3601.29,null,3601.29,null,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[19370,null,"See CPT",null,1222.01,null,1222.01,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19371,null,"See CPT",null,1293.76,null,1293.76,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19380,null,"See CPT",null,1465.83,null,1465.83,null,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[19396,null,"See CPT",null,492.31,null,256.07,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,1059.8599999999999,null,1059.8599999999999,null,10,0.1,0.8,0.1,0,2,1,2,0,0,null,"R"]
[20101,null,"See CPT",null,1019.03,null,371.56,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20102,null,"See CPT",null,1090.19,null,455.56,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20103,null,"See CPT",null,1020.19,null,617.71,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[20150,null,"See CPT",null,1812.9,null,1812.9,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[20200,null,"See CPT",null,391.39,null,170.32,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20205,null,"See CPT",null,548.29999999999995,null,274.14999999999998,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20206,null,"See CPT",null,395.48,null,102.08,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20220,null,"See CPT",null,418.81,null,153.99,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20225,null,"See CPT",null,683.04,null,228.65,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20240,null,"See CPT",null,249.07,null,249.07,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20245,null,"See CPT",null,606.63,null,606.63,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20250,null,"See CPT",null,706.96,null,706.96,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20251,null,"See CPT",null,775.79,null,775.79,null,10,0.1,0.8,0.1,0,2,0,2,0,0,null,"R"]
[20500,null,"See CPT",null,230.99,null,164.49,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20501,null,"See CPT",null,256.64999999999998,null,63.58,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20520,null,"See CPT",null,400.14,null,271.23,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20525,null,"See CPT",null,854.53,null,450.89,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20526,null,"See CPT",null,151.07,null,101.49,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20527,null,"See CPT",null,160.41,null,118.41,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20550,null,"See CPT",null,105.58,null,68.83,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20551,null,"See CPT",null,104.41,null,68.25,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20552,null,"See CPT",null,95.08,null,64.75,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[20553,null,"See CPT",null,109.66,null,73.5,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,46.08,null,26.83,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[20561,null,"See CPT",null,67.66,null,40.25,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[20600,null,"See CPT",null,97.99,null,63.58,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20604,null,"See CPT",null,151.66,null,82.25,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20605,null,"See CPT",null,99.74,null,65.33,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20606,null,"See CPT",null,163.91,null,92.16,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20610,null,"See CPT",null,117.83,null,80.5,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20611,null,"See CPT",null,180.24,null,104.41,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[20612,null,"See CPT",null,119.58,null,73.5,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20615,null,"See CPT",null,455.56,null,290.48,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20650,null,"See CPT",null,429.89,null,307.98,null,10,0.1,0.8,0.1,0,2,0,1,1,0,null,"R"]
[20660,null,"See CPT",null,419.98,null,419.98,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[20661,null,"See CPT",null,950.2,null,950.2,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20662,null,"See CPT",null,965.36,null,965.36,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20663,null,"See CPT",null,890.7,null,890.7,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[20664,null,"See CPT",null,1616.91,null,1616.91,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20665,null,"See CPT",null,219.9,null,181.99,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[20670,null,"See CPT",null,648.04999999999995,null,266.57,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[20680,null,"See CPT",null,1093.0999999999999,null,764.71,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20690,null,"See CPT",null,1082.5999999999999,null,1082.5999999999999,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20692,null,"See CPT",null,2054.9699999999998,null,2054.9699999999998,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20693,null,"See CPT",null,827.7,null,827.7,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20694,null,"See CPT",null,797.95,null,633.46,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[20696,null,"See CPT",null,2098.71,null,2098.71,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20697,null,"See CPT",null,3191.23,null,3191.23,null,0,0,0,0,3,0,0,2,1,0,null,"R"]
[20700,null,"See CPT",null,147.57,null,147.57,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20701,null,"See CPT",null,111.99,null,111.99,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20702,null,"See CPT",null,250.82,null,250.82,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20703,null,"See CPT",null,184.32,null,184.32,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20704,null,"See CPT",null,264.23,null,264.23,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20705,null,"See CPT",null,218.15,null,218.15,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[20802,null,"See CPT",null,4894.47,null,4894.47,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20805,null,"See CPT",null,5803.25,null,5803.25,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20808,null,"See CPT",null,6986.77,null,6986.77,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20816,null,"See CPT",null,3664.29,null,3664.29,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20822,null,"See CPT",null,3177.82,null,3177.82,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20824,null,"See CPT",null,3672.46,null,3672.46,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20827,null,"See CPT",null,3262.4,null,3262.4,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20838,null,"See CPT",null,4968.55,null,4968.55,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20900,null,"See CPT",null,697.04,null,320.82,null,0,0,0,0,0,2,0,2,1,0,null,"R"]
[20902,null,"See CPT",null,485.89,null,485.89,null,0,0,0,0,0,2,0,2,1,0,null,"R"]
[20910,null,"See CPT",null,883.12,null,883.12,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20912,null,"See CPT",null,879.62,null,879.62,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[20920,null,"See CPT",null,731.46,null,731.46,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[20922,null,"See CPT",null,1117.5999999999999,null,904.12,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20924,null,"See CPT",null,926.86,null,926.86,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,192.49,null,192.49,null,0,0,0,0,0,0,0,1,1,0,null,"R"]
[20932,null,"See CPT",null,1323.51,null,1323.51,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[20933,null,"See CPT",null,1214.43,null,1214.43,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[20934,null,"See CPT",null,1322.92,null,1322.92,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,291.64999999999998,null,291.64999999999998,null,0,0,0,0,0,0,0,2,1,0,null,"R"]
[20938,null,"See CPT",null,317.89999999999998,null,317.89999999999998,null,0,0,0,0,0,0,0,2,1,0,null,"R"]
[20939,null,"See CPT",null,121.91,null,121.91,null,0,0,0,0,0,0,1,0,0,0,null,"R",null,"Y-UR"]
[20950,null,"See CPT",null,475.39,null,160.41,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[20955,null,"See CPT",null,4349.08,null,4349.08,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20956,null,"See CPT",null,4704.8999999999996,null,4704.8999999999996,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20957,null,"See CPT",null,4903.22,null,4903.22,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20962,null,"See CPT",null,4795.3100000000004,null,4795.3100000000004,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20969,null,"See CPT",null,4826.22,null,4826.22,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20970,null,"See CPT",null,5075.88,null,5075.88,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[20972,null,"See CPT",null,5059.54,null,5059.54,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[20973,null,"See CPT",null,5338.94,null,5338.94,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[20974,null,"See CPT",null,158.66,null,93.91,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-ONC"]
[20975,null,"See CPT",null,317.32,null,317.32,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-ONC"]
[20979,null,"See CPT",null,102.08,null,54.83,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-ONC"]
[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,254.32,null,254.32,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,1348.01,null,1348.01,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[21011,null,"See CPT",null,690.04,null,484.14,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21012,null,"See CPT",null,620.04999999999995,null,620.04999999999995,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21013,null,"See CPT",null,974.11,null,732.04,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21014,null,"See CPT",null,949.03,null,949.03,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21015,null,"See CPT",null,1271.01,null,1271.01,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,1470.5,null,1219.0999999999999,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21026,null,"See CPT",null,1009.69,null,804.95,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21029,null,"See CPT",null,1420.92,null,1145.02,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[21030,null,"See CPT",null,846.37,null,665.55,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[21031,null,"See CPT",null,703.46,null,501.64,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[21032,null,"See CPT",null,691.21,null,482.97,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[21034,null,"See CPT",null,2346.62,null,2024.63,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21040,null,"See CPT",null,854.53,null,668.46,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[21044,null,"See CPT",null,1560.33,null,1560.33,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21045,null,"See CPT",null,2159.38,null,2159.38,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21046,null,"See CPT",null,1793.65,null,1793.65,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR"]
[21047,null,"See CPT",null,2187.38,null,2187.38,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21048,null,"See CPT",null,1815.81,null,1815.81,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR"]
[21049,null,"See CPT",null,2074.8000000000002,null,2074.8000000000002,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21050,null,"See CPT",null,1571.99,null,1571.99,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[21060,null,"See CPT",null,1423.84,null,1423.84,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[21070,null,"See CPT",null,1108.27,null,1108.27,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[21073,null,"See CPT",null,752.46,null,450.89,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[21076,null,"See CPT",null,1606.99,null,1284.43,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[21077,null,"See CPT",null,3891.19,null,3141.65,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21079,null,"See CPT",null,2689.6,null,2120.88,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21080,null,"See CPT",null,3059.99,null,2385.11,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21081,null,"See CPT",null,2819.67,null,2186.79,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21082,null,"See CPT",null,2658.1,null,2029.3,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21083,null,"See CPT",null,2519.86,null,1873.56,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21084,null,"See CPT",null,2871,null,2164.63,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21085,null,"See CPT",null,1255.8399999999999,null,876.12,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[21086,null,"See CPT",null,2888.5,null,2317.4499999999998,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21087,null,"See CPT",null,2888.5,null,2317.4499999999998,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,1150.27,null,664.96,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21110,null,"See CPT",null,1572.58,null,1300.18,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21116,null,"See CPT",null,384.98,null,78.75,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[21120,null,"See CPT",null,1213.26,null,928.03,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[21121,null,"See CPT",null,1167.77,null,974.69,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21122,null,"See CPT",null,1359.67,null,1359.67,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21123,null,"See CPT",null,1530.58,null,1530.58,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21125,null,"See CPT",null,4731.7299999999996,null,1222.5999999999999,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21127,null,"See CPT",null,7308.17,null,1411.59,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21137,null,"See CPT",null,1365.51,null,1365.51,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21138,null,"See CPT",null,1656.57,null,1656.57,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21139,null,"See CPT",null,1966.3,null,1966.3,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21141,null,"See CPT",null,2410.7800000000002,null,2410.7800000000002,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21142,null,"See CPT",null,2472.61,null,2472.61,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21143,null,"See CPT",null,2547.85,null,2547.85,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21145,null,"See CPT",null,2794.01,null,2794.01,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21146,null,"See CPT",null,2918.83,null,2918.83,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21147,null,"See CPT",null,3067.57,null,3067.57,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21150,null,"See CPT",null,2934,null,2934,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21151,null,"See CPT",null,3226.23,null,3226.23,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21154,null,"See CPT",null,3473.55,null,3473.55,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21155,null,"See CPT",null,3849.2,null,3849.2,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21159,null,"See CPT",null,4605.1499999999996,null,4605.1499999999996,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21160,null,"See CPT",null,4990.71,null,4990.71,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21172,null,"See CPT",null,3741.29,null,3741.29,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21175,null,"See CPT",null,3944.86,null,3944.86,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21179,null,"See CPT",null,2725.18,null,2725.18,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21180,null,"See CPT",null,3040.74,null,3040.74,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21181,null,"See CPT",null,1345.67,null,1345.67,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[21182,null,"See CPT",null,3780.37,null,3780.37,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21183,null,"See CPT",null,4108.7700000000004,null,4108.7700000000004,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21184,null,"See CPT",null,4415.58,null,4415.58,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21188,null,"See CPT",null,2848.84,null,2848.84,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21193,null,"See CPT",null,2223.54,null,2223.54,null,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR"]
[21194,null,"See CPT",null,2569.44,null,2569.44,null,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-UR"]
[21195,null,"See CPT",null,2418.9499999999998,null,2418.9499999999998,null,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-UR"]
[21196,null,"See CPT",null,2582.27,null,2582.27,null,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR"]
[21198,null,"See CPT",null,1823.98,null,1823.98,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21199,null,"See CPT",null,1832.15,null,1832.15,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21206,null,"See CPT",null,1767.98,null,1767.98,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21208,null,"See CPT",null,2991.16,null,1349.76,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21209,null,"See CPT",null,1444.83,null,1103.5999999999999,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21210,null,"See CPT",null,3230.32,null,1392.92,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21215,null,"See CPT",null,7465.66,null,1448.33,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[21230,null,"See CPT",null,1346.84,null,1346.84,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21235,null,"See CPT",null,1350.34,null,1042.94,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21240,null,"See CPT",null,1903.31,null,1903.31,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[21242,null,"See CPT",null,1837.4,null,1837.4,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[21243,null,"See CPT",null,2926.42,null,2926.42,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[21244,null,"See CPT",null,1819.9,null,1819.9,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21245,null,"See CPT",null,2221.79,null,1716.65,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21246,null,"See CPT",null,1537,null,1537,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21247,null,"See CPT",null,2851.17,null,2851.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21248,null,"See CPT",null,1798.31,null,1448.33,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21249,null,"See CPT",null,2437.0300000000002,null,2017.63,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21255,null,"See CPT",null,2417.7800000000002,null,2417.7800000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21256,null,"See CPT",null,2241.62,null,2241.62,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,1869.48,null,1355.59,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21275,null,"See CPT",null,1525.91,null,1525.91,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21280,null,"See CPT",null,1075.6099999999999,null,1075.6099999999999,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21282,null,"See CPT",null,736.12,null,736.12,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,284.64999999999998,null,107.33,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[21320,null,"See CPT",null,398.39,null,169.74,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[21325,null,"See CPT",null,817.79,null,817.79,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21330,null,"See CPT",null,978.19,null,978.19,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21335,null,"See CPT",null,1301.3399999999999,null,1301.3399999999999,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21336,null,"See CPT",null,1166.02,null,1166.02,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21337,null,"See CPT",null,768.21,null,558.79999999999995,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21338,null,"See CPT",null,1233.0999999999999,null,1233.0999999999999,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21339,null,"See CPT",null,1388.84,null,1388.84,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21340,null,"See CPT",null,1364.34,null,1364.34,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21343,null,"See CPT",null,1973.3,null,1973.3,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21344,null,"See CPT",null,2501.77,null,2501.77,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21345,null,"See CPT",null,1469.33,null,1167.18,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21346,null,"See CPT",null,1836.81,null,1836.81,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[21347,null,"See CPT",null,1886.98,null,1886.98,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21348,null,"See CPT",null,1964.55,null,1964.55,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21355,null,"See CPT",null,823.04,null,600.79999999999995,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[21356,null,"See CPT",null,1006.19,null,739.04,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[21360,null,"See CPT",null,958.95,null,958.95,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21365,null,"See CPT",null,1956.39,null,1956.39,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21366,null,"See CPT",null,2298.79,null,2298.79,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[21385,null,"See CPT",null,1331.09,null,1331.09,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21386,null,"See CPT",null,1258.18,null,1258.18,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21387,null,"See CPT",null,1389.42,null,1389.42,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21390,null,"See CPT",null,1450.08,null,1450.08,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21395,null,"See CPT",null,1810.56,null,1810.56,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21400,null,"See CPT",null,410.06,null,320.23,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21401,null,"See CPT",null,941.45,null,612.47,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[21406,null,"See CPT",null,1067.44,null,1067.44,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21407,null,"See CPT",null,1181.77,null,1181.77,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21408,null,"See CPT",null,1631.49,null,1631.49,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[21421,null,"See CPT",null,1196.93,null,1009.11,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21422,null,"See CPT",null,1150.8499999999999,null,1150.8499999999999,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21423,null,"See CPT",null,1439,null,1439,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21431,null,"See CPT",null,1273.93,null,1273.93,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21432,null,"See CPT",null,1299.5899999999999,null,1299.5899999999999,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21433,null,"See CPT",null,3108.41,null,3108.41,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21435,null,"See CPT",null,2539.1,null,2539.1,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21436,null,"See CPT",null,3659.04,null,3659.04,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
[21440,null,"See CPT",null,1391.17,null,1110.5999999999999,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21445,null,"See CPT",null,1418.59,null,1146.18,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21450,null,"See CPT",null,1093.0999999999999,null,888.37,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21451,null,"See CPT",null,1421.5,null,1181.77,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21452,null,"See CPT",null,1335.76,null,838.2,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21453,null,"See CPT",null,1994.3,null,1693.9,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21454,null,"See CPT",null,906.45,null,906.45,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[21461,null,"See CPT",null,3277.56,null,1909.14,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[21462,null,"See CPT",null,3574.46,null,2117.96,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21465,null,"See CPT",null,1466.42,null,1466.42,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21470,null,"See CPT",null,2106.88,null,2106.88,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21480,null,"See CPT",null,258.39999999999998,null,55.41,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[21485,null,"See CPT",null,1751.65,null,1428.5,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[21490,null,"See CPT",null,1446,null,1446,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[21497,null,"See CPT",null,1312.43,null,1088.44,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,897.7,null,622.38,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21502,null,"See CPT",null,908.2,null,908.2,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21510,null,"See CPT",null,814.29,null,814.29,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[21550,null,"See CPT",null,485.89,null,282.89999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[21552,null,"See CPT",null,808.45,null,808.45,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21554,null,"See CPT",null,1315.34,null,1315.34,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21555,null,"See CPT",null,792.7,null,563.47,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[21556,null,"See CPT",null,960.11,null,960.11,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[21557,null,"See CPT",null,1706.74,null,1706.74,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,1042.94,null,1042.94,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21601,null,"See CPT",null,2025.22,null,2025.22,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[21602,null,"See CPT",null,2745.59,null,2745.59,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[21603,null,"See CPT",null,2967.25,null,2967.25,null,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R"]
[21610,null,"See CPT",null,2159.96,null,2159.96,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21615,null,"See CPT",null,1098.94,null,1098.94,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[21616,null,"See CPT",null,1244.76,null,1244.76,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[21620,null,"See CPT",null,901.78,null,901.78,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21627,null,"See CPT",null,991.61,null,991.61,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21630,null,"See CPT",null,2368.7800000000002,null,2368.7800000000002,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,620.63,null,620.63,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[21705,null,"See CPT",null,921.03,null,921.03,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[21720,null,"See CPT",null,974.69,null,974.69,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21725,null,"See CPT",null,996.86,null,996.86,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[21740,null,"See CPT",null,1791.9,null,1791.9,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,1187.5999999999999,null,1187.5999999999999,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[21811,null,"See CPT",null,1028.3599999999999,null,1028.3599999999999,null,0,0,0,0,0,2,1,2,0,0,null,"R"]
[21812,null,"See CPT",null,1246.51,null,1246.51,null,0,0,0,0,0,2,1,2,0,0,null,"R"]
[21813,null,"See CPT",null,1702.65,null,1702.65,null,0,0,0,0,0,2,1,2,0,0,null,"R"]
[21820,null,"See CPT",null,288.73,null,286.39999999999998,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21825,null,"See CPT",null,996.86,null,996.86,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,466.64,null,281.73,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[21925,null,"See CPT",null,908.2,null,695.29,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21930,null,"See CPT",null,917.53,null,664.96,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[21931,null,"See CPT",null,849.28,null,849.28,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[21932,null,"See CPT",null,1199.26,null,1199.26,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21933,null,"See CPT",null,1324.67,null,1324.67,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[21935,null,"See CPT",null,1816.4,null,1816.4,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,1760.4,null,1760.4,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[22015,null,"See CPT",null,1720.15,null,1720.15,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[22100,null,"See CPT",null,1717.24,null,1717.24,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22101,null,"See CPT",null,1614.57,null,1614.57,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22102,null,"See CPT",null,1380.67,null,1380.67,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22103,null,"See CPT",null,232.74,null,232.74,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22110,null,"See CPT",null,1903.31,null,1903.31,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22112,null,"See CPT",null,2051.4699999999998,null,2051.4699999999998,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22114,null,"See CPT",null,2051.4699999999998,null,2051.4699999999998,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22116,null,"See CPT",null,246.74,null,246.74,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22206,null,"See CPT",null,4346.75,null,4346.75,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22207,null,"See CPT",null,4247.59,null,4247.59,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22208,null,"See CPT",null,1024.8599999999999,null,1024.8599999999999,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22210,null,"See CPT",null,3197.07,null,3197.07,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22212,null,"See CPT",null,2726.93,null,2726.93,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22214,null,"See CPT",null,2723.43,null,2723.43,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22216,null,"See CPT",null,632.29999999999995,null,632.29999999999995,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22220,null,"See CPT",null,2917.67,null,2917.67,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22222,null,"See CPT",null,3152.15,null,3152.15,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22224,null,"See CPT",null,2848.84,null,2848.84,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22226,null,"See CPT",null,627.63,null,627.63,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22310,null,"See CPT",null,577.47,null,551.22,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[22315,null,"See CPT",null,1664.74,null,1429.67,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[22318,null,"See CPT",null,2940.42,null,2940.42,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22319,null,"See CPT",null,3257.15,null,3257.15,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22325,null,"See CPT",null,2660.43,null,2660.43,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22326,null,"See CPT",null,2702.43,null,2702.43,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22327,null,"See CPT",null,2761.34,null,2761.34,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22328,null,"See CPT",null,489.39,null,489.39,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR"]
[22505,null,"See CPT",null,267.73,null,267.73,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,3191.23,null,3191.23,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22533,null,"See CPT",null,2973.08,null,2973.08,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22534,null,"See CPT",null,628.21,null,628.21,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22548,null,"See CPT",null,3495.13,null,3495.13,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22551,null,"See CPT",null,3018.58,null,3018.58,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22552,null,"See CPT",null,688.29,null,688.29,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22554,null,"See CPT",null,2259.12,null,2259.12,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22556,null,"See CPT",null,3002.25,null,3002.25,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22558,null,"See CPT",null,2712.35,null,2712.35,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22585,null,"See CPT",null,562.88,null,562.88,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22586,null,"See CPT",null,3612.38,null,3612.38,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22590,null,"See CPT",null,2847.09,null,2847.09,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22595,null,"See CPT",null,2721.68,null,2721.68,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22600,null,"See CPT",null,2343.6999999999998,null,2343.6999999999998,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22610,null,"See CPT",null,2309.87,null,2309.87,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22612,null,"See CPT",null,2817.34,null,2817.34,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22614,null,"See CPT",null,679.54,null,679.54,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22630,null,"See CPT",null,2784.09,null,2784.09,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22632,null,"See CPT",null,555.88,null,555.88,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22633,null,"See CPT",null,3217.48,null,3217.48,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22634,null,"See CPT",null,841.7,null,841.7,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22800,null,"See CPT",null,2455.69,null,2455.69,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22802,null,"See CPT",null,3747.7,null,3747.7,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22804,null,"See CPT",null,4297.75,null,4297.75,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22808,null,"See CPT",null,3227.4,null,3227.4,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22810,null,"See CPT",null,3586.13,null,3586.13,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22812,null,"See CPT",null,3932.03,null,3932.03,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22818,null,"See CPT",null,3829.36,null,3829.36,null,90,0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22819,null,"See CPT",null,4408.58,null,4408.58,null,90,0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22830,null,"See CPT",null,1485.67,null,1485.67,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,1311.84,null,1311.84,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,1325.84,null,1325.84,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22843,null,"See CPT",null,1420.34,null,1420.34,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22844,null,"See CPT",null,1717.82,null,1717.82,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22845,null,"See CPT",null,1259.93,null,1259.93,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22846,null,"See CPT",null,1311.84,null,1311.84,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22847,null,"See CPT",null,1401.09,null,1401.09,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22848,null,"See CPT",null,626.46,null,626.46,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22849,null,"See CPT",null,2330.87,null,2330.87,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22850,null,"See CPT",null,1332.84,null,1332.84,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22852,null,"See CPT",null,1283.8399999999999,null,1283.8399999999999,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22853,null,"See CPT",null,447.39,null,447.39,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22854,null,"See CPT",null,582.13,null,582.13,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22855,null,"See CPT",null,1980.3,null,1980.3,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22856,null,"See CPT",null,2887.34,null,2887.34,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22857,null,"See CPT",null,3124.74,null,3124.74,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22858,null,"See CPT",null,881.95,null,881.95,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22859,null,"See CPT",null,581.54999999999995,null,581.54999999999995,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,4091.85,null,4091.85,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22862,null,"See CPT",null,4102.3500000000004,null,4102.3500000000004,null,90,0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22864,null,"See CPT",null,3659.62,null,3659.62,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[22865,null,"See CPT",null,4007.27,null,4007.27,null,90,0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[22867,null,"See CPT",null,1900.39,null,1900.39,null,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[22868,null,"See CPT",null,419.98,null,419.98,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[22869,null,"See CPT",null,779.87,null,779.87,null,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[22870,null,"See CPT",null,207.07,null,207.07,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,1023.69,null,1023.69,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22901,null,"See CPT",null,1197.51,null,1197.51,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22902,null,"See CPT",null,860.37,null,609.54999999999995,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[22903,null,"See CPT",null,795.62,null,795.62,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,1021.36,null,663.8,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23020,null,"See CPT",null,1266.3399999999999,null,1266.3399999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23030,null,"See CPT",null,803.79,null,465.47,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[23031,null,"See CPT",null,792.7,null,410.06,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[23035,null,"See CPT",null,1245.93,null,1245.93,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23040,null,"See CPT",null,1312.43,null,1312.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23044,null,"See CPT",null,1026.02,null,1026.02,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,1062.19,null,688.88,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[23071,null,"See CPT",null,764.12,null,764.12,null,90,0.1,0.8,0.1,0,2,1,2,0,0,null,"R"]
[23073,null,"See CPT",null,1260.51,null,1260.51,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[23075,null,"See CPT",null,940.28,null,604.29999999999995,null,90,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23076,null,"See CPT",null,995.69,null,995.69,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,940.86,null,940.86,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23101,null,"See CPT",null,848.12,null,848.12,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23105,null,"See CPT",null,1178.8499999999999,null,1178.8499999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23106,null,"See CPT",null,933.86,null,933.86,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23107,null,"See CPT",null,1220.26,null,1220.26,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23120,null,"See CPT",null,1086.0999999999999,null,1086.0999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23125,null,"See CPT",null,1301.3399999999999,null,1301.3399999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23130,null,"See CPT",null,1142.0999999999999,null,1142.0999999999999,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23140,null,"See CPT",null,1026.02,null,1026.02,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[23145,null,"See CPT",null,1276.26,null,1276.26,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23146,null,"See CPT",null,1151.43,null,1151.43,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[23150,null,"See CPT",null,1226.0999999999999,null,1226.0999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23155,null,"See CPT",null,1460,null,1460,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23156,null,"See CPT",null,1248.8499999999999,null,1248.8499999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23170,null,"See CPT",null,1043.52,null,1043.52,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[23172,null,"See CPT",null,1054.02,null,1054.02,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23174,null,"See CPT",null,1405.17,null,1405.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23180,null,"See CPT",null,1269.26,null,1269.26,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23182,null,"See CPT",null,1239.51,null,1239.51,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23184,null,"See CPT",null,1355.59,null,1355.59,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23190,null,"See CPT",null,1061.6099999999999,null,1061.6099999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23195,null,"See CPT",null,1369.59,null,1369.59,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,554.14,null,310.32,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[23333,null,"See CPT",null,878.45,null,878.45,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[23334,null,"See CPT",null,1924.31,null,1924.31,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23335,null,"See CPT",null,2280.12,null,2280.12,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23350,null,"See CPT",null,291.07,null,87.5,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[23395,null,"See CPT",null,2323.87,null,2323.87,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[23397,null,"See CPT",null,2053.8000000000002,null,2053.8000000000002,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[23400,null,"See CPT",null,1765.07,null,1765.07,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23405,null,"See CPT",null,1124.02,null,1124.02,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[23406,null,"See CPT",null,1346.84,null,1346.84,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[23410,null,"See CPT",null,1495,null,1495,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23412,null,"See CPT",null,1552.16,null,1552.16,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23415,null,"See CPT",null,1286.76,null,1286.76,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[23420,null,"See CPT",null,1776.15,null,1776.15,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23430,null,"See CPT",null,1360.84,null,1360.84,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23440,null,"See CPT",null,1378.92,null,1378.92,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23450,null,"See CPT",null,1713.74,null,1713.74,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23455,null,"See CPT",null,1757.48,null,1757.48,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23460,null,"See CPT",null,1972.14,null,1972.14,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23462,null,"See CPT",null,1927.81,null,1927.81,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23465,null,"See CPT",null,2021.13,null,2021.13,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23466,null,"See CPT",null,2031.05,null,2031.05,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23470,null,"See CPT",null,2158.21,null,2158.21,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23472,null,"See CPT",null,2592.19,null,2592.19,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23473,null,"See CPT",null,2879.17,null,2879.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23474,null,"See CPT",null,3105.49,null,3105.49,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23480,null,"See CPT",null,1495,null,1495,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[23485,null,"See CPT",null,1726.57,null,1726.57,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23490,null,"See CPT",null,1566.16,null,1566.16,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[23491,null,"See CPT",null,1842.64,null,1842.64,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23500,null,"See CPT",null,431.64,null,442.72,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23505,null,"See CPT",null,687.71,null,635.79999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23515,null,"See CPT",null,1321.17,null,1321.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23520,null,"See CPT",null,465.47,null,461.97,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23525,null,"See CPT",null,762.37,null,694.13,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23530,null,"See CPT",null,1062.77,null,1062.77,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[23532,null,"See CPT",null,1155.52,null,1155.52,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[23540,null,"See CPT",null,456.72,null,453.81,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23545,null,"See CPT",null,693.54,null,618.29999999999995,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23550,null,"See CPT",null,1052.27,null,1052.27,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23552,null,"See CPT",null,1185.8499999999999,null,1185.8499999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23570,null,"See CPT",null,453.22,null,469.56,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23575,null,"See CPT",null,782.79,null,720.96,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[23585,null,"See CPT",null,1767.98,null,1767.98,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23600,null,"See CPT",null,644.54999999999995,null,609.54999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23605,null,"See CPT",null,888.95,null,802.62,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23615,null,"See CPT",null,1610.49,null,1610.49,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23616,null,"See CPT",null,2225.29,null,2225.29,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[23620,null,"See CPT",null,523.79999999999995,null,500.47,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23625,null,"See CPT",null,725.63,null,660.88,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23630,null,"See CPT",null,1432,null,1432,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23650,null,"See CPT",null,637.54999999999995,null,572.22,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23655,null,"See CPT",null,763.54,null,763.54,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23660,null,"See CPT",null,1078.52,null,1078.52,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23665,null,"See CPT",null,827.12,null,755.96,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23670,null,"See CPT",null,1591.83,null,1591.83,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23675,null,"See CPT",null,1039.44,null,934.45,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[23680,null,"See CPT",null,1693.32,null,1693.32,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[23700,null,"See CPT",null,360.48,null,360.48,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23800,null,"See CPT",null,1860.73,null,1860.73,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23802,null,"See CPT",null,2322.6999999999998,null,2322.6999999999998,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23900,null,"See CPT",null,2491.27,null,2491.27,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[23920,null,"See CPT",null,2033.38,null,2033.38,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[23921,null,"See CPT",null,875.53,null,875.53,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[23929,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"]
[23930,null,"See CPT",null,655.63,null,393.73,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23931,null,"See CPT",null,553.54999999999995,null,297.48,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[23935,null,"See CPT",null,951.95,null,951.95,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24000,null,"See CPT",null,888.37,null,888.37,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,"Y-UR"]
[24006,null,"See CPT",null,1311.84,null,1311.84,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,"Y-UR"]
[24065,null,"See CPT",null,474.22,null,297.48,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[24066,null,"See CPT",null,1159.02,null,783.37,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24071,null,"See CPT",null,737.87,null,737.87,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24073,null,"See CPT",null,1255.26,null,1255.26,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24075,null,"See CPT",null,968.28,null,607.22,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24076,null,"See CPT",null,1002.11,null,1002.11,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,783.37,null,783.37,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24101,null,"See CPT",null,935.03,null,935.03,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24102,null,"See CPT",null,1136.27,null,1136.27,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24105,null,"See CPT",null,678.96,null,678.96,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24110,null,"See CPT",null,1091.94,null,1091.94,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24115,null,"See CPT",null,1349.76,null,1349.76,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24116,null,"See CPT",null,1563.83,null,1563.83,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24120,null,"See CPT",null,989.28,null,989.28,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24125,null,"See CPT",null,1149.0999999999999,null,1149.0999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24126,null,"See CPT",null,1198.68,null,1198.68,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24130,null,"See CPT",null,952.53,null,952.53,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[24134,null,"See CPT",null,1369.59,null,1369.59,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24136,null,"See CPT",null,1164.8499999999999,null,1164.8499999999999,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24138,null,"See CPT",null,1272.76,null,1272.76,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24140,null,"See CPT",null,1289.68,null,1289.68,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[24145,null,"See CPT",null,1096.02,null,1096.02,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24147,null,"See CPT",null,1163.0999999999999,null,1163.0999999999999,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24149,null,"See CPT",null,2152.96,null,2152.96,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,1549.24,null,1549.24,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24160,null,"See CPT",null,2265.54,null,2265.54,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24164,null,"See CPT",null,1327.01,null,1327.01,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[24200,null,"See CPT",null,410.06,null,263.64999999999998,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[24201,null,"See CPT",null,1136.27,null,745.46,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24220,null,"See CPT",null,344.15,null,116.66,null,0,0,0,0,0,2,1,0,0,0,null,"R"]
[24300,null,"See CPT",null,837.04,null,837.04,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24301,null,"See CPT",null,1371.92,null,1371.92,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[24305,null,"See CPT",null,1072.1099999999999,null,1072.1099999999999,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[24310,null,"See CPT",null,871.45,null,871.45,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[24320,null,"See CPT",null,1425.59,null,1425.59,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[24330,null,"See CPT",null,1315.92,null,1315.92,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24331,null,"See CPT",null,1434.33,null,1434.33,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24332,null,"See CPT",null,1138.5999999999999,null,1138.5999999999999,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[24340,null,"See CPT",null,1115.8499999999999,null,1115.8499999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24341,null,"See CPT",null,1381.84,null,1381.84,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24342,null,"See CPT",null,1413.92,null,1413.92,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24343,null,"See CPT",null,1322.92,null,1322.92,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24344,null,"See CPT",null,2012.97,null,2012.97,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24345,null,"See CPT",null,1309.51,null,1309.51,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24346,null,"See CPT",null,2012.97,null,2012.97,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24357,null,"See CPT",null,768.79,null,768.79,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24358,null,"See CPT",null,985.19,null,985.19,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24359,null,"See CPT",null,1219.68,null,1219.68,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24360,null,"See CPT",null,1642.57,null,1642.57,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24361,null,"See CPT",null,1829.23,null,1829.23,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24362,null,"See CPT",null,1921.39,null,1921.39,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24363,null,"See CPT",null,2606.77,null,2606.77,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24365,null,"See CPT",null,1178.27,null,1178.27,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24366,null,"See CPT",null,1250.01,null,1250.01,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24370,null,"See CPT",null,2763.68,null,2763.68,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24371,null,"See CPT",null,3162.65,null,3162.65,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24400,null,"See CPT",null,1511.91,null,1511.91,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,1934.22,null,1934.22,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24430,null,"See CPT",null,1914.97,null,1914.97,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24435,null,"See CPT",null,1966.3,null,1966.3,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24470,null,"See CPT",null,1236.01,null,1236.01,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24495,null,"See CPT",null,1680.49,null,1680.49,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24498,null,"See CPT",null,1570.83,null,1570.83,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24500,null,"See CPT",null,697.63,null,640.46,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24505,null,"See CPT",null,953.7,null,848.7,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24515,null,"See CPT",null,1606.99,null,1606.99,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24516,null,"See CPT",null,1561.49,null,1561.49,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[24530,null,"See CPT",null,734.96,null,670.21,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24535,null,"See CPT",null,1170.0999999999999,null,1069.19,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24538,null,"See CPT",null,1448.33,null,1448.33,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24545,null,"See CPT",null,1690.99,null,1690.99,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24546,null,"See CPT",null,1884.64,null,1884.64,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[24560,null,"See CPT",null,641.04999999999995,null,565.79999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24565,null,"See CPT",null,1024.27,null,931.53,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24566,null,"See CPT",null,1332.84,null,1332.84,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24575,null,"See CPT",null,1350.34,null,1350.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24576,null,"See CPT",null,678.96,null,603.13,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24577,null,"See CPT",null,1053.44,null,956.03,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24579,null,"See CPT",null,1530,null,1530,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24582,null,"See CPT",null,1508.41,null,1508.41,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24586,null,"See CPT",null,1962.22,null,1962.22,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24587,null,"See CPT",null,1968.64,null,1968.64,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24600,null,"See CPT",null,716.29,null,646.29999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24605,null,"See CPT",null,890.12,null,890.12,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24615,null,"See CPT",null,1306.5899999999999,null,1306.5899999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24620,null,"See CPT",null,1095.44,null,1095.44,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[24635,null,"See CPT",null,1250.01,null,1250.01,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,513.89,null,477.72,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24655,null,"See CPT",null,855.12,null,766.46,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24665,null,"See CPT",null,1216.76,null,1216.76,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24666,null,"See CPT",null,1343.92,null,1343.92,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24670,null,"See CPT",null,565.79999999999995,null,515.04999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24675,null,"See CPT",null,870.28,null,785.12,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[24685,null,"See CPT",null,1206.26,null,1206.26,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[24800,null,"See CPT",null,1523.58,null,1523.58,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24802,null,"See CPT",null,1819.9,null,1819.9,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24900,null,"See CPT",null,1399.34,null,1399.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24920,null,"See CPT",null,1340.42,null,1340.42,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[24925,null,"See CPT",null,1052.8599999999999,null,1052.8599999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24930,null,"See CPT",null,1411,null,1411,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24931,null,"See CPT",null,1688.07,null,1688.07,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[24935,null,"See CPT",null,2211.87,null,2211.87,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[24940,null,"See CPT",null,2095.27,null,2095.27,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,653.88,null,653.88,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25001,null,"See CPT",null,659.13,null,659.13,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25020,null,"See CPT",null,1354.42,null,1354.42,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25023,null,"See CPT",null,2384.5300000000002,null,2384.5300000000002,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[25024,null,"See CPT",null,1419.17,null,1419.17,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25025,null,"See CPT",null,2217.12,null,2217.12,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[25028,null,"See CPT",null,1268.0899999999999,null,1268.0899999999999,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25031,null,"See CPT",null,690.04,null,690.04,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25035,null,"See CPT",null,1087.8499999999999,null,1087.8499999999999,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25040,null,"See CPT",null,1031.27,null,1031.27,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25065,null,"See CPT",null,467.81,null,288.73,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[25066,null,"See CPT",null,694.13,null,694.13,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25071,null,"See CPT",null,774.62,null,774.62,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25073,null,"See CPT",null,985.78,null,985.78,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25075,null,"See CPT",null,946.7,null,584.47,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25076,null,"See CPT",null,958.95,null,958.95,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,835.29,null,835.29,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25100,null,"See CPT",null,656.21,null,656.21,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25101,null,"See CPT",null,760.04,null,760.04,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25105,null,"See CPT",null,908.2,null,908.2,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25107,null,"See CPT",null,1152.02,null,1152.02,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25109,null,"See CPT",null,995.69,null,995.69,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25110,null,"See CPT",null,648.63,null,648.63,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[25111,null,"See CPT",null,614.21,null,614.21,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25112,null,"See CPT",null,732.62,null,732.62,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25115,null,"See CPT",null,1397,null,1397,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25116,null,"See CPT",null,1123.44,null,1123.44,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25118,null,"See CPT",null,718.63,null,718.63,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25119,null,"See CPT",null,933.28,null,933.28,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25120,null,"See CPT",null,932.7,null,932.7,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25125,null,"See CPT",null,1101.27,null,1101.27,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25126,null,"See CPT",null,1108.27,null,1108.27,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25130,null,"See CPT",null,845.79,null,845.79,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25135,null,"See CPT",null,1041.19,null,1041.19,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25136,null,"See CPT",null,925.7,null,925.7,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25145,null,"See CPT",null,967.11,null,967.11,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25150,null,"See CPT",null,1050.52,null,1050.52,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25151,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"]
[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,918.7,null,918.7,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[25215,null,"See CPT",null,1145.5999999999999,null,1145.5999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25230,null,"See CPT",null,809.04,null,809.04,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25240,null,"See CPT",null,803.2,null,803.2,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25246,null,"See CPT",null,349.98,null,127.74,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[25248,null,"See CPT",null,772.29,null,772.29,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25250,null,"See CPT",null,989.28,null,989.28,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25251,null,"See CPT",null,1318.26,null,1318.26,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25259,null,"See CPT",null,795.62,null,795.62,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25260,null,"See CPT",null,1177.68,null,1177.68,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[25263,null,"See CPT",null,1172.43,null,1172.43,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[25265,null,"See CPT",null,1382.42,null,1382.42,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[25270,null,"See CPT",null,919.86,null,919.86,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[25272,null,"See CPT",null,1034.77,null,1034.77,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[25274,null,"See CPT",null,1228.43,null,1228.43,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[25275,null,"See CPT",null,1240.68,null,1240.68,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[25280,null,"See CPT",null,1048.19,null,1048.19,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[25290,null,"See CPT",null,814.29,null,814.29,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[25295,null,"See CPT",null,978.19,null,978.19,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[25300,null,"See CPT",null,1272.76,null,1272.76,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25301,null,"See CPT",null,1186.43,null,1186.43,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25310,null,"See CPT",null,1317.09,null,1317.09,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[25312,null,"See CPT",null,1318.84,null,1318.84,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[25315,null,"See CPT",null,1405.75,null,1405.75,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25316,null,"See CPT",null,1667.07,null,1667.07,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25320,null,"See CPT",null,1826.31,null,1826.31,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[25332,null,"See CPT",null,1547.49,null,1547.49,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,1636.74,null,1636.74,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25350,null,"See CPT",null,1241.26,null,1241.26,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25355,null,"See CPT",null,1399.92,null,1399.92,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25360,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"]
[25365,null,"See CPT",null,1668.24,null,1668.24,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25370,null,"See CPT",null,1842.64,null,1842.64,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25375,null,"See CPT",null,1733.57,null,1733.57,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25390,null,"See CPT",null,1408.67,null,1408.67,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25391,null,"See CPT",null,1807.65,null,1807.65,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25392,null,"See CPT",null,1838.56,null,1838.56,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25393,null,"See CPT",null,2039.8,null,2039.8,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25394,null,"See CPT",null,1435.5,null,1435.5,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25400,null,"See CPT",null,1465.83,null,1465.83,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25405,null,"See CPT",null,1885.23,null,1885.23,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25415,null,"See CPT",null,1757.48,null,1757.48,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25420,null,"See CPT",null,2107.46,null,2107.46,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25425,null,"See CPT",null,1749.32,null,1749.32,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25426,null,"See CPT",null,2028.13,null,2028.13,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25430,null,"See CPT",null,1346.26,null,1346.26,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25431,null,"See CPT",null,1440.75,null,1440.75,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25440,null,"See CPT",null,1408.67,null,1408.67,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25441,null,"See CPT",null,1706.15,null,1706.15,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25442,null,"See CPT",null,1485.08,null,1485.08,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25443,null,"See CPT",null,1437.83,null,1437.83,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25444,null,"See CPT",null,1517.16,null,1517.16,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25445,null,"See CPT",null,1323.51,null,1323.51,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25446,null,"See CPT",null,2122.63,null,2122.63,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25447,null,"See CPT",null,1472.25,null,1472.25,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25448,null,"See CPT",null,1623.32,null,1623.32,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25449,null,"See CPT",null,1877.06,null,1877.06,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25450,null,"See CPT",null,1140.3499999999999,null,1140.3499999999999,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[25455,null,"See CPT",null,1341.59,null,1341.59,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[25490,null,"See CPT",null,1318.26,null,1318.26,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25491,null,"See CPT",null,1353.84,null,1353.84,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25492,null,"See CPT",null,1651.32,null,1651.32,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25500,null,"See CPT",null,551.79999999999995,null,498.72,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25505,null,"See CPT",null,961.86,null,867.37,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25515,null,"See CPT",null,1237.18,null,1237.18,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25520,null,"See CPT",null,1087.27,null,1022.52,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25525,null,"See CPT",null,1451.83,null,1451.83,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[25526,null,"See CPT",null,1746.4,null,1746.4,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[25530,null,"See CPT",null,516.22,null,473.06,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25535,null,"See CPT",null,936.2,null,860.37,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25545,null,"See CPT",null,1158.43,null,1158.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25560,null,"See CPT",null,562.29999999999995,null,501.05,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25565,null,"See CPT",null,980.53,null,868.53,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25574,null,"See CPT",null,1247.68,null,1247.68,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[25575,null,"See CPT",null,1655.99,null,1655.99,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25600,null,"See CPT",null,657.38,null,629.96,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25605,null,"See CPT",null,1016.69,null,956.03,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25606,null,"See CPT",null,1241.26,null,1241.26,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25607,null,"See CPT",null,1369.59,null,1369.59,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25608,null,"See CPT",null,1523,null,1523,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25609,null,"See CPT",null,1927.81,null,1927.81,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25622,null,"See CPT",null,596.13,null,548.29999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25624,null,"See CPT",null,938.53,null,846.95,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25628,null,"See CPT",null,1325.26,null,1325.26,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25630,null,"See CPT",null,589.72,null,547.14,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25635,null,"See CPT",null,889.53,null,803.79,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25645,null,"See CPT",null,1055.77,null,1055.77,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25650,null,"See CPT",null,632.88,null,586.22,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25651,null,"See CPT",null,916.36,null,916.36,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25652,null,"See CPT",null,1155.52,null,1155.52,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[25660,null,"See CPT",null,848.7,null,848.7,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25670,null,"See CPT",null,1117.02,null,1117.02,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25671,null,"See CPT",null,998.03,null,998.03,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[25675,null,"See CPT",null,871.45,null,782.21,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25676,null,"See CPT",null,1163.68,null,1163.68,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25680,null,"See CPT",null,995.11,null,995.11,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25685,null,"See CPT",null,1346.84,null,1346.84,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25690,null,"See CPT",null,922.78,null,922.78,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25695,null,"See CPT",null,1166.5999999999999,null,1166.5999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[25800,null,"See CPT",null,1342.17,null,1342.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25805,null,"See CPT",null,1546.91,null,1546.91,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25810,null,"See CPT",null,1590.66,null,1590.66,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25820,null,"See CPT",null,1199.26,null,1199.26,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25825,null,"See CPT",null,1461.17,null,1461.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25830,null,"See CPT",null,1880.56,null,1880.56,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[25900,null,"See CPT",null,1322.92,null,1322.92,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25905,null,"See CPT",null,1285.01,null,1285.01,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25907,null,"See CPT",null,1132.77,null,1132.77,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25909,null,"See CPT",null,1257.5899999999999,null,1257.5899999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25915,null,"See CPT",null,2102.8000000000002,null,2102.8000000000002,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25920,null,"See CPT",null,1338.67,null,1338.67,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25922,null,"See CPT",null,1188.18,null,1188.18,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25924,null,"See CPT",null,1306.5899999999999,null,1306.5899999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25927,null,"See CPT",null,1577.24,null,1577.24,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[25929,null,"See CPT",null,1104.77,null,1104.77,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[25931,null,"See CPT",null,1460,null,1460,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,620.63,null,260.14999999999998,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[26011,null,"See CPT",null,867.37,null,341.23,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[26020,null,"See CPT",null,1033.02,null,1033.02,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26025,null,"See CPT",null,776.96,null,776.96,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26030,null,"See CPT",null,911.7,null,911.7,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26034,null,"See CPT",null,1027.19,null,1027.19,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26035,null,"See CPT",null,1579.58,null,1579.58,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26037,null,"See CPT",null,1036.52,null,1036.52,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26040,null,"See CPT",null,596.72,null,596.72,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26045,null,"See CPT",null,881.95,null,881.95,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26055,null,"See CPT",null,1085.52,null,550.04999999999995,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26060,null,"See CPT",null,476.56,null,476.56,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26070,null,"See CPT",null,605.47,null,605.47,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26075,null,"See CPT",null,635.21,null,635.21,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26080,null,"See CPT",null,749.54,null,749.54,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26100,null,"See CPT",null,638.71,null,638.71,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26105,null,"See CPT",null,642.79999999999995,null,642.79999999999995,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26110,null,"See CPT",null,611.88,null,611.88,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26111,null,"See CPT",null,769.96,null,769.96,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26113,null,"See CPT",null,1013.19,null,1013.19,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26115,null,"See CPT",null,1013.19,null,621.79999999999995,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26116,null,"See CPT",null,974.69,null,974.69,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,1110.02,null,1110.02,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26123,null,"See CPT",null,1546.91,null,1546.91,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26125,null,"See CPT",null,474.81,null,474.81,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[26130,null,"See CPT",null,874.95,null,874.95,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26135,null,"See CPT",null,1028.3599999999999,null,1028.3599999999999,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26140,null,"See CPT",null,944.95,null,944.95,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26145,null,"See CPT",null,960.7,null,960.7,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26160,null,"See CPT",null,1132.19,null,593.79999999999995,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26170,null,"See CPT",null,762.37,null,762.37,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26180,null,"See CPT",null,843.45,null,843.45,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26185,null,"See CPT",null,1041.77,null,1041.77,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26200,null,"See CPT",null,838.79,null,838.79,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26205,null,"See CPT",null,1115.27,null,1115.27,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26210,null,"See CPT",null,838.2,null,838.2,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26215,null,"See CPT",null,1047.02,null,1047.02,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26230,null,"See CPT",null,928.03,null,928.03,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26235,null,"See CPT",null,915.2,null,915.2,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26236,null,"See CPT",null,823.62,null,823.62,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26250,null,"See CPT",null,1933.06,null,1933.06,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26260,null,"See CPT",null,1453.58,null,1453.58,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26262,null,"See CPT",null,1162.52,null,1162.52,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26320,null,"See CPT",null,655.04999999999995,null,655.04999999999995,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26340,null,"See CPT",null,686.54,null,686.54,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26341,null,"See CPT",null,217.57,null,144.08000000000001,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[26350,null,"See CPT",null,1377.17,null,1377.17,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26352,null,"See CPT",null,1526.5,null,1526.5,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26356,null,"See CPT",null,1471.67,null,1471.67,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26357,null,"See CPT",null,1638.49,null,1638.49,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26358,null,"See CPT",null,1801.81,null,1801.81,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26370,null,"See CPT",null,1440.75,null,1440.75,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26372,null,"See CPT",null,1672.32,null,1672.32,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26373,null,"See CPT",null,1611.07,null,1611.07,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26390,null,"See CPT",null,1601.74,null,1601.74,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26392,null,"See CPT",null,1823.98,null,1823.98,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26410,null,"See CPT",null,1109.44,null,1109.44,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26412,null,"See CPT",null,1313.01,null,1313.01,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26415,null,"See CPT",null,1555.08,null,1555.08,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26416,null,"See CPT",null,1681.65,null,1681.65,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26418,null,"See CPT",null,1156.68,null,1156.68,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26420,null,"See CPT",null,1359.09,null,1359.09,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26426,null,"See CPT",null,937.36,null,937.36,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26428,null,"See CPT",null,1461.75,null,1461.75,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26432,null,"See CPT",null,1009.11,null,1009.11,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26433,null,"See CPT",null,1053.44,null,1053.44,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26434,null,"See CPT",null,1279.18,null,1279.18,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26437,null,"See CPT",null,1230.18,null,1230.18,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26440,null,"See CPT",null,1198.68,null,1198.68,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26442,null,"See CPT",null,1822.23,null,1822.23,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26445,null,"See CPT",null,1117.02,null,1117.02,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26449,null,"See CPT",null,1300.18,null,1300.18,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26450,null,"See CPT",null,862.12,null,862.12,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26455,null,"See CPT",null,855.7,null,855.7,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26460,null,"See CPT",null,838.79,null,838.79,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26471,null,"See CPT",null,1219.68,null,1219.68,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26474,null,"See CPT",null,1201.01,null,1201.01,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26476,null,"See CPT",null,1186.43,null,1186.43,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26477,null,"See CPT",null,1160.77,null,1160.77,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[26478,null,"See CPT",null,1215.5999999999999,null,1215.5999999999999,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26479,null,"See CPT",null,1244.18,null,1244.18,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26480,null,"See CPT",null,1318.26,null,1318.26,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26483,null,"See CPT",null,1596.49,null,1596.49,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26485,null,"See CPT",null,1535.83,null,1535.83,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26489,null,"See CPT",null,1759.23,null,1759.23,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26490,null,"See CPT",null,1537.58,null,1537.58,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26492,null,"See CPT",null,1696.82,null,1696.82,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26494,null,"See CPT",null,1543.41,null,1543.41,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26496,null,"See CPT",null,1655.41,null,1655.41,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26497,null,"See CPT",null,1653.66,null,1653.66,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26498,null,"See CPT",null,2140.71,null,2140.71,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26499,null,"See CPT",null,1595.33,null,1595.33,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26500,null,"See CPT",null,1266.3399999999999,null,1266.3399999999999,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26502,null,"See CPT",null,1385.92,null,1385.92,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26508,null,"See CPT",null,1245.3499999999999,null,1245.3499999999999,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26510,null,"See CPT",null,1182.93,null,1182.93,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26516,null,"See CPT",null,1368.42,null,1368.42,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26517,null,"See CPT",null,1586.58,null,1586.58,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26518,null,"See CPT",null,1605.24,null,1605.24,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26520,null,"See CPT",null,1253.51,null,1253.51,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26525,null,"See CPT",null,1262.26,null,1262.26,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[26530,null,"See CPT",null,1007.94,null,1007.94,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26531,null,"See CPT",null,1171.8499999999999,null,1171.8499999999999,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26535,null,"See CPT",null,823.62,null,823.62,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26536,null,"See CPT",null,1381.25,null,1381.25,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26540,null,"See CPT",null,1288.51,null,1288.51,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R"]
[26541,null,"See CPT",null,1535.25,null,1535.25,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26542,null,"See CPT",null,1329.92,null,1329.92,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26545,null,"See CPT",null,1348.59,null,1348.59,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26546,null,"See CPT",null,1919.06,null,1919.06,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26548,null,"See CPT",null,1469.92,null,1469.92,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26550,null,"See CPT",null,2973.66,null,2973.66,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26551,null,"See CPT",null,5880.83,null,5880.83,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[26553,null,"See CPT",null,5841.17,null,5841.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26554,null,"See CPT",null,6792.53,null,6792.53,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26555,null,"See CPT",null,2507.02,null,2507.02,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26556,null,"See CPT",null,6080.9,null,6080.9,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26560,null,"See CPT",null,1171.27,null,1171.27,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26561,null,"See CPT",null,1790.15,null,1790.15,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26562,null,"See CPT",null,2504.11,null,2504.11,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26565,null,"See CPT",null,1312.43,null,1312.43,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26567,null,"See CPT",null,1323.51,null,1323.51,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26568,null,"See CPT",null,1698.57,null,1698.57,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,908.2,null,908.2,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26593,null,"See CPT",null,1191.0999999999999,null,1191.0999999999999,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26596,null,"See CPT",null,1497.91,null,1497.91,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26600,null,"See CPT",null,584.47,null,557.04999999999995,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26605,null,"See CPT",null,634.04999999999995,null,569.88,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26607,null,"See CPT",null,940.28,null,940.28,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26608,null,"See CPT",null,900.62,null,900.62,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26615,null,"See CPT",null,1071.52,null,1071.52,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26641,null,"See CPT",null,801.45,null,727.96,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26645,null,"See CPT",null,823.62,null,747.21,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[26650,null,"See CPT",null,905.86,null,905.86,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[26665,null,"See CPT",null,1166.5999999999999,null,1166.5999999999999,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[26670,null,"See CPT",null,674.29,null,599.63,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26675,null,"See CPT",null,879.03,null,799.12,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26676,null,"See CPT",null,956.61,null,956.61,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26685,null,"See CPT",null,1076.19,null,1076.19,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[26686,null,"See CPT",null,1146.18,null,1146.18,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[26700,null,"See CPT",null,649.79999999999995,null,596.13,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26705,null,"See CPT",null,833.54,null,752.46,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26706,null,"See CPT",null,841.12,null,841.12,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26715,null,"See CPT",null,1066.8599999999999,null,1066.8599999999999,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26720,null,"See CPT",null,392.56,null,367.48,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26725,null,"See CPT",null,655.04999999999995,null,580.97,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26727,null,"See CPT",null,889.53,null,889.53,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26735,null,"See CPT",null,1104.77,null,1104.77,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26740,null,"See CPT",null,453.81,null,428.73,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26742,null,"See CPT",null,711.63,null,635.21,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26746,null,"See CPT",null,1366.67,null,1366.67,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26750,null,"See CPT",null,366.31,null,370.4,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26755,null,"See CPT",null,618.29999999999995,null,525.54999999999995,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26756,null,"See CPT",null,797.37,null,797.37,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26765,null,"See CPT",null,940.86,null,940.86,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26770,null,"See CPT",null,555.29999999999995,null,502.8,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26775,null,"See CPT",null,755.96,null,675.46,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26776,null,"See CPT",null,845.2,null,845.2,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26785,null,"See CPT",null,1023.69,null,1023.69,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26820,null,"See CPT",null,1521.83,null,1521.83,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26841,null,"See CPT",null,1421.5,null,1421.5,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[26842,null,"See CPT",null,1525.91,null,1525.91,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[26843,null,"See CPT",null,1433.75,null,1433.75,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26844,null,"See CPT",null,1575.49,null,1575.49,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26850,null,"See CPT",null,1351.51,null,1351.51,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26852,null,"See CPT",null,1532.33,null,1532.33,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26860,null,"See CPT",null,1133.3499999999999,null,1133.3499999999999,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26861,null,"See CPT",null,179.66,null,179.66,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[26862,null,"See CPT",null,1409.84,null,1409.84,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[26863,null,"See CPT",null,400.14,null,400.14,null,0,0,0,0,0,0,0,2,0,0,null,"R"]
[26910,null,"See CPT",null,1400.5,null,1400.5,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26951,null,"See CPT",null,1302.51,null,1302.51,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26952,null,"See CPT",null,1261.0899999999999,null,1261.0899999999999,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,1243.5999999999999,null,1243.5999999999999,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[26991,null,"See CPT",null,1279.76,null,958.36,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[26992,null,"See CPT",null,1822.81,null,1822.81,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[27000,null,"See CPT",null,717.46,null,717.46,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27001,null,"See CPT",null,989.86,null,989.86,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27003,null,"See CPT",null,1104.19,null,1104.19,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27005,null,"See CPT",null,1320.01,null,1320.01,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27006,null,"See CPT",null,1308.93,null,1308.93,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27025,null,"See CPT",null,1706.15,null,1706.15,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[27027,null,"See CPT",null,1597.66,null,1597.66,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27030,null,"See CPT",null,1694.49,null,1694.49,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27033,null,"See CPT",null,1762.15,null,1762.15,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27035,null,"See CPT",null,2064.3000000000002,null,2064.3000000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27036,null,"See CPT",null,1849.64,null,1849.64,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27040,null,"See CPT",null,618.29999999999995,null,361.65,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27041,null,"See CPT",null,1285.01,null,1285.01,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27043,null,"See CPT",null,847.53,null,847.53,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27045,null,"See CPT",null,1322.34,null,1322.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27047,null,"See CPT",null,898.28,null,657.96,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27048,null,"See CPT",null,1113.52,null,1113.52,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,758.87,null,758.87,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[27052,null,"See CPT",null,1070.94,null,1070.94,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27054,null,"See CPT",null,1262.8399999999999,null,1262.8399999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27057,null,"See CPT",null,1818.73,null,1818.73,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,864.45,null,864.45,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27062,null,"See CPT",null,838.2,null,838.2,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27065,null,"See CPT",null,968.28,null,968.28,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27066,null,"See CPT",null,1495.58,null,1495.58,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27067,null,"See CPT",null,1879.39,null,1879.39,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27070,null,"See CPT",null,1592.41,null,1592.41,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27071,null,"See CPT",null,1759.23,null,1759.23,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27075,null,"See CPT",null,3713.87,null,3713.87,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27076,null,"See CPT",null,4475.66,null,4475.66,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27077,null,"See CPT",null,4984.88,null,4984.88,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27078,null,"See CPT",null,3663.12,null,3663.12,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27080,null,"See CPT",null,925.7,null,925.7,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[27086,null,"See CPT",null,572.79999999999995,null,312.64999999999998,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27087,null,"See CPT",null,1117.02,null,1117.02,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27090,null,"See CPT",null,1506.08,null,1506.08,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27091,null,"See CPT",null,2855.25,null,2855.25,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27093,null,"See CPT",null,413.56,null,120.16,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[27095,null,"See CPT",null,555.88,null,144.08000000000001,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[27096,null,"See CPT",null,300.98,null,148.74,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27097,null,"See CPT",null,1252.93,null,1252.93,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27098,null,"See CPT",null,1276.8399999999999,null,1276.8399999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27100,null,"See CPT",null,1517.16,null,1517.16,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27105,null,"See CPT",null,1587.16,null,1587.16,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27110,null,"See CPT",null,1762.15,null,1762.15,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27111,null,"See CPT",null,1644.32,null,1644.32,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27120,null,"See CPT",null,2338.4499999999998,null,2338.4499999999998,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27122,null,"See CPT",null,1991.97,null,1991.97,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27125,null,"See CPT",null,2042.72,null,2042.72,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27130,null,"See CPT",null,2305.1999999999998,null,2305.1999999999998,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27132,null,"See CPT",null,2991.75,null,2991.75,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27134,null,"See CPT",null,3393.06,null,3393.06,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27137,null,"See CPT",null,2623.1,null,2623.1,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27138,null,"See CPT",null,2723.43,null,2723.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27140,null,"See CPT",null,1629.74,null,1629.74,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27146,null,"See CPT",null,2306.37,null,2306.37,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27147,null,"See CPT",null,2627.18,null,2627.18,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27151,null,"See CPT",null,2835.42,null,2835.42,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27156,null,"See CPT",null,3051.24,null,3051.24,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27158,null,"See CPT",null,2514.61,null,2514.61,null,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R"]
[27161,null,"See CPT",null,2201.96,null,2201.96,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27165,null,"See CPT",null,2466.19,null,2466.19,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27170,null,"See CPT",null,2106.88,null,2106.88,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27175,null,"See CPT",null,1216.76,null,1216.76,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[27176,null,"See CPT",null,1677.57,null,1677.57,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27177,null,"See CPT",null,2019.38,null,2019.38,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27178,null,"See CPT",null,1677.57,null,1677.57,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27179,null,"See CPT",null,1774.98,null,1774.98,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[27181,null,"See CPT",null,2027.55,null,2027.55,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[27185,null,"See CPT",null,1315.92,null,1315.92,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[27187,null,"See CPT",null,1807.06,null,1807.06,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27197,null,"See CPT",null,242.65,null,242.65,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[27198,null,"See CPT",null,569.29999999999995,null,569.29999999999995,null,0,0,0,0,0,2,0,0,2,0,null,"R"]
[27200,null,"See CPT",null,362.23,null,367.48,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[27202,null,"See CPT",null,965.94,null,965.94,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[27215,null,"See CPT",null,1086.69,null,1086.69,null,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27216,null,"See CPT",null,1605.82,null,1605.82,null,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27217,null,"See CPT",null,1509.58,null,1509.58,null,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27218,null,"See CPT",null,2065.4699999999998,null,2065.4699999999998,null,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R"]
[27220,null,"See CPT",null,770.54,null,760.62,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27222,null,"See CPT",null,1778.48,null,1778.48,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27226,null,"See CPT",null,1900.39,null,1900.39,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27227,null,"See CPT",null,2958.5,null,2958.5,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27228,null,"See CPT",null,3353.39,null,3353.39,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27230,null,"See CPT",null,906.45,null,890.12,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27232,null,"See CPT",null,1312.43,null,1312.43,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27235,null,"See CPT",null,1644.32,null,1644.32,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27236,null,"See CPT",null,2152.38,null,2152.38,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27238,null,"See CPT",null,870.87,null,870.87,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27240,null,"See CPT",null,1731.82,null,1731.82,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27244,null,"See CPT",null,2213.62,null,2213.62,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27245,null,"See CPT",null,2210.71,null,2210.71,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27246,null,"See CPT",null,728.54,null,722.13,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27248,null,"See CPT",null,1350.34,null,1350.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27250,null,"See CPT",null,310.89999999999998,null,310.89999999999998,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[27252,null,"See CPT",null,1352.09,null,1352.09,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27253,null,"See CPT",null,1701.49,null,1701.49,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27254,null,"See CPT",null,2288.87,null,2288.87,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27256,null,"See CPT",null,578.04999999999995,null,427.56,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27257,null,"See CPT",null,652.13,null,652.13,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27258,null,"See CPT",null,2008.89,null,2008.89,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27259,null,"See CPT",null,2773.59,null,2773.59,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27265,null,"See CPT",null,779.29,null,779.29,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27266,null,"See CPT",null,1067.44,null,1067.44,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27267,null,"See CPT",null,816.04,null,816.04,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27268,null,"See CPT",null,1005.61,null,1005.61,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27269,null,"See CPT",null,2228.79,null,2228.79,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27275,null,"See CPT",null,340.06,null,340.06,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,1448.33,null,1448.33,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27280,null,"See CPT",null,2433.5300000000002,null,2433.5300000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27282,null,"See CPT",null,1567.91,null,1567.91,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27284,null,"See CPT",null,2865.17,null,2865.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27286,null,"See CPT",null,2942.75,null,2942.75,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27290,null,"See CPT",null,2914.17,null,2914.17,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[27295,null,"See CPT",null,2243.37,null,2243.37,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,1232.51,null,932.11,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27303,null,"See CPT",null,1176.52,null,1176.52,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27305,null,"See CPT",null,894.2,null,894.2,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27306,null,"See CPT",null,638.71,null,638.71,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27307,null,"See CPT",null,760.04,null,760.04,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R"]
[27310,null,"See CPT",null,1341.01,null,1341.01,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27323,null,"See CPT",null,501.05,null,321.39999999999998,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27324,null,"See CPT",null,758.29,null,758.29,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27325,null,"See CPT",null,1042.3599999999999,null,1042.3599999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[27326,null,"See CPT",null,968.86,null,968.86,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27327,null,"See CPT",null,910.53,null,578.63,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27328,null,"See CPT",null,1130.44,null,1130.44,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27329,null,"See CPT",null,1865.98,null,1865.98,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27330,null,"See CPT",null,787.46,null,787.46,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27331,null,"See CPT",null,885.45,null,885.45,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27332,null,"See CPT",null,1190.52,null,1190.52,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27333,null,"See CPT",null,1089.02,null,1089.02,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27334,null,"See CPT",null,1261.68,null,1261.68,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27335,null,"See CPT",null,1400.5,null,1400.5,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27337,null,"See CPT",null,763.54,null,763.54,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27339,null,"See CPT",null,1363.17,null,1363.17,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27340,null,"See CPT",null,701.71,null,701.71,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27345,null,"See CPT",null,905.28,null,905.28,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27347,null,"See CPT",null,976.44,null,976.44,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27350,null,"See CPT",null,1203.3499999999999,null,1203.3499999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27355,null,"See CPT",null,1122.27,null,1122.27,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27356,null,"See CPT",null,1355.59,null,1355.59,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27357,null,"See CPT",null,1490.33,null,1490.33,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27358,null,"See CPT",null,481.22,null,481.22,null,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-UR"]
[27360,null,"See CPT",null,1644.32,null,1644.32,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,3664.29,null,3664.29,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27369,null,"See CPT",null,319.07,null,70.58,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[27372,null,"See CPT",null,1079.1099999999999,null,737.87,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27380,null,"See CPT",null,1144.43,null,1144.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27381,null,"See CPT",null,1498.5,null,1498.5,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27385,null,"See CPT",null,1119.3499999999999,null,1119.3499999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27386,null,"See CPT",null,1564.41,null,1564.41,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27390,null,"See CPT",null,838.2,null,838.2,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27391,null,"See CPT",null,1069.19,null,1069.19,null,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR"]
[27392,null,"See CPT",null,1308.3399999999999,null,1308.3399999999999,null,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR"]
[27393,null,"See CPT",null,928.03,null,928.03,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27394,null,"See CPT",null,1203.93,null,1203.93,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[27395,null,"See CPT",null,1607.57,null,1607.57,null,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR"]
[27396,null,"See CPT",null,1139.18,null,1139.18,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27397,null,"See CPT",null,1669.99,null,1669.99,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27400,null,"See CPT",null,1277.43,null,1277.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27403,null,"See CPT",null,1186.43,null,1186.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27405,null,"See CPT",null,1240.0999999999999,null,1240.0999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27407,null,"See CPT",null,1458.83,null,1458.83,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27409,null,"See CPT",null,1756.32,null,1756.32,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27412,null,"See CPT",null,2962,null,2962,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27415,null,"See CPT",null,2479.61,null,2479.61,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27416,null,"See CPT",null,1778.48,null,1778.48,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[27418,null,"See CPT",null,1490.33,null,1490.33,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27420,null,"See CPT",null,1366.09,null,1366.09,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27422,null,"See CPT",null,1360.26,null,1360.26,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27424,null,"See CPT",null,1371.34,null,1371.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27425,null,"See CPT",null,846.95,null,846.95,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27427,null,"See CPT",null,1296.0899999999999,null,1296.0899999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27428,null,"See CPT",null,2033.38,null,2033.38,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27429,null,"See CPT",null,2292.37,null,2292.37,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27430,null,"See CPT",null,1356.17,null,1356.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27435,null,"See CPT",null,1477.5,null,1477.5,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27437,null,"See CPT",null,1213.26,null,1213.26,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27438,null,"See CPT",null,1531.75,null,1531.75,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27440,null,"See CPT",null,1456.5,null,1456.5,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27441,null,"See CPT",null,1502.58,null,1502.58,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27442,null,"See CPT",null,1585.99,null,1585.99,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27443,null,"See CPT",null,1489.16,null,1489.16,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27445,null,"See CPT",null,2259.12,null,2259.12,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27446,null,"See CPT",null,2068.38,null,2068.38,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27447,null,"See CPT",null,2302.29,null,2302.29,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27448,null,"See CPT",null,1509,null,1509,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27450,null,"See CPT",null,1823.4,null,1823.4,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27454,null,"See CPT",null,2331.4499999999998,null,2331.4499999999998,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27455,null,"See CPT",null,1743.48,null,1743.48,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27457,null,"See CPT",null,1728.32,null,1728.32,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27465,null,"See CPT",null,2247.4499999999998,null,2247.4499999999998,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27466,null,"See CPT",null,2140.13,null,2140.13,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27468,null,"See CPT",null,2414.2800000000002,null,2414.2800000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27470,null,"See CPT",null,2131.96,null,2131.96,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27472,null,"See CPT",null,2279.54,null,2279.54,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,2525.11,null,2525.11,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27487,null,"See CPT",null,3135.24,null,3135.24,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27488,null,"See CPT",null,2167.54,null,2167.54,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27495,null,"See CPT",null,2040.97,null,2040.97,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27496,null,"See CPT",null,1019.03,null,1019.03,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27497,null,"See CPT",null,1067.44,null,1067.44,null,90,0.1,0.69,0.21,0,2,1,0,2,0,null,"R"]
[27498,null,"See CPT",null,1210.93,null,1210.93,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27499,null,"See CPT",null,1287.93,null,1287.93,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27500,null,"See CPT",null,971.78,null,887.78,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27501,null,"See CPT",null,933.28,null,921.03,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27502,null,"See CPT",null,1365.51,null,1365.51,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27503,null,"See CPT",null,1458.83,null,1458.83,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27506,null,"See CPT",null,2414.2800000000002,null,2414.2800000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27507,null,"See CPT",null,1744.65,null,1744.65,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27508,null,"See CPT",null,983.44,null,928.03,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27509,null,"See CPT",null,1243.5999999999999,null,1243.5999999999999,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27510,null,"See CPT",null,1239.51,null,1239.51,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27511,null,"See CPT",null,1787.81,null,1787.81,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27513,null,"See CPT",null,2207.79,null,2207.79,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27514,null,"See CPT",null,1737.65,null,1737.65,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27516,null,"See CPT",null,978.19,null,912.28,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27517,null,"See CPT",null,1272.18,null,1272.18,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27519,null,"See CPT",null,1605.24,null,1605.24,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27520,null,"See CPT",null,627.04999999999995,null,577.47,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27524,null,"See CPT",null,1376.59,null,1376.59,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27530,null,"See CPT",null,594.38,null,557.04999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27532,null,"See CPT",null,1155.52,null,1073.8599999999999,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27535,null,"See CPT",null,1615.16,null,1615.16,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27536,null,"See CPT",null,2145.96,null,2145.96,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27538,null,"See CPT",null,914.03,null,848.12,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27540,null,"See CPT",null,1486.83,null,1486.83,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27550,null,"See CPT",null,960.7,null,876.7,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27552,null,"See CPT",null,1171.8499999999999,null,1171.8499999999999,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27556,null,"See CPT",null,1577.83,null,1577.83,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27557,null,"See CPT",null,1874.14,null,1874.14,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27558,null,"See CPT",null,2127.3000000000002,null,2127.3000000000002,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27560,null,"See CPT",null,709.29,null,644.54999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27562,null,"See CPT",null,916.36,null,916.36,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27566,null,"See CPT",null,1622.74,null,1622.74,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27570,null,"See CPT",null,286.39999999999998,null,286.39999999999998,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27580,null,"See CPT",null,2655.18,null,2655.18,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27590,null,"See CPT",null,1367.84,null,1367.84,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27591,null,"See CPT",null,1747.57,null,1747.57,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27592,null,"See CPT",null,1191.0999999999999,null,1191.0999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27594,null,"See CPT",null,908.2,null,908.2,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27596,null,"See CPT",null,1258.76,null,1258.76,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27598,null,"See CPT",null,1231.93,null,1231.93,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,722.71,null,722.71,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27601,null,"See CPT",null,798.54,null,798.54,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27602,null,"See CPT",null,839.37,null,839.37,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27603,null,"See CPT",null,951.36,null,709.29,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27604,null,"See CPT",null,843.45,null,607.79999999999995,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27605,null,"See CPT",null,599.63,null,334.23,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27606,null,"See CPT",null,492.89,null,492.89,null,10,0.1,0.8,0.1,0,2,1,1,1,0,null,"R"]
[27607,null,"See CPT",null,1088.44,null,1088.44,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27610,null,"See CPT",null,1178.8499999999999,null,1178.8499999999999,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[27612,null,"See CPT",null,1054.02,null,1054.02,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27613,null,"See CPT",null,463.14,null,295.14999999999998,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[27614,null,"See CPT",null,1066.8599999999999,null,755.37,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,885.45,null,561.72,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27619,null,"See CPT",null,849.87,null,849.87,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27620,null,"See CPT",null,827.7,null,827.7,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27625,null,"See CPT",null,1042.3599999999999,null,1042.3599999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27626,null,"See CPT",null,1118.19,null,1118.19,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27630,null,"See CPT",null,992.78,null,662.63,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27632,null,"See CPT",null,743.71,null,743.71,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27634,null,"See CPT",null,1211.51,null,1211.51,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27635,null,"See CPT",null,1056.94,null,1056.94,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27637,null,"See CPT",null,1371.34,null,1371.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27638,null,"See CPT",null,1357.92,null,1357.92,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27640,null,"See CPT",null,1502,null,1502,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27641,null,"See CPT",null,1196.3499999999999,null,1196.3499999999999,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27645,null,"See CPT",null,3163.24,null,3163.24,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27646,null,"See CPT",null,2755.51,null,2755.51,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27647,null,"See CPT",null,1780.23,null,1780.23,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27648,null,"See CPT",null,379.15,null,90.41,null,0,0,0,0,0,2,1,0,0,0,null,"R"]
[27650,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"]
[27652,null,"See CPT",null,1213.8499999999999,null,1213.8499999999999,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27654,null,"See CPT",null,1312.43,null,1312.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27656,null,"See CPT",null,958.36,null,624.13,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[27658,null,"See CPT",null,683.63,null,683.63,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[27659,null,"See CPT",null,865.03,null,865.03,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[27664,null,"See CPT",null,659.13,null,659.13,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[27665,null,"See CPT",null,768.21,null,768.21,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[27675,null,"See CPT",null,910.53,null,910.53,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27676,null,"See CPT",null,1115.8499999999999,null,1115.8499999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27680,null,"See CPT",null,779.87,null,779.87,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[27681,null,"See CPT",null,935.03,null,935.03,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27685,null,"See CPT",null,1201.01,null,856.28,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27686,null,"See CPT",null,971.78,null,971.78,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27687,null,"See CPT",null,835.87,null,835.87,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27690,null,"See CPT",null,1173.02,null,1173.02,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27691,null,"See CPT",null,1359.67,null,1359.67,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27692,null,"See CPT",null,180.24,null,180.24,null,0,0,0,0,0,0,0,2,1,0,null,"R"]
[27695,null,"See CPT",null,894.78,null,894.78,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27696,null,"See CPT",null,1001.53,null,1001.53,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27698,null,"See CPT",null,1163.0999999999999,null,1163.0999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27700,null,"See CPT",null,1301.93,null,1301.93,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27702,null,"See CPT",null,1739.4,null,1739.4,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27703,null,"See CPT",null,2009.47,null,2009.47,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[27704,null,"See CPT",null,1034.77,null,1034.77,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27705,null,"See CPT",null,1352.67,null,1352.67,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27707,null,"See CPT",null,753.62,null,753.62,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[27709,null,"See CPT",null,2057.3000000000002,null,2057.3000000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27712,null,"See CPT",null,1996.64,null,1996.64,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27715,null,"See CPT",null,1938.89,null,1938.89,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27720,null,"See CPT",null,1588.91,null,1588.91,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27722,null,"See CPT",null,1630.32,null,1630.32,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27724,null,"See CPT",null,2249.79,null,2249.79,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27725,null,"See CPT",null,2203.12,null,2203.12,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27726,null,"See CPT",null,1732.98,null,1732.98,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,1083.77,null,1083.77,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[27732,null,"See CPT",null,844.62,null,844.62,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[27734,null,"See CPT",null,1208.5999999999999,null,1208.5999999999999,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[27740,null,"See CPT",null,1297.26,null,1297.26,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[27742,null,"See CPT",null,1422.09,null,1422.09,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[27745,null,"See CPT",null,1336.92,null,1336.92,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27750,null,"See CPT",null,666.71,null,615.96,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27752,null,"See CPT",null,1001.53,null,910.53,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27756,null,"See CPT",null,1086.69,null,1086.69,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27758,null,"See CPT",null,1631.49,null,1631.49,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27759,null,"See CPT",null,1806.48,null,1806.48,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27760,null,"See CPT",null,642.21,null,590.29999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27762,null,"See CPT",null,912.28,null,819.54,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27766,null,"See CPT",null,1114.69,null,1114.69,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27767,null,"See CPT",null,561.13,null,562.29999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27768,null,"See CPT",null,843.45,null,843.45,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27769,null,"See CPT",null,1325.84,null,1325.84,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27780,null,"See CPT",null,596.72,null,547.72,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27781,null,"See CPT",null,830.62,null,762.37,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27784,null,"See CPT",null,1299.5899999999999,null,1299.5899999999999,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27786,null,"See CPT",null,600.22,null,547.14,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27788,null,"See CPT",null,805.54,null,724.46,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27792,null,"See CPT",null,1179.43,null,1179.43,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27808,null,"See CPT",null,646.88,null,586.79999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27810,null,"See CPT",null,895.95,null,801.45,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27814,null,"See CPT",null,1392.34,null,1392.34,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27816,null,"See CPT",null,636.38,null,562.88,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27818,null,"See CPT",null,929.78,null,822.45,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27822,null,"See CPT",null,1590.08,null,1590.08,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27823,null,"See CPT",null,1787.23,null,1787.23,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27824,null,"See CPT",null,602.54999999999995,null,582.72,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27825,null,"See CPT",null,1023.11,null,915.78,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27826,null,"See CPT",null,1555.08,null,1555.08,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27827,null,"See CPT",null,2036.88,null,2036.88,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27828,null,"See CPT",null,2395.61,null,2395.61,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27829,null,"See CPT",null,1290.8399999999999,null,1290.8399999999999,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[27830,null,"See CPT",null,743.12,null,684.79,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27831,null,"See CPT",null,770.54,null,770.54,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27832,null,"See CPT",null,1391.17,null,1391.17,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27840,null,"See CPT",null,725.63,null,725.63,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27842,null,"See CPT",null,911.7,null,911.7,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27846,null,"See CPT",null,1320.01,null,1320.01,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27848,null,"See CPT",null,1446,null,1446,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27860,null,"See CPT",null,300.39999999999998,null,300.39999999999998,null,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[27870,null,"See CPT",null,1821.65,null,1821.65,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27871,null,"See CPT",null,1257.5899999999999,null,1257.5899999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27880,null,"See CPT",null,1571.41,null,1571.41,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27881,null,"See CPT",null,1462.33,null,1462.33,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[27882,null,"See CPT",null,1038.8599999999999,null,1038.8599999999999,null,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,"Y-UR"]
[27884,null,"See CPT",null,1031.8599999999999,null,1031.8599999999999,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[27886,null,"See CPT",null,1152.02,null,1152.02,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27888,null,"See CPT",null,998.03,null,998.03,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[27889,null,"See CPT",null,1130.44,null,1130.44,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[27892,null,"See CPT",null,981.11,null,981.11,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27893,null,"See CPT",null,1132.19,null,1132.19,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[27894,null,"See CPT",null,1470.5,null,1470.5,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,309.73,null,170.91,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[28002,null,"See CPT",null,443.89,null,250.24,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[28003,null,"See CPT",null,675.46,null,455.56,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[28005,null,"See CPT",null,1040.02,null,1040.02,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28008,null,"See CPT",null,780.46,null,541.29999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28010,null,"See CPT",null,433.39,null,386.14,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28011,null,"See CPT",null,583.88,null,516.79999999999995,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28020,null,"See CPT",null,974.69,null,664.38,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[28022,null,"See CPT",null,888.95,null,602.54999999999995,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28024,null,"See CPT",null,849.28,null,572.22,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28035,null,"See CPT",null,974.69,null,665.55,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28039,null,"See CPT",null,858.03,null,612.47,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28041,null,"See CPT",null,820.12,null,820.12,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28043,null,"See CPT",null,695.29,null,478.31,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28045,null,"See CPT",null,880.2,null,639.88,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,758.87,null,513.29999999999995,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28052,null,"See CPT",null,708.71,null,469.56,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28054,null,"See CPT",null,669.63,null,432.81,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28055,null,"See CPT",null,711.63,null,711.63,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28060,null,"See CPT",null,942.03,null,660.3,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28062,null,"See CPT",null,1064.52,null,746.62,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28070,null,"See CPT",null,932.11,null,634.63,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28072,null,"See CPT",null,896.53,null,599.04999999999995,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28080,null,"See CPT",null,988.11,null,708.13,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28086,null,"See CPT",null,947.28,null,638.13,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28088,null,"See CPT",null,848.7,null,544.22,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28090,null,"See CPT",null,850.45,null,568.72,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28092,null,"See CPT",null,772.29,null,503.97,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28100,null,"See CPT",null,1124.02,null,770.54,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28102,null,"See CPT",null,1126.94,null,1126.94,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28103,null,"See CPT",null,706.38,null,706.38,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28104,null,"See CPT",null,965.36,null,654.46,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[28106,null,"See CPT",null,776.96,null,776.96,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[28107,null,"See CPT",null,926.28,null,635.21,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R"]
[28108,null,"See CPT",null,795.04,null,533.14,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28110,null,"See CPT",null,848.12,null,544.22,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28111,null,"See CPT",null,862.12,null,582.13,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28112,null,"See CPT",null,880.78,null,576.88,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28113,null,"See CPT",null,1071.52,null,789.79,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[28114,null,"See CPT",null,1951.14,null,1536.41,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28116,null,"See CPT",null,1238.3499999999999,null,949.03,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28118,null,"See CPT",null,1109.44,null,778.71,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28119,null,"See CPT",null,958.95,null,669.05,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28120,null,"See CPT",null,1220.26,null,906.45,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28122,null,"See CPT",null,1080.27,null,805.54,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28124,null,"See CPT",null,873.2,null,617.71,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28126,null,"See CPT",null,711.04,null,459.06,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28130,null,"See CPT",null,1146.18,null,1146.18,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28140,null,"See CPT",null,1024.27,null,767.62,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[28150,null,"See CPT",null,762.37,null,514.47,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28153,null,"See CPT",null,735.54,null,485.89,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28160,null,"See CPT",null,745.46,null,492.89,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,436.31,null,241.49,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[28192,null,"See CPT",null,836.45,null,571.04999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28193,null,"See CPT",null,946.7,null,666.71,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28200,null,"See CPT",null,903.53,null,601.38,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[28202,null,"See CPT",null,1096.5999999999999,null,788.04,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[28208,null,"See CPT",null,881.37,null,589.72,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[28210,null,"See CPT",null,1069.19,null,768.79,null,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR"]
[28220,null,"See CPT",null,816.62,null,559.38,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28222,null,"See CPT",null,977.61,null,676.63,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28225,null,"See CPT",null,756.54,null,489.97,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28226,null,"See CPT",null,1132.77,null,741.96,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28230,null,"See CPT",null,789.79,null,524.97,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[28232,null,"See CPT",null,687.13,null,444.47,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28234,null,"See CPT",null,753.04,null,502.22,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28238,null,"See CPT",null,1209.76,null,883.12,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28240,null,"See CPT",null,806.12,null,540.14,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28250,null,"See CPT",null,1076.19,null,758.29,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28260,null,"See CPT",null,1313.59,null,978.78,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28261,null,"See CPT",null,1969.8,null,1544.58,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28262,null,"See CPT",null,2505.86,null,2011.22,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28264,null,"See CPT",null,1627.41,null,1250.01,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R"]
[28270,null,"See CPT",null,889.53,null,616.54999999999995,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28272,null,"See CPT",null,696.46,null,461.39,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28280,null,"See CPT",null,907.03,null,624.13,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28285,null,"See CPT",null,989.86,null,715.71,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28286,null,"See CPT",null,800.29,null,542.47,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28288,null,"See CPT",null,1100.69,null,802.04,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28289,null,"See CPT",null,1255.26,null,848.12,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28291,null,"See CPT",null,1239.51,null,869.7,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28292,null,"See CPT",null,1276.8399999999999,null,893.62,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28295,null,"See CPT",null,1888.73,null,1094.8499999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28296,null,"See CPT",null,1609.32,null,943.2,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28297,null,"See CPT",null,1843.81,null,1092.52,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28298,null,"See CPT",null,1514.25,null,926.86,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28299,null,"See CPT",null,1840.89,null,1089.5999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28300,null,"See CPT",null,1186.43,null,1186.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28302,null,"See CPT",null,1310.68,null,1310.68,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28304,null,"See CPT",null,1508.41,null,1121.0999999999999,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28305,null,"See CPT",null,1222.01,null,1222.01,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28306,null,"See CPT",null,1108.8499999999999,null,745.46,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28307,null,"See CPT",null,1437.83,null,956.03,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[28308,null,"See CPT",null,1043.52,null,714.54,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28309,null,"See CPT",null,1640.82,null,1640.82,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[28310,null,"See CPT",null,1005.61,null,672.54,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28312,null,"See CPT",null,1027.19,null,655.04999999999995,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR"]
[28313,null,"See CPT",null,972.94,null,669.63,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[28315,null,"See CPT",null,873.78,null,599.63,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R"]
[28320,null,"See CPT",null,1121.69,null,1121.69,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28322,null,"See CPT",null,1430.25,null,1053.44,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,473.06,null,438.64,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28405,null,"See CPT",null,855.12,null,765.29,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28406,null,"See CPT",null,1094.8499999999999,null,1094.8499999999999,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28415,null,"See CPT",null,2034.55,null,2034.55,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28420,null,"See CPT",null,2351.2800000000002,null,2351.2800000000002,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28430,null,"See CPT",null,458.47,null,401.89,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28435,null,"See CPT",null,705.79,null,622.96,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28436,null,"See CPT",null,926.28,null,926.28,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28445,null,"See CPT",null,1894.56,null,1894.56,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,403.64,null,364.56,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28455,null,"See CPT",null,480.06,null,429.31,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28456,null,"See CPT",null,698.79,null,698.79,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28465,null,"See CPT",null,1181.77,null,1181.77,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28470,null,"See CPT",null,415.89,null,391.98,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28475,null,"See CPT",null,492.31,null,431.06,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28476,null,"See CPT",null,733.79,null,733.79,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28485,null,"See CPT",null,1035.94,null,1035.94,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[28490,null,"See CPT",null,272.98,null,239.74,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28495,null,"See CPT",null,345.31,null,285.82,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28496,null,"See CPT",null,936.78,null,519.14,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28505,null,"See CPT",null,1185.27,null,908.78,null,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R"]
[28510,null,"See CPT",null,232.15,null,232.15,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28515,null,"See CPT",null,313.23,null,272.98,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28525,null,"See CPT",null,1027.19,null,741.96,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28530,null,"See CPT",null,226.32,null,197.74,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28531,null,"See CPT",null,607.22,null,337.73,null,90,0.1,0.69,0.21,0,2,1,1,2,0,null,"R"]
[28540,null,"See CPT",null,372.15,null,333.65,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28545,null,"See CPT",null,594.38,null,518.54999999999995,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28546,null,"See CPT",null,1088.44,null,666.71,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28555,null,"See CPT",null,1538.75,null,1186.43,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28570,null,"See CPT",null,456.72,null,380.89,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28575,null,"See CPT",null,722.13,null,645.71,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28576,null,"See CPT",null,730.29,null,730.29,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R"]
[28585,null,"See CPT",null,1652.49,null,1302.51,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R"]
[28600,null,"See CPT",null,418.23,null,355.23,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28605,null,"See CPT",null,656.8,null,585.04999999999995,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28606,null,"See CPT",null,739.04,null,739.04,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28615,null,"See CPT",null,1517.75,null,1517.75,null,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R"]
[28630,null,"See CPT",null,286.98,null,202.41,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[28635,null,"See CPT",null,317.89999999999998,null,240.32,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[28636,null,"See CPT",null,655.63,null,412.98,null,10,0.1,0.8,0.1,0,2,0,1,2,0,null,"R"]
[28645,null,"See CPT",null,1187.5999999999999,null,891.87,null,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R"]
[28660,null,"See CPT",null,235.65,null,172.66,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[28665,null,"See CPT",null,279.39999999999998,null,230.99,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[28666,null,"See CPT",null,318.48,null,318.48,null,10,0.1,0.8,0.1,0,2,0,1,2,0,null,"R"]
[28675,null,"See CPT",null,1051.69,null,762.37,null,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R"]
[28705,null,"See CPT",null,2195.54,null,2195.54,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28715,null,"See CPT",null,1713.74,null,1713.74,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28725,null,"See CPT",null,1418.59,null,1418.59,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28730,null,"See CPT",null,1320.59,null,1320.59,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28735,null,"See CPT",null,1415.09,null,1415.09,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28737,null,"See CPT",null,1246.51,null,1246.51,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28740,null,"See CPT",null,1499.66,null,1121.69,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28750,null,"See CPT",null,1415.09,null,1048.77,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[28755,null,"See CPT",null,926.86,null,618.88,null,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR"]
[28760,null,"See CPT",null,1398.17,null,1039.44,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28800,null,"See CPT",null,955.45,null,955.45,null,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR"]
[28805,null,"See CPT",null,1264.01,null,1264.01,null,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[28810,null,"See CPT",null,762.37,null,762.37,null,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R"]
[28820,null,"See CPT",null,534.29999999999995,null,314.98,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[28825,null,"See CPT",null,524.39,null,307.39999999999998,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,685.96,null,359.31,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29010,null,"See CPT",null,532.54999999999995,null,293.98,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29015,null,"See CPT",null,568.13,null,329.56,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29035,null,"See CPT",null,503.39,null,264.82,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29040,null,"See CPT",null,572.22,null,318.48,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29044,null,"See CPT",null,561.13,null,307.39999999999998,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29046,null,"See CPT",null,612.47,null,344.73,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29049,null,"See CPT",null,190.16,null,128.33000000000001,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29055,null,"See CPT",null,433.39,null,252.57,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29058,null,"See CPT",null,233.32,null,170.91,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29065,null,"See CPT",null,183.74,null,124.83,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29075,null,"See CPT",null,167.41,null,115.49,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29085,null,"See CPT",null,183.16,null,124.24,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29086,null,"See CPT",null,148.16,null,90.99,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29105,null,"See CPT",null,155.74,null,72.91,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29125,null,"See CPT",null,127.74,null,74.08,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29126,null,"See CPT",null,149.91,null,90.41,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29130,null,"See CPT",null,78.75,null,51.33,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29131,null,"See CPT",null,102.66,null,62.41,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29200,null,"See CPT",null,57.75,null,31.5,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[29240,null,"See CPT",null,53.66,null,31.5,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29260,null,"See CPT",null,52.5,null,33.25,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29280,null,"See CPT",null,53.66,null,35,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29305,null,"See CPT",null,478.31,null,290.48,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29325,null,"See CPT",null,527.29999999999995,null,325.48,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[29345,null,"See CPT",null,254.32,null,180.24,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29355,null,"See CPT",null,264.82,null,191.32,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29358,null,"See CPT",null,307.98,null,187.24,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29365,null,"See CPT",null,234.49,null,158.66,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29405,null,"See CPT",null,151.66,null,107.33,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29425,null,"See CPT",null,142.33000000000001,null,99.16,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29435,null,"See CPT",null,233.9,null,157.49,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29440,null,"See CPT",null,79.91,null,49.58,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29445,null,"See CPT",null,234.49,null,175.57,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,173.24,null,96.24,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29515,null,"See CPT",null,137.08000000000001,null,90.99,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[29584,null,"See CPT",null,145.83000000000001,null,28,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"]
[29807,null,"See CPT",null,1873.56,null,1873.56,null,90,0.1,0.69,0.21,0,3,1,1,1,0,29805,"R",null,"Y-UR"]
[29836,null,"See CPT",null,1078.52,null,1078.52,null,90,0.1,0.69,0.21,0,3,1,2,1,0,29830,"R",null,"Y-UR"]
[29855,null,"See CPT",null,1425,null,1425,null,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R"]
[29861,null,"See CPT",null,1265.18,null,1265.18,null,90,0.1,0.69,0.21,0,3,1,2,1,0,29860,"R",null,"Y-UR"]
[29873,null,"See CPT",null,996.86,null,996.86,null,90,0.1,0.69,0.21,0,3,1,1,1,0,29870,"R",null,"Y-UR"]
[29886,null,"See CPT",null,1170.68,null,1170.68,null,90,0.1,0.69,0.21,0,3,1,1,0,0,29870,"R",null,"Y-UR"]
[29904,null,"See CPT",null,1175.3499999999999,null,1175.3499999999999,null,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[29915,null,"See CPT",null,1834.48,null,1834.48,null,90,0.1,0.69,0.21,0,3,1,2,1,0,29860,"R",null,"Y-UR"]
[30125,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"]
[30140,null,"See CPT",null,540.14,null,318.48,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[30468,null,"See CPT",null,4467.49,null,302.73,null,0,0,0,0,0,2,2,1,0,0,null,"R",null,"Y-CM"]
[30540,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"]
[30802,null,"See CPT",null,510.97,null,366.9,null,10,0.1,0.8,0.1,0,2,2,1,0,0,null,"R"]
[31030,null,"See CPT",null,1184.68,null,943.78,null,90,0.1,0.76,0.14000000000000001,0,2,1,1,0,0,null,"R"]
[31080,null,"See CPT",null,1974.47,null,1974.47,null,90,0.1,0.76,0.14000000000000001,0,2,1,2,0,0,null,"R"]
[31225,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"X"]
[31256,null,"See CPT",null,321.39999999999998,null,321.39999999999998,null,0,0,0,0,0,3,1,1,0,0,31231,"R"]
[31290,null,"See CPT",null,2044.47,null,2044.47,null,10,0.1,0.8,0.1,0,3,1,0,0,0,31231,"R"]
[31297,null,"See CPT",null,2915.92,null,256.07,null,0,0,0,0,0,3,1,0,0,0,31231,"R"]
[31395,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,246.74,null,246.74,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[31529,null,"See CPT",null,286.98,null,286.98,null,0,0,0,0,0,3,0,0,0,0,31525,"R"]
[31545,null,"See CPT",null,638.71,null,638.71,null,0,0,0,0,0,3,1,1,0,0,31526,"R"]
[31574,null,"See CPT",null,1674.07,null,267.14999999999998,null,0,0,0,0,0,3,1,0,0,0,31575,"R",null,"Y-CM"]
[31591,null,"See CPT",null,2008.3,null,2008.3,null,90,0.1,0.76,0.14000000000000001,0,2,1,0,1,0,null,"R",null,"Y-UR"]
[31613,null,"See CPT",null,767.62,null,767.62,null,90,0.1,0.76,0.14000000000000001,0,2,0,1,0,0,null,"R"]
[31631,null,"See CPT",null,394.31,null,394.31,null,0,0,0,0,0,3,0,1,0,0,31622,"R"]
[31634,null,"See CPT",null,2618.4299999999998,null,328.4,null,0,0,0,0,0,3,0,2,0,0,31622,"R"]
[31645,null,"See CPT",null,501.05,null,256.64999999999998,null,0,0,0,0,0,3,0,1,0,0,31622,"R"]
[31720,null,"See CPT",null,93.91,null,93.91,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[31780,null,"See CPT",null,2145.96,null,2145.96,null,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R"]
[32036,null,"See CPT",null,1381.25,null,1381.25,null,90,0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"R"]
[32160,null,"See CPT",null,1406.92,null,1406.92,null,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R"]
[32320,null,"See CPT",null,2787.01,null,2787.01,null,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,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,327.81,null,277.64999999999998,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[32562,null,"See CPT",null,153.41,null,104.41,null,0,0,0,0,0,2,0,2,0,0,null,"R"]
[32651,null,"See CPT",null,1900.39,null,1900.39,null,90,0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[32659,null,"See CPT",null,1285.01,null,1285.01,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[32674,null,"See CPT",null,363.98,null,363.98,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[32850,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"]
[32994,null,"See CPT",null,8611.84,null,760.04,null,0,0,0,0,0,2,1,2,0,0,null,"R",null,"Y-UR"]
[33031,null,"See CPT",null,4234.76,null,4234.76,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33207,null,"See CPT",null,831.2,null,831.2,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,2,0,null,"R",null,"Y-CM"]
[33211,null,"See CPT",null,286.39999999999998,null,286.39999999999998,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33229,null,"See CPT",null,649.21,null,649.21,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33233,null,"See CPT",null,412.39,null,412.39,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33251,null,"See CPT",null,2799.84,null,2799.84,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33264,null,"See CPT",null,701.71,null,701.71,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33274,null,"See CPT",null,827.7,null,827.7,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,2,0,null,"R",null,"Y-UR"]
[33300,null,"See CPT",null,4184.59,null,4184.59,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33330,null,"See CPT",null,2451.0300000000002,null,2451.0300000000002,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33362,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,2,1,null,"X"]
[33412,null,"See CPT",null,5349.44,null,5349.44,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33422,null,"See CPT",null,2860.5,null,2860.5,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33463,null,"See CPT",null,5253.2,null,5253.2,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33477,null,"See CPT",null,2236.37,null,2236.37,null,0,0,0,0,0,2,0,0,1,1,null,"R",null,"Y-CM"]
[33512,null,"See CPT",null,4141.43,null,4141.43,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[33530,null,"See CPT",null,886.62,null,886.62,null,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-CM"]
[33548,null,"See CPT",null,5036.8,null,5036.8,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R"]
[33620,null,"See CPT",null,2821.42,null,2821.42,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33670,null,"See CPT",null,3355.14,null,3355.14,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33677,null,"See CPT",null,3590.21,null,3590.21,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33702,null,"See CPT",null,2669.18,null,2669.18,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[33750,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"]
[33777,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"X"]
[33782,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X"]
[33840,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"]
[33852,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"X"]
[33894,null,"See CPT",null,1666.49,null,1666.49,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[33900,null,"See CPT",null,1006.19,null,1006.19,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[33925,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"]
[33949,null,"See CPT",null,400.73,null,400.73,null,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM"]
[33956,null,"See CPT",null,1413.34,null,1413.34,null,0,0,0,0,0,2,0,0,1,1,null,"R",null,"Y-CM"]
[33965,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,1225.51,null,1225.51,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[33982,null,"See CPT",null,3286.31,null,3286.31,null,0,0,0,0,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[34051,null,"See CPT",null,1721.9,null,1721.9,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[34151,null,"See CPT",null,2356.5300000000002,null,2356.5300000000002,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[34701,null,"See CPT",null,2091.71,null,2091.71,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[34708,null,"See CPT",null,3057.08,null,3057.08,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,2,0,null,"R",null,"Y-UR"]
[34717,null,"See CPT",null,740.21,null,740.21,null,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR"]
[34839,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"]
[35011,null,"See CPT",null,1715.49,null,1715.49,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35082,null,"See CPT",null,3656.71,null,3656.71,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[35152,null,"See CPT",null,2360.62,null,2360.62,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35184,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"]
[35236,null,"See CPT",null,1739.4,null,1739.4,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R"]
[35276,null,"See CPT",null,2509.94,null,2509.94,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R"]
[35341,null,"See CPT",null,2327.37,null,2327.37,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35371,null,"See CPT",null,1380.09,null,1380.09,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35521,null,"See CPT",null,2076.5500000000002,null,2076.5500000000002,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35525,null,"See CPT",null,1858.39,null,1858.39,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35558,null,"See CPT",null,2070.7199999999998,null,2070.7199999999998,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35585,null,"See CPT",null,2815.01,null,2815.01,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35638,null,"See CPT",null,2950.33,null,2950.33,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[35647,null,"See CPT",null,2592.19,null,2592.19,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[35685,null,"See CPT",null,331.9,null,331.9,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[35700,null,"See CPT",null,253.74,null,253.74,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[35876,null,"See CPT",null,1597.08,null,1597.08,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[35903,null,"See CPT",null,967.69,null,967.69,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[36215,null,"See CPT",null,1847.89,null,368.06,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[36224,null,"See CPT",null,3736.04,null,637.54999999999995,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[36260,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"X"]
[36299,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[36456,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[36473,null,"See CPT",null,2106.3000000000002,null,309.14999999999998,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[36512,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
[36556,null,"See CPT",null,380.89,null,146.41,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[36575,null,"See CPT",null,258.39999999999998,null,58.33,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[36580,null,"See CPT",null,335.4,null,112.58,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[36596,null,"See CPT",null,209.99,null,80.5,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[36680,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[36832,null,"See CPT",null,1291.43,null,1291.43,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R"]
[36902,null,"See CPT",null,2133.13,null,410.06,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[37180,null,"See CPT",null,3713.29,null,3713.29,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[37187,null,"See CPT",null,2960.25,null,673.71,null,0,0,0,0,0,2,1,1,2,0,null,"R"]
[37214,null,"See CPT",null,208.24,null,208.24,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[37220,null,"See CPT",null,4388.75,null,674.29,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[37236,null,"See CPT",null,4804.6400000000003,null,743.71,null,0,0,0,0,0,2,1,0,0,0,null,"R"]
[37246,null,"See CPT",null,3171.99,null,592.04999999999995,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[37565,null,"See CPT",null,1282.0899999999999,null,1282.0899999999999,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,0,1,0,null,"R"]
[37616,null,"See CPT",null,1996.05,null,1996.05,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R"]
[37780,null,"See CPT",null,411.23,null,411.23,null,90,0.09,0.84,7.0000000000000007E-2,0,2,1,1,1,0,null,"R",null,"Y-CM"]
[38101,null,"See CPT",null,2047.97,null,2047.97,null,90,0.11,0.73,0.16,0,2,0,2,1,0,null,"R"]
[38210,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[38240,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[38382,null,"See CPT",null,1205.0999999999999,null,1205.0999999999999,null,90,0.11,0.73,0.16,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[38510,null,"See CPT",null,950.2,null,747.79,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[38573,null,"See CPT",null,2096.96,null,2096.96,null,10,0.1,0.8,0.1,0,3,2,2,2,0,49320,"R",null,"Y-UR"]
[38746,null,"See CPT",null,363.4,null,363.4,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[39010,null,"See CPT",null,1380.09,null,1380.09,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R"]
[39545,null,"See CPT",null,1571.99,null,1571.99,null,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R"]
[40530,null,"See CPT",null,1018.44,null,739.62,null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[40654,null,"See CPT",null,1080.27,null,783.96,null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R"]
[40816,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"X"]
[40830,null,"See CPT",null,414.73,null,269.48,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[40899,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[41113,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"X"]
[41140,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"]
[41252,null,"See CPT",null,596.13,null,377.98,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[41599,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[41872,null,"See CPT",null,872.62,null,566.38,null,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[42180,null,"See CPT",null,463.14,null,342.4,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[42200,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"]
[42260,null,"See CPT",null,1562.66,null,1212.68,null,90,0.09,0.81,0.1,0,2,0,2,0,0,null,"R"]
[42405,null,"See CPT",null,556.47,null,412.39,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[42440,null,"See CPT",null,755.96,null,755.96,null,90,0.09,0.81,0.1,0,2,1,2,1,0,null,"R"]
[42699,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,2,1,1,null,"N"]
[42821,null,"See CPT",null,555.88,null,555.88,null,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[42870,null,"See CPT",null,1078.52,null,1078.52,null,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R"]
[42961,null,"See CPT",null,764.12,null,764.12,null,90,0.09,0.81,0.1,0,2,0,2,0,0,null,"R"]
[43100,null,"See CPT",null,1152.02,null,1152.02,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43101,null,"See CPT",null,1752.82,null,1752.82,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43130,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"]
[43194,null,"See CPT",null,341.23,null,341.23,null,0,0,0,0,0,3,0,1,0,0,43191,"R"]
[43213,null,"See CPT",null,2169.29,null,454.39,null,0,0,0,0,0,3,0,1,0,0,43200,"R"]
[43235,null,"See CPT",null,524.39,null,216.99,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[43244,null,"See CPT",null,429.31,null,429.31,null,0,0,0,0,0,3,0,1,0,0,43235,"R",null,"Y-CM"]
[43255,null,"See CPT",null,1120.52,null,352.31,null,0,0,0,0,0,3,0,1,0,0,43235,"R"]
[43260,null,"See CPT",null,564.04999999999995,null,564.04999999999995,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[43280,null,"See CPT",null,1897.47,null,1897.47,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43285,null,"See CPT",null,1194.5999999999999,null,1194.5999999999999,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[49592,null,"See CPT",null,832.95,null,832.95,null,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[43331,null,"See CPT",null,2327.37,null,2327.37,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43340,null,"See CPT",null,2431.19,null,2431.19,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43405,null,"See CPT",null,2539.1,null,2539.1,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43425,null,"See CPT",null,2501.19,null,2501.19,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43605,null,"See CPT",null,1496.75,null,1496.75,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43632,null,"See CPT",null,3568.63,null,3568.63,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43651,null,"See CPT",null,1174.77,null,1174.77,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[43761,null,"See CPT",null,217.57,null,180.24,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[43825,null,"See CPT",null,2313.9499999999998,null,2313.9499999999998,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[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"]
[43999,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,0,1,1,null,"N"]
[44120,null,"See CPT",null,2149.46,null,2149.46,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[44127,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"]
[44137,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,2,1,0,null,"N"]
[44156,null,"See CPT",null,4029.44,null,4029.44,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[44187,null,"See CPT",null,1931.89,null,1931.89,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[44238,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,2,1,1,null,"N"]
[44361,null,"See CPT",null,279.39999999999998,null,279.39999999999998,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"]
[44389,null,"See CPT",null,745.46,null,302.14999999999998,null,0,0,0,0,0,3,0,1,0,0,44388,"R",null,"Y-CM"]
[44403,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,3,0,1,0,0,44388,"X"]
[44408,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,3,0,1,0,0,44388,"X"]
[44650,null,"See CPT",null,2520.44,null,2520.44,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[44715,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,2,1,0,null,"N"]
[44960,null,"See CPT",null,1549.83,null,1549.83,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[45119,null,"See CPT",null,3309.64,null,3309.64,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[45136,null,"See CPT",null,3153.9,null,3153.9,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[45305,null,"See CPT",null,327.23,null,130.66,null,0,0,0,0,0,3,0,1,0,0,45300,"R",null,"Y-CM"]
[45333,null,"See CPT",null,594.38,null,166.82,null,0,0,0,0,0,3,0,1,0,0,45330,"R",null,"Y-CM"]
[45337,null,"See CPT",null,200.66,null,200.66,null,0,0,0,0,0,3,0,1,0,0,45330,"R",null,"Y-CM"]
[45382,null,"See CPT",null,1191.0999999999999,null,453.81,null,0,0,0,0,0,3,0,1,0,0,45378,"R",null,"Y-CM"]
[45390,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,3,0,1,0,0,45378,"X"]
[45505,null,"See CPT",null,1093.0999999999999,null,1093.0999999999999,null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[45563,null,"See CPT",null,2926.42,null,2926.42,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[46040,null,"See CPT",null,1020.78,null,781.04,null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R"]
[46255,null,"See CPT",null,951.36,null,644.54999999999995,null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R"]
[46261,null,"See CPT",null,964.19,null,964.19,null,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R"]
[46320,null,"See CPT",null,389.06,null,205.32,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[46614,null,"See CPT",null,304.48,null,116.08,null,0,0,0,0,0,3,0,1,0,0,46600,"R",null,"Y-CM"]
[46730,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"]
[46754,null,"See CPT",null,641.63,null,445.64,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[46922,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"]
[47010,null,"See CPT",null,2147.71,null,2147.71,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[47144,null,"See CPT",null,"By Report ",null,"By Report ",null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"N",null,"Y-CM"]
[47361,null,"See CPT",null,5259.03,null,5259.03,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[47399,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,0,1,1,1,null,"N"]
[47531,null,"See CPT",null,755.37,null,123.66,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[47538,null,"See CPT",null,6633.29,null,405.39,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[47564,null,"See CPT",null,1984.39,null,1984.39,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[47610,null,"See CPT",null,2211.87,null,2211.87,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R"]
[47760,null,"See CPT",null,3942.52,null,3942.52,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[48102,null,"See CPT",null,914.61,null,411.81,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[48152,null,"See CPT",null,5045.55,null,5045.55,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[48155,null,"See CPT",null,3208.15,null,3208.15,null,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[48556,null,"See CPT",null,2306.37,null,2306.37,null,90,0.09,0.81,0.1,0,2,0,2,2,2,null,"R",null,"Y-CM"]
[49014,null,"See CPT",null,660.3,null,660.3,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[49188,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"]
[49325,null,"See CPT",null,727.96,null,727.96,null,10,0.1,0.8,0.1,0,3,0,2,2,0,49320,"R"]
[49411,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[49429,null,"See CPT",null,810.2,null,810.2,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[49451,null,"See CPT",null,1130.44,null,152.82,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[49465,null,"See CPT",null,248.49,null,52.5,null,0,0,0,0,0,2,0,0,0,0,null,"R"]
[49557,null,"See CPT",null,1283.8399999999999,null,1283.8399999999999,null,90,0.09,0.81,0.1,0,2,1,2,1,0,null,"R"]
[49617,null,"See CPT",null,1552.74,null,1552.74,null,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[49651,null,"See CPT",null,1016.11,null,1016.11,null,90,0.09,0.81,0.1,0,2,1,2,1,0,null,"R"]
[50010,null,"See CPT",null,1263.43,null,1263.43,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R"]
[50220,null,"See CPT",null,1874.73,null,1874.73,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R"]
[50300,null,"See CPT",null,4175.09,null,4175.09,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
[50340,null,"See CPT",null,1725.4,null,1725.4,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[50370,null,"See CPT",null,2175.13,null,2175.13,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[50434,null,"See CPT",null,1619.24,null,331.9,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[50437,null,"See CPT",null,441.56,null,441.56,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[50544,null,"See CPT",null,2191.46,null,2191.46,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[50562,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"]
[50606,null,"See CPT",null,874.37,null,239.74,null,0,0,0,0,0,0,1,1,0,0,null,"R",null,"Y-CM"]
[50695,null,"See CPT",null,2382.7800000000002,null,592.04999999999995,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[50728,null,"See CPT",null,1255.26,null,1255.26,null,90,0.08,0.83,0.09,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[50760,null,"See CPT",null,1998.97,null,1998.97,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[50940,null,"See CPT",null,1582.49,null,1582.49,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R"]
[50947,null,"See CPT",null,2444.0300000000002,null,2444.0300000000002,null,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[50980,null,"See CPT",null,622.96,null,622.96,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[51060,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"]
[51575,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"]
[51600,null,"See CPT",null,380.31,null,75.83,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[51705,null,"See CPT",null,178.49,null,93.33,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[51726,"TC","See CPT",null,365.73,null,365.73,null,0,0,0,0,1,2,0,1,0,0,null,"R"]
[51741,"TC","See CPT",null,11.08,null,11.08,null,0,0,0,0,1,2,0,1,0,0,null,"R"]
[51785,null,"See CPT",null,728.54,null,728.54,null,0,0,0,0,1,2,0,0,0,0,null,"R"]
[51865,null,"See CPT",null,1591.83,null,1591.83,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R"]
[51920,null,"See CPT",null,1366.67,null,1366.67,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[52005,null,"See CPT",null,520.89,null,236.24,null,0,0,0,0,0,3,0,1,0,0,52000,"R"]
[52260,null,"See CPT",null,370.4,null,370.4,null,0,0,0,0,0,3,0,1,0,0,52000,"R"]
[52290,null,"See CPT",null,428.73,null,428.73,null,0,0,0,0,0,3,2,1,0,0,52000,"R"]
[52318,null,"See CPT",null,827.7,null,827.7,null,0,0,0,0,0,3,0,1,0,0,52000,"R"]
[52351,null,"See CPT",null,531.39,null,531.39,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[52354,null,"See CPT",null,730.87,null,730.87,null,0,0,0,0,0,3,1,1,0,0,52351,"R",null,"Y-CM"]
[52601,null,"See CPT",null,1297.26,null,1297.26,null,90,0.08,0.83,0.09,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[53040,null,"See CPT",null,709.29,null,709.29,null,90,0.08,0.83,0.09,0,2,0,0,0,0,null,"R"]
[53260,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"]
[53410,null,"See CPT",null,1741.73,null,1741.73,null,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[53450,null,"See CPT",null,740.79,null,740.79,null,90,0.08,0.83,0.09,0,2,0,1,0,0,null,"R"]
[53453,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
[53620,null,"See CPT",null,305.64999999999998,null,153.99,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
[53855,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[54100,null,"See CPT",null,370.98,null,219.9,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[54115,null,"See CPT",null,832.95,null,772.87,null,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"R"]
[54200,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"]
[54240,26,"See CPT",null,113.74,null,113.74,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[54322,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"X"]
[54352,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"]
[54415,null,"See CPT",null,958.95,null,958.95,null,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[54450,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
[54640,null,"See CPT",null,774.62,null,774.62,null,90,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[54670,null,"See CPT",null,740.79,null,740.79,null,90,0.1,0.8,0.1,0,2,1,0,0,0,null,"R"]
[55000,null,"See CPT",null,218.15,null,151.66,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[55120,null,"See CPT",null,645.71,null,645.71,null,90,0.1,0.8,0.1,0,2,0,0,0,0,null,"R"]
[55540,null,"See CPT",null,996.28,null,996.28,null,90,0.1,0.8,0.1,0,2,1,1,1,0,null,"R"]
[55700,null,"See CPT",null,438.64,null,228.07,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[55845,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.8,0.1,0,2,2,2,1,0,null,"X"]
[55865,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.8,0.1,0,2,2,2,1,0,null,"X"]
[56405,null,"See CPT",null,265.39999999999998,null,231.57,null,10,0.1,0.8,0.1,0,2,0,1,2,0,null,"R",null,"Y-CM"]
[56605,null,"See CPT",null,173.24,null,104.41,null,0,0,0,0,0,2,0,1,2,0,null,"R",null,"Y-CM"]
[56633,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"]
[57023,null,"See CPT",null,571.63,null,571.63,null,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[57120,null,"See CPT",null,953.11,null,953.11,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[57170,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[57270,null,"See CPT",null,1447.75,null,1447.75,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[57284,null,"See CPT",null,1489.75,null,1489.75,null,90,0.08,0.83,0.09,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[57330,null,"See CPT",null,1374.84,null,1374.84,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[57426,null,"See CPT",null,1560.33,null,1560.33,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[57454,null,"See CPT",null,303.32,null,237.4,null,0,0,0,0,0,3,0,1,0,0,57452,"R",null,"Y-CM"]
[57522,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.12,0.74,0.14000000000000001,0,2,0,1,0,0,null,"X"]
[58140,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"]
[58180,null,"See CPT",null,1710.82,null,1710.82,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[58290,null,"See CPT",null,2039.22,null,2039.22,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[58292,null,"See CPT",null,2318.0300000000002,null,2318.0300000000002,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[58542,null,"See CPT",null,1477.5,null,1477.5,null,90,0.12,0.74,0.14000000000000001,0,2,0,2,2,0,null,"R",null,"Y-CM"]
[58545,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"]
[58565,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.12,0.74,0.14000000000000001,0,3,2,1,2,0,58555,"X"]
[58578,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,2,1,1,null,"N"]
[58672,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.8,0.1,0,3,1,2,0,0,49320,"X"]
[58800,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.12,0.74,0.14000000000000001,0,2,2,1,0,0,null,"X"]
[58943,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"]
[58956,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"]
[59025,null,"See CPT",null,88.66,null,88.66,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[59030,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
[59140,null,"See CPT",null,741.37,null,741.37,null,90,0.17,0.6,0.23,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[59350,null,"See CPT",null,480.06,null,480.06,null,0,0,0,0,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[59525,null,"See CPT",null,829.45,null,829.45,null,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM"]
[59821,null,"See CPT",null,774.62,null,674.88,null,90,0.17,0.6,0.23,0,2,0,0,0,0,null,"R",null,"Y-CM"]
[59870,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.17,0.6,0.23,0,2,0,2,0,0,null,"X"]
[60200,null,"See CPT",null,1202.76,null,1202.76,null,90,0.09,0.82,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[60280,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",null,"Y-CM"]
[60505,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"]
[60600,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"]
[61120,null,"See CPT",null,1353.84,null,1353.84,null,90,0.11,0.76,0.13,0,2,0,0,0,0,null,"R"]
[61250,null,"See CPT",null,1559.16,null,1559.16,null,90,0.11,0.76,0.13,0,2,1,2,1,0,null,"R"]
[61315,null,"See CPT",null,3653.79,null,3653.79,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[61500,null,"See CPT",null,2312.1999999999998,null,2312.1999999999998,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[61517,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,1,0,0,null,"X"]
[61535,null,"See CPT",null,1809.4,null,1809.4,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[61536,null,"See CPT",null,4536.91,null,4536.91,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[61548,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.11,0.76,0.13,0,2,0,2,2,0,null,"X"]
[61571,null,"See CPT",null,3524.88,null,3524.88,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[61595,null,"See CPT",null,4256.34,null,4256.34,null,90,0.11,0.76,0.13,0,2,1,1,1,2,null,"R",null,"Y-CM"]
[61606,null,"See CPT",null,5133.62,null,5133.62,null,90,0.11,0.76,0.13,0,2,0,2,1,2,null,"R",null,"Y-CM"]
[61630,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,2,1,0,null,"X"]
[61684,null,"See CPT",null,4998.88,null,4998.88,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[61708,null,"See CPT",null,4480.91,null,4480.91,null,90,0.11,0.76,0.13,0,2,0,2,0,0,null,"R",null,"Y-CM"]
[61715,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
[61798,null,"See CPT",null,2448.11,null,2448.11,null,90,0.11,0.76,0.13,0,0,0,2,0,0,null,"R",null,"Y-CM"]
[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"]
[61886,null,"See CPT",null,1603.49,null,1603.49,null,90,0.11,0.76,0.13,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[62100,null,"See CPT",null,2788.76,null,2788.76,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[62165,null,"See CPT",null,2695.43,null,2695.43,null,90,0.11,0.76,0.13,0,2,0,0,1,0,null,"R",null,"Y-CM"]
[62220,null,"See CPT",null,1732.4,null,1732.4,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[62252,26,"See CPT",null,79.91,null,79.91,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[62284,null,"See CPT",null,337.15,null,146.99,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[62291,null,"See CPT",null,556.47,null,251.99,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-UR"]
[62324,null,"See CPT",null,247.32,null,158.07,null,0,0,0,0,0,2,9,1,0,0,null,"R",null,"Y-UR"]
[62360,null,"See CPT",null,566.38,null,566.38,null,10,0.1,0.8,0.1,0,2,0,0,1,0,null,"R",null,"Y-UR"]
[63011,null,"See CPT",null,1956.97,null,1956.97,null,90,0.11,0.76,0.13,0,2,0,2,2,0,null,"R",null,"Y-UR"]
[63040,null,"See CPT",null,2458.0300000000002,null,2458.0300000000002,null,90,0.11,0.76,0.13,0,2,1,2,2,0,null,"R",null,"Y-UR"]
[63055,null,"See CPT",null,2882.67,null,2882.67,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63086,null,"See CPT",null,331.31,null,331.31,null,0,0,0,0,0,0,0,2,2,2,null,"R",null,"Y-UR"]
[63087,null,"See CPT",null,4282.59,null,4282.59,null,90,0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR"]
[63185,null,"See CPT",null,2203.71,null,2203.71,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63270,null,"See CPT",null,3674.79,null,3674.79,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63278,null,"See CPT",null,2840.09,null,2840.09,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63303,null,"See CPT",null,4083.1,null,4083.1,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[63661,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",null,"Y-UR"]
[63685,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",null,"Y-UR"]
[64415,null,"See CPT",null,243.24,null,123.08,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[64430,null,"See CPT",null,178.49,null,97.99,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[64449,null,"See CPT",null,114.91,null,114.91,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[64468,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,2,1,0,0,null,"X"]
[64484,null,"See CPT",null,201.24,null,89.83,null,0,0,0,0,0,0,1,1,0,0,null,"R",null,"Y-UR"]
[64510,null,"See CPT",null,264.82,null,137.08000000000001,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[64568,null,"See CPT",null,1087.27,null,1087.27,null,90,0.11,0.76,0.13,0,2,1,0,0,0,null,"R",null,"Y-UR"]
[64596,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"]
[64616,null,"See CPT",null,249.07,null,194.82,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[64635,null,"See CPT",null,799.7,null,345.31,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-UR"]
[64642,null,"See CPT",null,278.23,null,190.16,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[64714,null,"See CPT",null,1391.17,null,1391.17,null,90,0.11,0.76,0.13,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[64722,null,"See CPT",null,680.13,null,680.13,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR"]
[64760,null,"See CPT",null,936.78,null,936.78,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM"]
[64782,null,"See CPT",null,839.37,null,839.37,null,90,0.11,0.76,0.13,0,2,0,1,1,0,null,"R"]
[64818,null,"See CPT",null,1409.25,null,1409.25,null,90,0.11,0.76,0.13,0,2,1,2,1,0,null,"R",null,"Y-CM"]
[64856,null,"See CPT",null,1813.48,null,1813.48,null,90,0.11,0.76,0.13,0,2,0,1,1,0,null,"R"]
[64862,null,"See CPT",null,2458.61,null,2458.61,null,90,0.11,0.76,0.13,0,2,1,2,0,0,null,"R"]
[64874,null,"See CPT",null,302.73,null,302.73,null,0,0,0,0,0,0,0,2,1,0,null,"R"]
[64910,null,"See CPT",null,1384.17,null,1384.17,null,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R"]
[65101,null,"See CPT",null,1535.25,null,1535.25,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[65140,null,"See CPT",null,1675.82,null,1675.82,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[65222,null,"See CPT",null,123.08,null,89.24,null,0,0,0,0,0,2,1,1,0,0,null,"R"]
[65410,null,"See CPT",null,260.14999999999998,null,184.91,null,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM"]
[65756,null,"See CPT",null,2117.96,null,2117.96,null,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R"]
[65772,null,"See CPT",null,827.12,null,733.79,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[65815,null,"See CPT",null,1159.5999999999999,null,861.53,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[65920,null,"See CPT",null,1425.59,null,1425.59,null,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[66030,null,"See CPT",null,322.56,null,202.41,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[66500,null,"See CPT",null,711.63,null,711.63,null,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[66625,null,"See CPT",null,774.62,null,774.62,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[66762,null,"See CPT",null,863.87,null,767.62,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[66983,null,"See CPT",null,"By Report ",null,"By Report ",null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"N"]
[66990,null,"See CPT",null,156.91,null,156.91,null,0,0,0,0,0,0,0,1,0,0,null,"R"]
[67005,null,"See CPT",null,864.45,null,864.45,null,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[67105,null,"See CPT",null,536.04999999999995,null,495.81,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[67115,null,"See CPT",null,901.2,null,901.2,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[67228,null,"See CPT",null,610.72,null,543.04999999999995,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[67332,null,"See CPT",null,360.48,null,360.48,null,0,0,0,0,0,0,1,1,1,0,null,"R",null,"Y-CM"]
[67400,null,"See CPT",null,1862.48,null,1862.48,null,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[67430,null,"See CPT",null,2486.61,null,2486.61,null,90,0.1,0.7,0.2,0,2,1,2,0,0,null,"R"]
[67715,null,"See CPT",null,477.14,null,195.99,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[67801,null,"See CPT",null,296.89999999999998,null,236.24,null,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R"]
[67903,null,"See CPT",null,1091.3499999999999,null,865.03,null,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R"]
[67921,null,"See CPT",null,865.03,null,569.29999999999995,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[67935,null,"See CPT",null,1085.52,null,784.54,null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R"]
[67974,null,"See CPT",null,1653.07,null,1653.07,null,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R"]
[68115,null,"See CPT",null,598.47,null,329.56,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[68371,null,"See CPT",null,744.29,null,744.29,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[68550,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"X"]
[68745,null,"See CPT",null,1468.75,null,1468.75,null,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R"]
[69020,null,"See CPT",null,422.31,null,264.23,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R"]
[69105,null,"See CPT",null,262.49,null,117.83,null,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[69210,null,"See CPT",null,86.91,null,56.58,null,0,0,0,0,0,2,2,1,0,0,null,"R"]
[69433,null,"See CPT",null,369.81,null,243.82,null,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM"]
[69552,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,0,0,null,"X"]
[69637,null,"See CPT",null,2551.94,null,2551.94,null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,null,"R"]
[69650,null,"See CPT",null,1453,null,1453,null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R"]
[69662,null,"See CPT",null,2072.46,null,2072.46,null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R"]
[69711,null,"See CPT",null,1514.25,null,1514.25,null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,2,0,0,null,"R",null,"Y-CM"]
[69730,null,"See CPT",null,"Not Covered",null,"Not Covered",null,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"X"]
[69979,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,0,2,1,0,1,1,null,"N"]
[70010,null,"See CPT",null,103.24,null,103.24,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[70120,"TC","See CPT",null,56,null,56,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[70134,26,"See CPT",null,30.33,null,30.33,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70160,"TC","See CPT",null,55.41,null,55.41,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70200,null,"See CPT",null,88.66,null,88.66,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70260,"TC","See CPT",null,58.91,null,58.91,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70310,null,"See CPT",null,75.83,null,75.83,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70336,null,"See CPT",null,494.06,null,494.06,null,0,0,0,0,1,4,2,0,0,0,null,"R"]
[70350,null,"See CPT",null,32.08,null,32.08,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70370,26,"See CPT",null,26.83,null,26.83,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70390,26,"See CPT",null,32.08,null,32.08,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[70480,26,"See CPT",null,107.91,null,107.91,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70482,null,"See CPT",null,395.48,null,395.48,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70491,"TC","See CPT",null,229.82,null,229.82,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70492,"TC","See CPT",null,279.39999999999998,null,279.39999999999998,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70540,26,"See CPT",null,112.58,null,112.58,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70545,null,"See CPT",null,429.89,null,429.89,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70549,null,"See CPT",null,652.71,null,652.71,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[70552,"TC","See CPT",null,359.9,null,359.9,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[70557,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[71045,null,"See CPT",null,47.83,null,47.83,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[71048,null,"See CPT",null,84.58,null,84.58,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[71101,"TC","See CPT",null,55.41,null,55.41,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[71250,26,"See CPT",null,90.41,null,90.41,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[71270,26,"See CPT",null,104.99,null,104.99,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[71551,null,"See CPT",null,705.21,null,705.21,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[71555,"TC","See CPT",null,477.72,null,477.72,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72052,"TC","See CPT",null,89.83,null,89.83,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72074,null,"See CPT",null,82.83,null,82.83,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72083,null,"See CPT",null,149.32,null,149.32,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72110,null,"See CPT",null,96.83,null,96.83,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72125,26,"See CPT",null,83.41,null,83.41,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72126,26,"See CPT",null,102.08,null,102.08,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72130,"TC","See CPT",null,267.73,null,267.73,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72133,"TC","See CPT",null,264.23,null,264.23,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72147,"TC","See CPT",null,362.81,null,362.81,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[72156,null,"See CPT",null,600.79999999999995,null,600.79999999999995,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR"]
[72170,null,"See CPT",null,51.91,null,51.91,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72190,null,"See CPT",null,78.16,null,78.16,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72194,26,"See CPT",null,102.08,null,102.08,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72196,26,"See CPT",null,144.66,null,144.66,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[72200,26,"See CPT",null,15.17,null,15.17,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72255,"TC","See CPT",null,119.58,null,119.58,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[72295,"TC","See CPT",null,134.16,null,134.16,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR"]
[73010,"TC","See CPT",null,28.58,null,28.58,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73060,null,"See CPT",null,59.5,null,59.5,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[73070,null,"See CPT",null,54.25,null,54.25,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73092,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,3,0,0,0,null,"X"]
[73110,26,"See CPT",null,15.17,null,15.17,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73130,null,"See CPT",null,69.41,null,69.41,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73202,26,"See CPT",null,101.49,null,101.49,null,0,0,0,0,1,4,3,0,0,0,null,"R"]
[73220,"TC","See CPT",null,589.13,null,589.13,null,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR"]
[73222,26,"See CPT",null,136.49,null,136.49,null,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR"]
[73502,"TC","See CPT",null,69.41,null,69.41,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[73522,"TC","See CPT",null,75.25,null,75.25,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[73552,"TC","See CPT",null,50.75,null,50.75,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73564,null,"See CPT",null,88.08,null,88.08,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73565,null,"See CPT",null,74.66,null,74.66,null,0,0,0,0,1,0,2,0,0,0,null,"R"]
[73600,null,"See CPT",null,59.5,null,59.5,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73630,26,"See CPT",null,14,null,14,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73660,26,"See CPT",null,11.08,null,11.08,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[73706,26,"See CPT",null,158.07,null,158.07,null,0,0,0,0,1,4,3,0,0,0,null,"R"]
[73720,null,"See CPT",null,634.04999999999995,null,634.04999999999995,null,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR"]
[73725,"TC","See CPT",null,484.14,null,484.14,null,0,0,0,0,1,4,3,0,0,0,null,"R"]
[74018,"TC","See CPT",null,40.25,null,40.25,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74150,26,"See CPT",null,99.74,null,99.74,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[74174,null,"See CPT",null,716.29,null,716.29,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[74176,"TC","See CPT",null,197.16,null,197.16,null,0,0,0,0,1,4,0,9,0,0,null,"R"]
[74183,"TC","See CPT",null,450.31,null,450.31,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[74210,26,"See CPT",null,49.58,null,49.58,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74230,null,"See CPT",null,226.9,null,226.9,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74248,null,"See CPT",null,149.91,null,149.91,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74250,"TC","See CPT",null,154.57,null,154.57,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74261,26,"See CPT",null,202.41,null,202.41,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[74290,26,"See CPT",null,27.42,null,27.42,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"]
[74355,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[74415,null,"See CPT",null,278.82,null,278.82,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74440,null,"See CPT",null,177.91,null,177.91,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74440,26,"See CPT",null,31.5,null,31.5,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74455,26,"See CPT",null,27.42,null,27.42,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[74713,26,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[75559,"TC","See CPT",null,452.06,null,452.06,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[75563,"TC","See CPT",null,540.72,null,540.72,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[75574,null,"See CPT",null,606.63,null,606.63,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[75630,null,"See CPT",null,282.89999999999998,null,282.89999999999998,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75710,null,"See CPT",null,268.32,null,268.32,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75726,26,"See CPT",null,165.66,null,165.66,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75731,"TC","See CPT",null,189.57,null,189.57,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75743,26,"See CPT",null,135.33000000000001,null,135.33000000000001,null,0,0,0,0,1,6,2,0,0,0,null,"R"]
[75774,null,"See CPT",null,174.99,null,174.99,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[75805,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[75822,"TC","See CPT",null,121.91,null,121.91,null,0,0,0,0,1,6,2,0,0,0,null,"R"]
[75827,26,"See CPT",null,92.74,null,92.74,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75833,26,"See CPT",null,120.74,null,120.74,null,0,0,0,0,1,6,2,0,0,0,null,"R"]
[75872,"TC","See CPT",null,139.99,null,139.99,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75880,"TC","See CPT",null,139.99,null,139.99,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75891,"TC","See CPT",null,136.49,null,136.49,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[75898,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[75957,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[75958,26,"See CPT",null,321.39999999999998,null,321.39999999999998,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76000,26,"See CPT",null,26.83,null,26.83,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76100,26,"See CPT",null,49,null,49,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76015,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
[76125,"TC","See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[76380,26,"See CPT",null,79.91,null,79.91,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[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,149.32,null,149.32,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76511,"TC","See CPT",null,40.25,null,40.25,null,0,0,0,0,1,7,3,0,0,0,null,"R"]
[76516,null,"See CPT",null,86.33,null,86.33,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[76641,null,"See CPT",null,188.99,null,188.99,null,0,0,0,0,1,0,1,0,0,0,null,"R",null,"Y-CM"]
[76700,"TC","See CPT",null,145.83000000000001,null,145.83000000000001,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[76706,26,"See CPT",null,46.08,null,46.08,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[76776,26,"See CPT",null,63.58,null,63.58,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[76802,null,"See CPT",null,109.08,null,109.08,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76812,"TC","See CPT",null,198.32,null,198.32,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76814,"TC","See CPT",null,50.75,null,50.75,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76818,26,"See CPT",null,88.66,null,88.66,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[76825,null,"See CPT",null,474.81,null,474.81,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[76828,26,"See CPT",null,46.66,null,46.66,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76830,"TC","See CPT",null,159.82,null,159.82,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76870,"TC","See CPT",null,131.24,null,131.24,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[76881,null,"See CPT",null,96.24,null,96.24,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76886,26,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[76937,26,"See CPT",null,23.92,null,23.92,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[76945,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[76975,"TC","See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[76978,"TC","See CPT",null,222.24,null,222.24,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[76981,null,"See CPT",null,195.99,null,195.99,null,0,0,0,0,1,4,0,0,0,0,null,"R"]
[76998,"TC","See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[77002,null,"See CPT",null,211.74,null,211.74,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[77011,26,"See CPT",null,109.08,null,109.08,null,0,0,0,0,1,0,0,9,0,0,null,"R",null,"Y-CM"]
[77014,null,"See CPT",null,221.07,null,221.07,null,0,0,0,0,1,0,0,9,0,0,null,"R",null,"Y-CM"]
[77047,26,"See CPT",null,134.16,null,134.16,null,0,0,0,0,1,4,2,0,0,0,null,"R",null,"Y-UR"]
[77054,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,9,0,0,null,"X"]
[77062,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,9,0,0,null,"X"]
[77067,"TC","See CPT",null,173.82,null,173.82,null,0,0,0,0,1,0,2,0,0,0,null,"R",null,"Y-CM"]
[77074,null,"See CPT",null,121.33,null,121.33,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[77075,null,"See CPT",null,183.74,null,183.74,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[77081,26,"See CPT",null,16.920000000000002,null,16.920000000000002,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77084,26,"See CPT",null,134.74,null,134.74,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[77262,null,"See CPT",null,196.57,null,196.57,null,0,0,0,0,2,0,0,0,0,0,null,"R",null,"Y-CM"]
[77290,26,"See CPT",null,148.74,null,148.74,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77300,null,"See CPT",null,124.24,null,124.24,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77301,null,"See CPT",null,3452.55,null,3452.55,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77318,"TC","See CPT",null,583.88,null,583.88,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77321,"TC","See CPT",null,84.58,null,84.58,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77334,26,"See CPT",null,109.66,null,109.66,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77399,26,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[77423,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
[77469,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[77605,"TC","See CPT",null,1584.83,null,1584.83,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77605,26,"See CPT",null,174.99,null,174.99,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77762,null,"See CPT",null,1032.44,null,1032.44,null,90,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77762,"TC","See CPT",null,482.39,null,482.39,null,90,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77772,26,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[77778,"TC","See CPT",null,884.28,null,884.28,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[77799,26,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[78015,"TC","See CPT",null,333.65,null,333.65,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78070,"TC","See CPT",null,428.14,null,428.14,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78072,null,"See CPT",null,725.63,null,725.63,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78104,null,"See CPT",null,419.39,null,419.39,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78110,null,"See CPT",null,130.08000000000001,null,130.08000000000001,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78130,26,"See CPT",null,42.58,null,42.58,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78140,26,"See CPT",null,42.58,null,42.58,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78199,"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"]
[78202,null,"See CPT",null,363.4,null,363.4,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78230,"TC","See CPT",null,265.39999999999998,null,265.39999999999998,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78231,"TC","See CPT",null,156.32,null,156.32,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78261,26,"See CPT",null,48.41,null,48.41,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78266,null,"See CPT",null,742.54,null,742.54,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78291,26,"See CPT",null,74.08,null,74.08,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78299,"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"]
[78350,null,"See CPT",null,58.91,null,58.91,null,0,0,0,0,1,9,9,9,9,9,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"]
[78430,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-UR"]
[78433,26,"See CPT",null,181.41,null,181.41,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR"]
[78452,26,"See CPT",null,132.99,null,132.99,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-UR"]
[78454,26,"See CPT",null,111.99,null,111.99,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-UR"]
[78466,"TC","See CPT",null,241.49,null,241.49,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[78468,"TC","See CPT",null,271.82,null,271.82,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[78481,"TC","See CPT",null,218.74,null,218.74,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[78492,null,"See CPT",null,3403.34,null,3403.34,null,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-UR"]
[78579,null,"See CPT",null,315.57,null,315.57,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78580,26,"See CPT",null,61.25,null,61.25,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78600,26,"See CPT",null,36.159999999999997,null,36.159999999999997,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78601,26,"See CPT",null,42,null,42,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78609,null,"See CPT",null,127.16,null,127.16,null,0,0,0,0,1,9,9,9,9,9,null,"R",null,"Y-CM"]
[78635,"TC","See CPT",null,514.47,null,514.47,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78699,26,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
[78707,null,"See CPT",null,395.48,null,395.48,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78730,null,"See CPT",null,123.66,null,123.66,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78761,"TC","See CPT",null,303.32,null,303.32,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[78801,26,"See CPT",null,59.5,null,59.5,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[78803,26,"See CPT",null,88.08,null,88.08,null,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM"]
[78812,null,"See CPT",null,"By Report ",null,"By Report ",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-UR"]
[78816,26,"See CPT",null,201.82,null,201.82,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR"]
[78831,"TC","See CPT",null,1033.6099999999999,null,1033.6099999999999,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[79005,null,"See CPT",null,245.57,null,245.57,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[79403,"TC","See CPT",null,153.41,null,153.41,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[79999,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"]
[80055,null,"See CPT",null,88.04,null,88.04,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80150,null,"See CPT",null,21.26,null,21.26,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80171,null,"See CPT",null,30.55,null,30.55,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80178,null,"See CPT",null,9.32,null,9.32,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80185,null,"See CPT",null,18.68,null,18.68,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80199,null,"See CPT",null,38.229999999999997,null,38.229999999999997,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[80285,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[80324,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[80336,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"]
[80356,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"]
[80369,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[80402,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[80424,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,128.54,null,128.54,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[81015,null,"See CPT",null,4.3,null,4.3,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[81107,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81162,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81170,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81177,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81192,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81206,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81216,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81228,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81236,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"]
[81259,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81271,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81285,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81294,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81306,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81314,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"]
[81329,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81343,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81349,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81360,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81381,null,"See CPT",null,239.56,null,239.56,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[81406,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81414,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81432,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81442,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81448,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81460,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81503,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81517,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81523,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[81554,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[82030,null,"See CPT",null,36.380000000000003,null,36.380000000000003,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82088,null,"See CPT",null,57.46,null,57.46,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82104,null,"See CPT",null,20.39,null,20.39,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82140,null,"See CPT",null,20.54,null,20.54,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82234,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[82252,null,"See CPT",null,6.43,null,6.43,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82331,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[82355,null,"See CPT",null,16.329999999999998,null,16.329999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82435,null,"See CPT",null,6.49,null,6.49,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82485,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[82525,null,"See CPT",null,17.5,null,17.5,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82575,null,"See CPT",null,13.34,null,13.34,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82615,null,"See CPT",null,13.47,null,13.47,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82657,null,"See CPT",null,31.26,null,31.26,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82693,null,"See CPT",null,21.01,null,21.01,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82757,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[82785,null,"See CPT",null,23.21,null,23.21,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82947,null,"See CPT",null,5.54,null,5.54,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[82951,null,"See CPT",null,18.149999999999999,null,18.149999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83003,null,"See CPT",null,23.5,null,23.5,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83015,null,"See CPT",null,29.53,null,29.53,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83051,null,"See CPT",null,10.31,null,10.31,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83080,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[83521,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[83615,null,"See CPT",null,8.52,null,8.52,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83631,null,"See CPT",null,27.68,null,27.68,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83670,null,"See CPT",null,13.83,null,13.83,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83735,null,"See CPT",null,9.4499999999999993,null,9.4499999999999993,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83872,null,"See CPT",null,8.26,null,8.26,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83921,null,"See CPT",null,29.91,null,29.91,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[83970,null,"See CPT",null,58.2,null,58.2,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84081,null,"See CPT",null,23.29,null,23.29,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"]
[84150,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[84163,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[84207,null,"See CPT",null,39.619999999999997,null,39.619999999999997,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84228,null,"See CPT",null,16.399999999999999,null,16.399999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84302,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[84376,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[84431,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[84450,null,"See CPT",null,7.3,null,7.3,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84485,null,"See CPT",null,10.15,null,10.15,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[84510,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[84586,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[84630,null,"See CPT",null,16.059999999999999,null,16.059999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85013,null,"See CPT",null,9.8699999999999992,null,9.8699999999999992,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85048,null,"See CPT",null,3.58,null,3.58,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85230,null,"See CPT",null,25.24,null,25.24,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85260,null,"See CPT",null,25.24,null,25.24,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85306,null,"See CPT",null,21.6,null,21.6,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85345,null,"See CPT",null,6.61,null,6.61,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85400,null,"See CPT",null,10.87,null,10.87,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[85475,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[85549,null,"See CPT",null,26.44,null,26.44,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[85610,null,"See CPT",null,6.05,null,6.05,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86000,null,"See CPT",null,9.84,null,9.84,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86015,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[86052,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[86152,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[86171,null,"See CPT",null,14.11,null,14.11,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86225,null,"See CPT",null,19.37,null,19.37,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86258,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[86317,null,"See CPT",null,21.14,null,21.14,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86335,null,"See CPT",null,41.38,null,41.38,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86356,null,"See CPT",null,37.76,null,37.76,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86367,null,"See CPT",null,109.67,null,109.67,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86382,null,"See CPT",null,23.84,null,23.84,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86590,null,"See CPT",null,17.850000000000001,null,17.850000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86596,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[86635,null,"See CPT",null,16.170000000000002,null,16.170000000000002,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86658,null,"See CPT",null,18.37,null,18.37,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86671,null,"See CPT",null,17.27,null,17.27,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86689,null,"See CPT",null,27.28,null,27.28,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86701,null,"See CPT",null,12.53,null,12.53,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86711,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[86759,null,"See CPT",null,25.7,null,25.7,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86768,null,"See CPT",null,18.600000000000001,null,18.600000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86805,null,"See CPT",null,267.20999999999998,null,267.20999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86808,null,"See CPT",null,41.85,null,41.85,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86829,null,"See CPT",null,90.51,null,90.51,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86880,null,"See CPT",null,7.6,null,7.6,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[86911,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[86950,null,"See CPT",null,290.38,null,290.38,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
[86977,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"]
[87073,null,"See CPT",null,13.62,null,13.62,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87107,null,"See CPT",null,14.55,null,14.55,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87154,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[87168,null,"See CPT",null,6.02,null,6.02,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87207,26,"See CPT",null,31.5,null,31.5,null,0,0,0,0,6,0,0,0,0,0,null,"R"]
[87252,null,"See CPT",null,36.76,null,36.76,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87269,null,"See CPT",null,19.190000000000001,null,19.190000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87279,null,"See CPT",null,23.17,null,23.17,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87335,null,"See CPT",null,17.850000000000001,null,17.850000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87339,null,"See CPT",null,22.56,null,22.56,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87426,null,"See CPT",null,49.82,null,49.82,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[87468,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[87483,null,"See CPT",null,587.66,null,587.66,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[87496,null,"See CPT",null,49.48,null,49.48,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87502,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[87520,null,"See CPT",null,44.02,null,44.02,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87537,null,"See CPT",null,30.91,null,30.91,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87539,null,"See CPT",null,82.65,null,82.65,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87557,null,"See CPT",null,60.4,null,60.4,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87594,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[87634,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[87662,null,"See CPT",null,72.349999999999994,null,72.349999999999994,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87809,null,"See CPT",null,30.68,null,30.68,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[87899,null,"See CPT",null,22.66,null,22.66,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
[88014,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[88025,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
[88045,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
[88112,26,"See CPT",null,47.83,null,47.83,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88141,null,"See CPT",null,46.08,null,46.08,null,0,0,0,0,2,0,0,0,0,0,null,"R",null,"Y-CM"]
[88148,null,"See CPT",null,25.65,null,25.65,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88166,null,"See CPT",null,25.65,null,25.65,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88172,26,"See CPT",null,61.83,null,61.83,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88182,null,"See CPT",null,298.64999999999998,null,298.64999999999998,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88199,"TC","See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[88241,null,"See CPT",null,17.05,null,17.05,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88273,null,"See CPT",null,49.08,null,49.08,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
[88302,"TC","See CPT",null,50.16,null,50.16,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88305,"TC","See CPT",null,67.08,null,67.08,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88311,"TC","See CPT",null,15.75,null,15.75,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88319,"TC","See CPT",null,205.9,null,205.9,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88332,26,"See CPT",null,53.66,null,53.66,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88334,26,"See CPT",null,65.33,null,65.33,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88342,null,"See CPT",null,208.82,null,208.82,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88350,null,"See CPT",null,205.32,null,205.32,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[88360,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[88362,26,"See CPT",null,193.66,null,193.66,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[88367,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[88369,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[88377,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[88380,"TC","See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
[88720,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[89060,26,"See CPT",null,31.5,null,31.5,null,0,0,0,0,6,0,0,0,0,0,null,"R"]
[89240,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N"]
[89272,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[89330,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[89346,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[90288,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"]
[90377,null,"See CPT",null,241.15,null,241.15,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
[90396,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[90619,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
[90632,null,"See CPT",null,72.16,null,72.16,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
[90656,null,"See CPT",null,22.35,null,22.35,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
[90673,null,"See CPT",null,83.49,null,83.49,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
[90685,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"]
[90733,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"]
[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"]
[90845,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[90868,null,"See CPT",null,464.91,null,464.91,null,0,0,0,0,0,0,0,1,0,0,null,"F",null,"Y-CM"]
[90912,null,"See CPT",null,146.99,null,75.25,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[90953,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[90964,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[90989,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
[91020,"TC","See CPT",null,373.9,null,373.9,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[91030,null,"See CPT",null,265.98,null,265.98,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[91035,"TC","See CPT",null,673.13,null,673.13,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[91111,null,"See CPT",null,1558.58,null,1558.58,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[91120,null,"See CPT",null,895.95,null,895.95,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[91132,"TC","See CPT",null,737.87,null,737.87,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[91133,26,"See CPT",null,58.91,null,58.91,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[91314,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[92004,null,"See CPT",null,270.07,null,166.24,null,0,0,0,0,0,0,2,0,0,0,null,"R"]
[92060,null,"See CPT",null,117.24,null,117.24,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92082,null,"See CPT",null,86.33,null,86.33,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92133,"TC","See CPT",null,26.83,null,26.83,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92137,null,"See CPT",null,107.91,null,107.91,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92235,"TC","See CPT",null,218.15,null,218.15,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92265,null,"See CPT",null,160.99,null,160.99,null,0,0,0,0,1,7,2,0,0,0,null,"R"]
[92283,26,"See CPT",null,15.75,null,15.75,null,0,0,0,0,1,7,2,0,0,0,null,"R",null,"Y-CM"]
[92284,null,"See CPT",null,57.16,null,57.16,null,0,0,0,0,3,7,2,0,0,0,null,"R",null,"Y-CM"]
[92314,null,"See CPT",null,158.07,null,59.5,null,0,0,0,0,9,9,9,9,9,9,null,"R"]
[92340,null,"See CPT",null,63.58,null,32.08,null,0,0,0,0,9,9,9,9,9,9,null,"R"]
[92504,null,"See CPT",null,53.08,null,16.920000000000002,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[92518,null,"See CPT",null,139.41,null,76.41,null,0,0,0,0,0,0,2,0,0,0,null,"R",null,"Y-CM"]
[92531,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
[92542,26,"See CPT",null,44.33,null,44.33,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[92545,"TC","See CPT",null,7,null,7,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[92548,null,"See CPT",null,85.16,null,85.16,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[92556,null,"See CPT",null,88.66,null,88.66,null,0,0,0,0,3,0,2,0,0,0,null,"R"]
[92568,null,"See CPT",null,26.83,null,26.83,null,0,0,0,0,7,0,2,0,0,0,null,"R"]
[92587,null,"See CPT",null,39.08,null,39.08,null,0,0,0,0,1,0,2,0,0,0,null,"R"]
[92593,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
[92608,null,"See CPT",null,89.24,null,89.24,null,0,0,0,0,7,0,0,0,0,0,null,"R",null,"Y-CM"]
[92616,null,"See CPT",null,427.56,null,177.91,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[92640,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,0,2,0,0,0,null,"X"]
[92652,null,"See CPT",null,197.74,null,197.74,null,0,0,0,0,0,0,2,0,0,0,null,"R",null,"Y-CM"]
[92934,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[92970,null,"See CPT",null,320.82,null,320.82,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[92979,26,"See CPT",null,128.91,null,128.91,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[93005,null,"See CPT",null,11.67,null,11.67,null,0,0,0,0,3,6,0,0,0,0,null,"R"]
[93041,null,"See CPT",null,12.25,null,12.25,null,0,0,0,0,3,6,0,0,0,0,null,"R"]
[93229,null,"See CPT",null,1446,null,1446,null,0,0,0,0,3,6,0,0,0,0,null,"R"]
[93244,null,"See CPT",null,40.25,null,40.25,null,0,0,0,0,2,0,0,0,0,0,null,"R",null,"Y-CM"]
[93260,"TC","See CPT",null,65.33,null,65.33,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93280,26,"See CPT",null,64.75,null,64.75,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93282,26,"See CPT",null,72.33,null,72.33,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93285,26,"See CPT",null,44.33,null,44.33,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93288,null,"See CPT",null,102.66,null,102.66,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93292,null,"See CPT",null,92.74,null,92.74,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93303,26,"See CPT",null,107.33,null,107.33,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93307,null,"See CPT",null,250.24,null,250.24,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[93313,null,"See CPT",null,19.25,null,19.25,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[93318,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,6,0,0,0,0,null,"N"]
[93319,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[93351,26,"See CPT",null,144.66,null,144.66,null,0,0,0,0,1,6,0,9,9,9,null,"R"]
[93451,"TC","See CPT",null,1299.01,null,1299.01,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[93455,"TC","See CPT",null,1301.93,null,1301.93,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[93458,null,"See CPT",null,1832.15,null,1832.15,null,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93462,null,"See CPT",null,352.9,null,352.9,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[93464,"TC","See CPT",null,239.15,null,239.15,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[93571,"TC","See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[93574,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[93591,null,"See CPT",null,1539.91,null,1539.91,null,0,0,0,0,0,2,0,0,2,1,null,"R",null,"Y-UR"]
[93596,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,2,0,0,0,0,null,"X"]
[93600,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"]
[93603,"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"]
[93615,"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,"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"]
[93622,26,"See CPT",null,289.89999999999998,null,289.89999999999998,null,0,0,0,0,1,0,0,0,0,0,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"]
[93644,26,"See CPT",null,249.07,null,249.07,null,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM"]
[93653,null,"See CPT",null,1423.25,null,1423.25,null,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-UR"]
[93724,"TC","See CPT",null,87.5,null,87.5,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93745,"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"]
[93799,26,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N"]
[93880,"TC","See CPT",null,282.32,null,282.32,null,0,0,0,0,1,6,2,0,0,0,null,"R"]
[93895,null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,1,6,0,0,0,0,null,"N"]
[93896,null,"See CPT",null,332.48,null,332.48,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[93926,null,"See CPT",null,264.23,null,264.23,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[93930,26,"See CPT",null,65.91,null,65.91,null,0,0,0,0,1,6,2,0,0,0,null,"R"]
[93975,26,"See CPT",null,96.24,null,96.24,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[93980,26,"See CPT",null,104.99,null,104.99,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[93986,"TC","See CPT",null,229.24,null,229.24,null,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM"]
[93990,"TC","See CPT",null,229.82,null,229.82,null,0,0,0,0,1,6,0,0,0,0,null,"R"]
[94060,26,"See CPT",null,18.079999999999998,null,18.079999999999998,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[94070,"TC","See CPT",null,68.25,null,68.25,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[94452,26,"See CPT",null,25.08,null,25.08,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[94453,null,"See CPT",null,124.24,null,124.24,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[94645,null,"See CPT",null,32.08,null,32.08,null,0,0,0,0,5,0,0,0,0,0,null,"R"]
[94680,null,"See CPT",null,97.41,null,97.41,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[94690,"TC","See CPT",null,84,null,84,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[94729,26,"See CPT",null,15.75,null,15.75,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[94781,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,1,0,0,null,"X"]
[95004,null,"See CPT",null,7,null,7,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[95117,null,"See CPT",null,23.33,null,23.33,null,0,0,0,0,5,0,0,0,0,0,null,"R",null,"Y-CM"]
[95145,null,"See CPT",null,65.91,null,5.83,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[95180,null,"See CPT",null,254.9,null,183.16,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[95706,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,370.4,null,362.81,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[95726,null,"See CPT",null,725.63,null,711.04,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[95801,26,"See CPT",null,71.75,null,71.75,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[95803,"TC","See CPT",null,168.57,null,168.57,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[95811,"TC","See CPT",null,1008.53,null,1008.53,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
[95812,"TC","See CPT",null,550.04999999999995,null,550.04999999999995,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95819,null,"See CPT",null,845.2,null,845.2,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95830,null,"See CPT",null,1234.8499999999999,null,162.16,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[95863,"TC","See CPT",null,212.32,null,212.32,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95867,null,"See CPT",null,191.91,null,191.91,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95870,null,"See CPT",null,148.74,null,148.74,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95872,null,"See CPT",null,330.73,null,330.73,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95886,26,"See CPT",null,79.91,null,79.91,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[95887,26,"See CPT",null,65.33,null,65.33,null,0,0,0,0,1,0,3,0,0,0,null,"R"]
[95908,null,"See CPT",null,201.82,null,201.82,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95911,null,"See CPT",null,380.31,null,380.31,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95923,null,"See CPT",null,217.57,null,217.57,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95925,"TC","See CPT",null,237.99,null,237.99,null,0,0,0,0,1,0,2,0,0,0,null,"R"]
[95927,"TC","See CPT",null,281.73,null,281.73,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95930,26,"See CPT",null,32.659999999999997,null,32.659999999999997,null,0,0,0,0,1,0,2,0,0,0,null,"R"]
[95954,"TC","See CPT",null,516.22,null,516.22,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95955,"TC","See CPT",null,243.82,null,243.82,null,0,0,0,0,1,0,0,0,0,0,null,"R"]
[95961,null,"See CPT",null,601.38,null,601.38,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"]
[95980,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[96002,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,2,0,0,0,null,"X"]
[96125,null,"See CPT",null,186.66,null,186.66,null,0,0,0,0,7,5,0,0,0,0,null,"R",null,"Y-CM"]
[96130,null,"See CPT",null,216.4,null,194.24,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[96170,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[96203,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[96370,null,"See CPT",null,29.75,null,29.75,null,0,0,0,0,5,0,0,0,0,0,null,"R"]
[96406,null,"See CPT",null,233.32,null,79.33,null,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM"]
[96446,null,"See CPT",null,283.48,null,34.409999999999997,null,0,0,0,0,5,0,0,0,0,0,null,"R",null,"Y-CM"]
[96542,null,"See CPT",null,235.07,null,73.5,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[96920,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
[96935,null,"See CPT",null,143.49,null,143.49,null,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM"]
[97018,null,"See CPT",null,11.67,null,11.67,null,0,0,0,0,7,5,0,0,0,0,null,"R"]
[97036,null,"See CPT",null,65.33,null,65.33,null,0,0,0,0,7,5,0,0,0,0,null,"R"]
[97124,null,"See CPT",null,56.58,null,56.58,null,0,0,0,0,7,5,0,0,0,0,null,"R",null,"Y-CM"]
[97158,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[97172,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[97546,null,"See CPT",null,86.67,null,86.67,null,0,0,0,0,7,0,0,0,0,0,null,"F",null,"Y-CM"]
[97608,null,"See CPT",null,652.13,null,42.58,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[97804,null,"See CPT",null,30.91,null,28,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[98007,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[98014,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[98926,null,"See CPT",null,82.25,null,61.25,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[98967,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[98980,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[99056,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B",null,"Y-CM"]
[99116,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
[99155,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[99192,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"]
[99202,null,"See CPT",null,131.24,null,83.41,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99231,null,"See CPT",null,86.91,null,86.91,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99242,null,"See CPT",null,135.91,null,98.58,null,0,0,0,0,9,9,9,9,9,9,null,"R"]
[99255,null,"See CPT",null,328.98,null,328.98,null,0,0,0,0,9,9,9,9,9,9,null,"R"]
[99309,null,"See CPT",null,193.07,null,193.07,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99350,null,"See CPT",null,328.4,null,328.4,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
[99374,null,"See CPT",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
[99386,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[99401,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[99404,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[99427,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[99439,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[99457,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[99472,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[99478,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
[99493,null,"See CPT",null,249.07,null,181.99,null,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM"]
[99500,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[99504,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
[99606,null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0010U",null,"See CPT",null,602.44000000000005,null,602.44000000000005,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
["0013A",null,"See CPT",null,40,null,40,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["0020U",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["0044A",null,"See CPT",null,40,null,40,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["0530U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0075T",26,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
["0089U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0093U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0098T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0102U",null,"See CPT",null,1838.57,null,1838.57,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-ONC"]
["0110U",null,"See CPT",null,38.229999999999997,null,38.229999999999997,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-ONC"]
["0122U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0126U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0140U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0143U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0153U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0159U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0201T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,2,0,0,0,null,"X"]
["0211T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0214T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,1,0,0,0,null,"X"]
["0220T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0220U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0228U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0236U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0241U",null,"See CPT",null,201.11,null,201.11,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
["0274T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0289U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0298U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0331T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0345T",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"]
["0373T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0378T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0395T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0406A",null,"See CPT",null,"State Rate",null,"State Rate",null,0,0,0,0,9,9,9,9,9,9,null,"S"]
["0413T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0420A",null,"See CPT",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["0426U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0430U",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["0440A",null,"See CPT",null,188.22,null,188.22,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["0447T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
["0484T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,2,1,null,"X"]
["0496T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,0,9,9,9,9,null,"X"]
["0513F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["0517T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
["0523T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0527T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
["0546T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0555T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0562T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0571T",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"]
["0585T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0623T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,4,0,0,0,0,0,null,"X"]
["0633T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,3,0,0,0,null,"X"]
["0674T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
["0677T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
["0693T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0697T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,4,0,0,0,0,null,"X"]
["0711T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,9,9,9,9,9,null,"X"]
["0744T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,2,1,0,null,"X"]
["0755T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0758T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0776T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0781T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,3,2,1,0,0,31622,"X"]
["0817T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,0,0,0,null,"X"]
["0825T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,0,1,0,0,null,"X"]
["0833T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0840T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0854T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0856T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0906T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0917T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["0926T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,6,0,0,0,0,null,"X"]
["0929T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,3,0,0,0,0,0,null,"X"]
["0936T",null,"See CPT",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,2,1,1,0,0,null,"X"]
["0801V",null,"See CPT",null,9.08,null,9.08,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["0830V",null,"See CPT",null,10.65,null,10.65,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["0842V",null,"See CPT",null,10.65,null,10.65,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["1003F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1015F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1031F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1034F",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,225.45,null,225.45,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["1065F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1074M",null,"AP response to vrc/employer request re: RTW",null,37.18,null,37.18,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["1088M",null,"HEALTH SERVICES COORDINATOR-SURGICAL",null,10.119999999999999,null,10.119999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["1111F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1118F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1128F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1135F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1150F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1158F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1181F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1195M",null,"Impairment rating by consult, complex",null,910.07,null,910.07,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["1243M",null,"Ur contract:  retrospective inpatient review without bill audit",null,"Contracted",null,"Contracted",null,0,0,0,0,9,9,9,9,9,9,null,"C"]
["1247M",null,"UR, advanced imaging, web-based",null,"Contracted",null,"Contracted",null,0,0,0,0,9,9,9,9,9,9,null,"C"]
["1278M",null,"CCM, VALUE BASE-INITIAL PHASE",null,"Contracted",null,"Contracted",null,0,0,0,0,9,9,9,9,9,9,null,"C"]
["1302W",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"]
["1303W",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"]
["1490F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["1502F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["2010M",null,"Pain clinic - evaluation",null,1343.26,null,1343.26,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["2023F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["2026F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3011F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3016F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3042F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3050F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3075F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3091F",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"]
["3118F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3142F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3250F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3270F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3285F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3321F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3331F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3350F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3386F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3475F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["3492F",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"]
["3551F",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"]
["3762F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4012F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4015F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4047F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4050F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4062F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4079F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4115F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4142F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4165F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4175F",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"]
["4193F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4220F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4267F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4276F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4340F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4541F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["4558F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["5060F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["5200F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["5934M",null,"Outpatient Day Program - Lunch",null,"State Rate",null,"State Rate",null,0,0,0,0,9,9,9,9,9,9,null,"S"]
["6070F",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,757.11,null,757.11,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["8893H",null,"See CPT",null,192.49,null,192.49,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["8952H",null,"See CPT",null,816.87,null,816.87,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["9005F",null,"See CPT",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"T"]
["9984M",null,"SCHEDULING SYS IN-PERSON INTERPRETING",null,"Contracted",null,"Contracted",null,0,0,0,0,9,9,9,9,9,9,null,"C"]
["A0090",null,"Interest escort in non er",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A0190",null,"Noner transport meals recip",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A0390",null,"Advanced life support mileag",null,31.29,null,31.29,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A0424",null,"Extra ambulance attendant",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A0999",null,"Unlisted ambulance service",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A2010",null,"Apis, per square centimeter",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A2017",null,"Permeaderm glove, each",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A2029",null,"Mirotract matrix sheet",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A4206",null,"1 cc sterile syringe&needle",null,1.1000000000000001,null,1.1000000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4209",null,"5+ cc sterile syringe&needle",null,6.33,null,6.33,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4232",null,"Syringe w/needle insulin 3cc",null,4.58,null,4.58,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4234",null,"J-cell batt for glucose mon",null,5.61,null,5.61,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4253",null,"Blood glucose/reagent strips",null,67.19,null,67.19,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4259",null,"Lancets per box",null,1.43,null,1.43,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["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,24.21,null,24.21,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4326",null,"Male external catheter",null,15.22,null,15.22,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4330",null,"Stool collection pouch",null,10.11,null,10.11,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4344",null,"Cath indw foley 2 way silicn",null,22.58,null,22.58,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4363",null,"Ostomy clamp, replacement",null,3.34,null,3.34,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4371",null,"Skin barrier powder per oz",null,5.07,null,5.07,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4379",null,"Urinary plastic pouch w fcpl",null,21.19,null,21.19,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4396",null,"Peristomal hernia supprt blt",null,57.13,null,57.13,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4408",null,"Ext wear ost skn barr >4sq\"",null,13.93,null,13.93,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4415",null,"Ost skn barr w/o conv >4 sqi",null,8.4600000000000009,null,8.4600000000000009,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4418",null,"Ost pch clsd w/o bar w filtr",null,2.56,null,2.56,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4431",null,"Ost pch urine w barrier/tapv",null,8.76,null,8.76,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4438",null,"Adhesive clip ext ens contr",null,1.95,null,1.95,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4461",null,"Surgicl dress hold non-reuse",null,4.66,null,4.66,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A4500",null,"Below knee surgical stocking",null,44.32,null,44.32,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["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"]
["A4561",null,"Pessary rubber, any type",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A4600",null,"Sleeve, inter limb comp dev",null,53.17,null,53.17,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4604",null,"Tubing with heating element",null,60.63,null,60.63,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4627",null,"Spacer bag/reservoir",null,34.869999999999997,null,34.869999999999997,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4629",null,"Tracheostomy care kit",null,6.52,null,6.52,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4648",null,"Implantable tissue marker",null,379.84,null,379.84,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4653",null,"Pd catheter anchor belt",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A4714",null,"Treated water per gallon",null,47.9,null,47.9,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4737",null,"Inj anesthetic per 10 ml",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A4750",null,"Art or venous blood tubing",null,22.89,null,22.89,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A4774",null,"Ammonia test strips",null,37.979999999999997,null,37.979999999999997,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A5053",null,"Clsd ostomy pouch faceplate",null,2.4300000000000002,null,2.4300000000000002,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A5057",null,"1 pc ost pou w built-in conv",null,13.54,null,13.54,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A5105",null,"Urinary suspensory",null,57.54,null,57.54,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A5126",null,"Disk/foam pad +or- adhesive",null,1.62,null,1.62,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A5508",null,"Diabetic deluxe shoe",null,42.04,null,42.04,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["A6197",null,"Alginate drsg >16 <=48 sq in",null,23.21,null,23.21,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6207",null,"Contact layer >16<= 48 sq in",null,10.36,null,10.36,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6214",null,"Foam drg > 48 sq in w/border",null,14.53,null,14.53,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6230",null,"Gauze > 48 sq in water/salne",null,2.34,null,2.34,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6233",null,"Hydrogel dressing >48 sq in",null,27.06,null,27.06,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6246",null,"Hydrogel drg >16<=48 in w/b",null,14.02,null,14.02,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6254",null,"Absorpt drg <=16 sq in w/bdr",null,1.69,null,1.69,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6404",null,"Sterile gauze > 48 sq in",null,1.27,null,1.27,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6441",null,"Pad band w>=3\" <5\"/yd",null,0.96,null,0.96,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6455",null,"Self-adher band >=5\"/yd",null,1.97,null,1.97,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6460",null,"Synthetic drsg <= 16 sq in",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A6511",null,"Compres burn garment panty",null,443.15,null,443.15,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A6520",null,"G com garmnt glove nghttime",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["A6532",null,"Compression stocking bk40-50",null,86.03,null,86.03,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A6541",null,"Gc stocking waistlngth 40-50",null,135.93,null,135.93,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A6558",null,"G com stcking thgh 40+ cust",null,314.87,null,314.87,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6565",null,"Grad comp gauntlet custom",null,172.55,null,172.55,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6576",null,"Custom grad com sleeve med",null,191.93,null,191.93,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6581",null,"Gradient comp glove",null,71.78,null,71.78,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6598",null,"G comp bandage med stretch",null,0.74,null,0.74,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A6606",null,"G com bandage padded textile",null,4.5999999999999996,null,4.5999999999999996,null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["A7002",null,"Tubing used w suction pump",null,3.88,null,3.88,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A7009",null,"Nebulizer reservoir bottle",null,126.61,null,126.61,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A7027",null,"Combination oral/nasal mask",null,281.81,null,281.81,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A7033",null,"Replacement nasal pillows",null,39.03,null,39.03,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A7047",null,"Resp suction oral interface",null,242.84,null,242.84,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A7509",null,"Heat & moisture exchange sys",null,1.99,null,1.99,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A8000",null,"Soft protect helmet prefab",null,216.42,null,216.42,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A8003",null,"Hard protect helmet custom",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["A9274",null,"Ext amb insulin delivery sys",null,86.95,null,86.95,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["A9281",null,"Reaching/grabbing device",null,40.340000000000003,null,40.340000000000003,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A9502",null,"Tc99m tetrofosmin",null,189.8,null,189.8,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["A9510",null,"Tc99m disofenin",null,241.53,null,241.53,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL"]
["A9529",null,"I131 iodide sol, dx",null,2.12,null,2.12,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["A9541",null,"Tc99m sulfur colloid",null,468.66,null,468.66,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["A9555",null,"Rb82 rubidium",null,1128.6099999999999,null,1128.6099999999999,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["A9558",null,"Xe133 xenon 10mci",null,403.48,null,403.48,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["A9570",null,"Indium in-111 auto wbc",null,6994.48,null,6994.48,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["A9579",null,"Gad-base mr contrast nos,1ml",null,7.04,null,7.04,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["A9591",null,"Fluoroestradiol f 18",null,1425.84,null,1425.84,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["A9600",null,"Sr89 strontium",null,1818,null,1818,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["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"]
["A9999",null,"Dme supply or accessory, nos",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["B4102",null,"Ef adult fluids and electro",null,5.08,null,5.08,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["B4150",null,"Ef complet w/intact nutrient",null,0.71,null,0.71,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["B4180",null,"Parenteral sol carb > 50%",null,35.75,null,35.75,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["B4216",null,"Parenteral nutrition additiv",null,11.31,null,11.31,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["B9004","NU","Parenteral infus pump portab",null,3697.42,null,3697.42,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["C1062",null,"Intravertebral fx aug impl",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-UR"]
["C1719",null,"Brachytx, ns, non-hdrir-192",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["C1728",null,"Cath, brachytx seed adm",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C1747",null,"Endo, single, urinary tract",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["C1757",null,"Cath, thrombectomy/embolect",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C1767",null,"Generator, neuro non-recharg",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C1770",null,"Imaging coil, mr, insertable",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C1788",null,"Port, indwelling, imp",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C1815",null,"Pros, urinary sph, imp",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C1827",null,"Gen, neuro, carot sinus baro",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["C1876",null,"Stent, non-coa/non-cov w/del",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C1888",null,"Endovas non-cardiac abl cath",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C1892",null,"Intro/sheath,fixed,peel-away",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C2617",null,"Stent, non-cor, tem w/o del",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C2622",null,"Prosthesis, penile, non-inf",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C2629",null,"Intro/sheath, laser",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C5271",null,"Low cost skin substitute app",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["C7500",null,"Deb bone 20 cm2 w/drug dev",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR"]
["C7507",null,"Perq thor&lumb vert aug",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM"]
["C7521",null,"R hrt angio w/ ivus or oct",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR"]
["C7523",null,"L hrt angio w/ ivus or oct",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR"]
["C7540",null,"Rmv&rplc pm dul w/l vnt lead",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR"]
["C7541",null,"Ercp w/ pancreatoscopy",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C7551",null,"Exc neuroma w/ implnt nv end",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR"]
["C7900",null,"Hopd mntl hlt, 15-29 min",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-CM"]
["C8003",null,"Imp extar knee shck absrb",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["C8912",null,"Mra w/cont, lwr ext",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C8927",null,"Tee w or w/o fol w/cont, mon",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C8937",null,"Cad breast mri",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["C9058",null,"Injection,pegfilgrastim-bmez",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["C9063",null,"Injection, eptinezumab-jjmr",null,10.050000000000001,null,10.050000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["C9352",null,"Neuragen nerve guide, per cm",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C9356",null,"Tenoglide tendon prot, cm2",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["C9462",null,"Injection, delafloxacin",null,"By report",null,"By report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["C9487",null,"Ustekinumab iv inj, 1 mg",null,"By report",null,"By report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["C9733",null,"Non-ophthalmic fva",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["C9755",null,"Rf magnetic-guide av fistula",null,"Facility Only",null,10622.05,null,0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-ONC"]
["C9760",null,"Non-blind interatrial shunt",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["C9774",null,"Revasc lithotr-ather tib/per",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["C9781",null,"Arthro/shoul surg; w/spacer",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-UR"]
["C9806",null,"Pump perist non-opioid dev",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["D0180",null,"Comp periodontal evaluation",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["D0250",null,"Extraoral 2d project image",null,77.599999999999994,null,77.599999999999994,null,0,0,0,0,1,0,0,0,0,0,null,"F"]
["D0320",null,"Dental tmj arthrogram incl i",null,683.2,null,683.2,null,0,0,0,0,1,0,0,0,0,0,null,"F"]
["D0370",null,"Max ultrasound capt & interp",null,589.6,null,589.6,null,0,0,0,0,1,0,0,0,0,0,null,"F"]
["D0387",null,"Comp image capture only",null,"By Report",null,"By Report",null,0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM"]
["D0394",null,"Digital sub 2 or more images",null,340.8,null,340.8,null,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-CM"]
["D0415",null,"Collection of microorganisms",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["D0473",null,"Micro exam, prep & report",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["D0480",null,"Cytopath smear prep & report",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
["D0605",null,"Antibody test pub hlth path",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
["D0803",null,"3d facial scan direct",null,344.8,null,344.8,null,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-CM"]
["D1120",null,"Dental prophylaxis child",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["D1520",null,"Remove unilat space maintain",null,462.4,null,462.4,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D1551",null,"Recement space maint - max",null,"Not Covered",null,"Not Covered",null,0,0,0,0,5,0,0,0,0,0,null,"X"]
["D1704",null,"Moderna Covid-19 vaccine administration - second dose",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,310.39999999999998,null,310.39999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D2391",null,"Post 1 srfc resinbased cmpst",null,241.6,null,241.6,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["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"]
["D2710",null,"Crown resin-based indirect",null,1224.8,null,1224.8,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D2751",null,"Crown porcelain fused base m",null,1360,null,1360,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D2792",null,"Crown full cast noble metal",null,1438.4,null,1438.4,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D2928",null,"Prefab porc/cer crown perm",null,648,null,648,null,0,0,0,0,5,0,0,0,0,0,null,"F",null,"Y-ONC"]
["D2940",null,"Protective restoration",null,176,null,176,null,0,0,0,0,5,0,0,0,0,0,null,"F"]
["D2976",null,"Band stabilization per tooth",null,391.2,null,391.2,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D2989",null,"Excavate tooth non-restorabl",null,292.8,null,292.8,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D3320",null,"End thxpy, premolar tooth",null,1113.5999999999999,null,1113.5999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D3356",null,"Pulpal regeneration interim",null,423.2,null,423.2,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D3430",null,"Retrograde filling",null,375.2,null,375.2,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D3910",null,"Isolation- tooth w rubb dam",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["D3999",null,"Endodontic procedure",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["D4240",null,"Gingival flap proc w/ planin",null,972,null,972,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D4270",null,"Pedicle soft tissue graft pr",null,1144,null,1144,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D4323",null,"Splint extra-coronal",null,600.79999999999995,null,600.79999999999995,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,2245.6,null,2245.6,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D5286",null,"Rem unilat dent 1 pc resin",null,1468,null,1468,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["D5630",null,"Rep partial denture clasp",null,344.8,null,344.8,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5711",null,"Dentures rebase cmplt mand",null,746.4,null,746.4,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5760",null,"Denture reln part maxil lab",null,589.6,null,589.6,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5821",null,"Denture interm part mandbl",null,884.8,null,884.8,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5866",null,"Overdenture partial mandib",null,2849.6,null,2849.6,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D5926",null,"Replacement nasal prosthesis",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["D5931",null,"Surgical obturator",null,4880,null,4880,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D5958",null,"Intraoral con def inter plt",null,"By Report",null,"By Report",null,0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM"]
["D5995",null,"Peri medicament w/seal, max",null,565.6,null,565.6,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC"]
["D6040",null,"Odontics eposteal implant",null,8827.2000000000007,null,8827.2000000000007,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D6055",null,"Implant connecting bar",null,3761.6,null,3761.6,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D6064",null,"Abutment supported mtl crown",null,1625.6,null,1625.6,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6075",null,"Implant supported retainer",null,1833.6,null,1833.6,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6089",null,"Access/retorq implant screw",null,306.39999999999998,null,306.39999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D6102",null,"Debridement & contouring",null,1128,null,1128,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6112",null,"Imp/abut rem dent part max",null,3627.2,null,3627.2,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["D6180",null,"Implnt maint proced",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["D6199",null,"Implant procedure",null,1036.8,null,1036.8,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D6210",null,"Prosthodont high noble metal",null,1428,null,1428,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6253",null,"Provisional pontic",null,879.2,null,879.2,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6611",null,"Onlay cst hgh nbl mtl >=3srf",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,9,9,9,9,9,null,"X"]
["D6624",null,"Inlay titanium",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,9,9,9,9,9,null,"X"]
["D6750",null,"Crown porcelain high noble",null,1456.8,null,1456.8,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D6783",null,"Crown 3/4 porcelain/ceramic",null,1392,null,1392,null,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7230",null,"Impact tooth remov part bony",null,501.6,null,501.6,null,0,0,0,0,0,9,9,9,9,9,null,"F"]
["D7260",null,"Oral antral fistula closure",null,1616.8,null,1616.8,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D7280",null,"Exposure of unerupted tooth",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["D7298",null,"Remove screw retained plate",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["D7310",null,"Alveoplasty w/ extraction",null,408,null,408,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"]
["D7472",null,"Removal of torus palatinus",null,1131.2,null,1131.2,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7560",null,"Maxillary sinusotomy",null,2248,null,2248,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7670",null,"Closd rductn splint alveolus",null,1979.2,null,1979.2,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7820",null,"Closed tmp manipulation",null,824,null,824,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7850",null,"Tmj meniscectomy",null,6112,null,6112,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7872",null,"Tmj diagnostic arthroscopy",null,3892.8,null,3892.8,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7912",null,"Suture complicate wnd > 5 cm",null,1254.4000000000001,null,1254.4000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D7948",null,"Reconstruct midface no graft",null,13010.4,null,13010.4,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7955",null,"Repair maxillofacial defects",null,3778.4,null,3778.4,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D7990",null,"Emergency tracheotomy",null,1956,null,1956,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["D7998",null,"Intraoral place of fix dev",null,2827.2,null,2827.2,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["D8090",null,"Compre dental tx adult",null,5690.4,null,5690.4,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["D8681",null,"Removable retainer adjust",null,262.39999999999998,null,262.39999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D9212",null,"Trigeminal block anesthesia",null,"Bundled",null,"Bundled",null,0,0,0,0,0,0,0,0,0,0,null,"B"]
["D9230",null,"Analgesia",null,115.2,null,115.2,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["D9610",null,"Dent therapeutic drug inject",null,132,null,132,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["D9913",null,"Admin of neuromod",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,302.39999999999998,null,302.39999999999998,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["D9951",null,"Limited occlusal adjustment",null,240.8,null,240.8,null,0,0,0,0,0,0,0,0,0,0,null,"F"]
["D9973",null,"Extrnl bleaching per tooth",null,285.60000000000002,null,285.60000000000002,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["D9992",null,"Case mgmt, care coordination",null,173.6,null,173.6,null,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM"]
["E0113","NU","Crutch underarm each wood",null,29.84,null,29.84,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0117","NU","Underarm springassist crutch",null,319.39999999999998,null,319.39999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0147","NU","Walker variable wheel resist",null,623.5,null,623.5,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0152",null,"Walker, battery power wheels",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["E0158","RR","Walker leg extenders set of4",null,3.62,null,3.62,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0165","NU","Commode chair with detacharm",null,280.17,null,280.17,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0183","RR","Press underlay alter w/pump",null,28.83,null,28.83,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0185","NU","Gel pressure mattress pad",null,339.52,null,339.52,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0196","RR","Gel pressure mattress",null,44.21,null,44.21,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0201",null,"Penile contractur devic manu",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["E0221",null,"Infrared heating pad system",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["E0245",null,"Tub stool or bench",null,72.849999999999994,null,72.849999999999994,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0256","RR","Hospital bed var ht w/o matt",null,90.64,null,91.64,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E0265","NU","Hosp bed total electr w/ mat",null,2120.39,null,2130.39,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E0277","RR","Powered pres-redu air mattrs",null,557.19000000000005,null,557.19000000000005,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E0290","RR","Hosp bed fx ht w/o rails w/m",null,83.76,null,83.76,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E0296","NU","Hosp bed total elect w/ matt",null,1704.48,null,1714.48,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0303","NU","Hosp bed hvy dty xtra wide",null,2944.55,null,2954.55,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0350","NU","Control unit bowel system",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["E0371","NU","Nonpower mattress overlay",null,3995.06,null,4005.06,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0439","RR","Stationary liquid 02",null,175.05,null,175.05,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0446","NU","Topical ox deliver sys, nos",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["E0465","RR","Home vent invasive interface",null,1144.95,null,1144.95,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0470","RR","Rad w/o backup non-inv intfc",null,229.32,null,230.32,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E0490",null,"Control unit nm hw remote",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["E0555","NU","Humidifier for use w/ regula",null,5.61,null,5.61,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0575","RR","Nebulizer ultrasonic",null,145.05000000000001,null,145.05000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0585","RR","Nebulizer w/ compressor & he",null,40.159999999999997,null,41.16,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0615","RR","Pacemaker monitr digital/vis",null,78.73,null,78.73,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0620","NU","Cap bld skin piercing laser",null,1233.72,null,1233.72,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0635","NU","Patient lift electric",null,4362.87,null,4362.87,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E0638","RR","Standing frame sys",null,504.31,null,504.31,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0655","NU","Pneumatic appliance half arm",null,152.31,null,152.31,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0656","RR","Segmental pneumatic trunk",null,81.55,null,81.55,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0668","RR","Seg pneumatic appl full arm",null,61.54,null,61.54,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0672","RR","Pressure pneum appl full arm",null,45.58,null,45.58,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0683",null,"Non pneu peristalic comp pmp",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["E0711",null,"Ue enclosure restr rom",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["E0736",null,"Transcut tibial nerv stimula",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["E0745","RR","Neuromuscular stim for shock",null,126.33,null,126.33,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["E0761","RR","Nontherm electromgntc device",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["E0766",null,"Elec stim cancer treatment",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["E0785",null,"Replacement impl pump cathet",null,660.19,null,660.19,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0840","NU","Tract frame attach headboard",null,103.39,null,103.39,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0849","RR","Cervical pneum trac equip",null,72.73,null,72.73,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0890","NU","Traction frame attach pelvic",null,169.9,null,169.9,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0940","RR","Trapeze bar free standing",null,35.270000000000003,null,35.270000000000003,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0947","RR","Fracture frame attachmnts pe",null,88.22,null,88.22,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0956","NU","W/c lateral trunk/hip suppor",null,110.52,null,110.52,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0961","RR","Wheelchair brake extension",null,3.55,null,3.55,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0970","NU","Wheelchair no. 2 footplates",null,168.1,null,168.1,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E0971","RR","Wheelchair anti-tipping devi",null,5.07,null,5.07,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E0983","NU","Add pwr joystick",null,3526.92,null,3536.92,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E0986","RR","Man w/c push-rim powr system",null,686.45,null,686.45,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1003","NU","Pwr seat recline",null,5337.85,null,5347.85,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1008","NU","Pwr seat combo pwr shear",null,10351.09,null,10351.09,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1016","NU","Shock absorber for power w/c",null,153.80000000000001,null,153.80000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E1020","NU","Residual limb support system",null,266.74,null,266.74,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E1036","RR","Patient transfer system >300",null,1174.53,null,1174.53,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E1039","NU","Transport chair pt wt >300lb",null,459.35,null,469.35,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E1070","RR","Wheelchair detachable foot r",null,154.58000000000001,null,155.58000000000001,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1092","RR","Wheelchair wide w/ leg rests",null,181.36,null,182.36,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1130","NU","Whlchr stand fxd arm ft rest",null,784.49,null,784.49,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E1160","RR","Wheelchair fixed arms",null,88.21,null,89.21,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E1171","NU","Wheelchair amputee w/o leg r",null,1131,null,1141,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E1222","NU","Wheelchair spec size w/ leg",null,956.37,null,966.37,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E1228","NU","Wheelchair spec sz spec ht b",null,390.26,null,390.26,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["E1229",null,"Pediatric wheelchair nos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["E1238",null,"Fld ped wc adjstabl w/o seat",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["E1285","NU","Wheelchair heavy duty fixed",null,2275.0100000000002,null,2275.0100000000002,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E1297","NU","Wheelchair special seat dept",null,147.62,null,147.62,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E1357","RR","Battery charger, port conc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL"]
["E1510","RR","Kidney dialysate delivry sys",null,100.86,null,100.86,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E1594","RR","Cycler dialysis machine",null,889.07,null,889.07,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E1634","NU","Peritoneal dialysis clamp",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["E1637","NU","Hemostats for dialysis, each",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["E1801","RR","Sps elbow device",null,182.05,null,182.05,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E1813",null,"Adjust knee extension device",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC"]
["E1828",null,"Adjust toe extension device",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC"]
["E1832","RR","Sps finger device",null,93.22,null,93.22,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["E2202","RR","Seat width 24-27 in",null,62.96,null,62.96,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2206","NU","Man wc whl lock comp repl ea",null,53.75,null,53.75,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2209","NU","Arm trough each",null,120.07,null,120.07,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2218","NU","Foam propulsion tire each",null,63.41,null,63.41,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2226","NU","Caster fork replacement only",null,52.56,null,52.56,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2294",null,"Contour seat for ped size wc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["E2311","RR","Electro connect btw 2 sys",null,278.74,null,279.74,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2324","RR","Chin cup interface",null,5.3,null,5.3,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2329","NU","Head control nonproportional",null,2148.0700000000002,null,2158.0700000000002,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2342","RR","W/c dpth 20-21 in seat frame",null,63.22,null,63.22,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2362","RR","Gr24 nonsealed leadacid",null,12.98,null,12.98,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2365","RR","U1 sealed leadacid battery",null,11.87,null,11.87,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2368","NU","Pwr wc drivewheel motor repl",null,583.28,null,583.28,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2375","NU","Non-expandable controller",null,965.36,null,965.36,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2381","RR","Pneum drive wheel tire",null,8.5500000000000007,null,8.5500000000000007,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2387","RR","Foam filled caster tire",null,7.34,null,7.34,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2394","RR","Drive wheel excludes tire",null,8.5,null,8.5,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2397","NU","Pwc acc, lith-based battery",null,584.41,null,584.41,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2510","NU","Sgd w multi methods msg/accs",null,9551.1299999999992,null,9551.1299999999992,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2599","NU","Sgd accessory noc",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["E2606","NU","Position wc cush wdth>=22 in",null,477.09,null,477.09,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2615","NU","Pos back post/lat wdth <22in",null,507.2,null,507.2,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E2623","NU","Adj skin pro wc cus wd>=22in",null,498.23,null,498.23,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["E8000",null,"Posterior gait trainer",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0022",null,"Comm hlth intg svs add 30 m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0032",null,"2+ antipsy schiz",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0042",null,"Ref to therapy",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0052",null,"Pt peri dialysis dur mo",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0055",null,"Adv care heart dx mvp",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0076",null,"Care manag h vst new pt 20 m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0080",null,"Care manag h vst new pt 75 m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0102",null,"Prostate ca screening; dre",null,43.16,null,15.75,null,0,0,0,0,0,9,9,9,9,9,null,"R",null,"Y-CM"]
["G0127",null,"Trim nail(s)",null,44.33,null,12.83,null,0,0,0,0,0,2,0,1,0,0,null,"R"]
["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"]
["G0153",null,"Hhcp-svs of s/l path,ea 15mn",null,47.53,null,47.53,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["G0161",null,"Hhc slp ea 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0176",null,"Opps/php;activity therapy",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0204","TC","Dx mammo incl cad bi",null,257.95,null,257.95,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["G0238",null,"Oth resp proc, indiv",null,19.25,null,19.25,null,0,0,0,0,5,0,0,0,0,0,null,"R"]
["G0252",26,"Pet imaging initial dx",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"]
["G0289",null,"Arthro, loose body + chondro",null,149.32,null,149.32,null,0,0,0,0,0,0,1,0,0,0,null,"R"]
["G0307",null,"Cbc without platelet",null,9.1199999999999992,null,9.1199999999999992,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
["G0323",null,"Prolong inpt eval add15 m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0343",null,"Laparotomy islet cell transp",null,"Not Covered",null,"Not Covered",null,90,0.09,0.81,0.1,0,2,0,2,1,0,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"]
["G0415",null,"Open tx post pelvic fxcture",null,2463.2800000000002,null,2463.2800000000002,null,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R"]
["G0416",26,"Prostate biopsy, any mthd",null,"Not Covered",null,"Not Covered",null,0,0,0,0,1,0,0,0,0,0,null,"X"]
["G0435",null,"Oral hiv-1/hiv-2 screen",null,16.89,null,16.89,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
["G0439",null,"Ppps, subseq visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0463",null,"Hospital outpt clinic visit",null,"Facility Only",null,"Facility Only",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["G0466",null,"Fqhc visit new patient",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0493",null,"Rn care ea 15 min hh/hospice",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0500",null,"Mod sedat endo service >5yrs",null,106.16,null,9.92,null,0,0,0,0,9,9,9,9,9,9,null,"R",null,"Y-CM"]
["G0513",null,"Prolong prev svcs, first 30m",null,112.58,null,104.41,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
["G0527",null,"Mgt est pt dmentia low cmplx",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0534",null,"Coordinated care/or referral",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G0546",null,"Phone/internet ehr assess",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0556",null,"Adv prim care mgmt lvl 1",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G0557",null,"Adv prim care mgmt lvl 2",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G1027",null,"Pt hemo < 3mo",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2001",null,"Post d/c h vst new pt 20 m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G2015",null,"Post-d/c care plan overs 60m",null,"Not Covered",null,"Not Covered",null,0,0,0,0,0,0,0,0,0,0,null,"X"]
["G2073",null,"Med tx naltrexone",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2081",null,"Pt 66+ snp or ltc pos > 90d",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2105",null,"Pt 66+ lt ints > 90",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2118",null,"Pt 81+ frailty",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2127",null,"Pt 66+ frailty med dem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2148",null,"Mpm used",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2151",null,"Dx degen neuro",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"]
["G2187",null,"Clin ind img hd trauma",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2200",null,"Unhlthy etoh rcvd couns",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G2206",null,"Adjv trtmt chemo her2",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G4000",null,"Dermatology ss",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G4003",null,"Emergency med 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"]
["G4023",null,"Pathology 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"]
["G6002",null,"Stereoscopic x-ray guidance",null,140.58000000000001,null,140.58000000000001,null,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM"]
["G6013",null,"Radiation treatment delivery",null,422.31,null,422.31,null,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM"]
["G8395",null,"Lvef>=40% doc normal or mild",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["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"]
["G8428",null,"Cur meds not document",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8536",null,"No doc elder mal scrn",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8540",null,"Foa not doc as being perf",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8567",null,"Pt no doc hear loss",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8576",null,"No postop ren fail",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8654",null,"Rafs crs hi no scor no surv",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8662",null,"Rafs crs lbi no scor no surv",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"]
["G8722",null,"Med reas pt, pn, not doc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8806",null,"Perf ultrsnd to lct preg doc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8816",null,"Statin med pres at disch",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8851",null,"Adhere pos air press therapy",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8856",null,"Ref for oto eval",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8876",null,"Doc reas no min inv dx",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8911",null,"Pt doc no fall in asc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8936",null,"Pt not eligible ace/arb",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G8955",null,"Most recent assess vol mgmt",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9005",null,"Mccd, risk adj, maintenance",null,"By Report ",null,"By Report ",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["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"]
["G9051",null,"Oncology tx decision-mgmt",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9062",null,"Onc prac guide differs nos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9074",null,"Onc dx brst stg3-noprogress",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"]
["G9097",null,"Onc dx esophageal t4 no prog",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9104",null,"Onc dx gastric unknown nos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9112",null,"Onc dx head/neck ext unknown",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9125",null,"Onc dx cml blast phase",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9147",null,"Outpt iv insulin tx any mea",null,"By Report ",null,"By Report ",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["G9189",null,"Beta pres or already taking",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9231",null,"Doc esrd dia trans preg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9273",null,"Sys<140 and dia<90",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9284",null,"No hist type doc on report",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"]
["G9318",null,"Image std nomenclature",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9354",null,"1 or no ct sinus w/in 90d dx",null,"Not Covered",null,"Not Covered",null,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"]
["G9395",null,"Ini phq9 >9 no remiss >=5",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"]
["G9431",null,"Patho rpt no pt ctg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9476",null,"Volun service at hospice",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9479",null,"Pharmacist at hospice",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9511",null,"Idx evt dte phq>9 doc 12 mo",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9518",null,"Doc active inj drug use",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9531",null,"Pt doc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9553",null,"Prior thyroid dise dx",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9597",null,"No low pecarn ped head traum",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9607",null,"Doc med rsn not perf cystosc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9629",null,"Med rsn no rpt bowel inj",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9642",null,"Current smoker",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9663",null,"Fast/dir ldl <= 190 mg/dl",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9689",null,"Inpt elect carotid intervent",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9691",null,"Pt hosp dur msmt period",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9705",null,"Ajcc br ca stg ib",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9723",null,"Hosp recd by pt dur msmt per",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9729",null,"Pt unbl cmplt hip fs prom",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9745",null,"Doc rsn no hbp scrn or f/u",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9752",null,"Urgent surgery",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9772",null,"Doc med rsn no temp >= 35.5",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9776",null,"Doc med rsn no proph antiem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9792",null,"Most rct tob stat not free",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9805",null,"Pt w/hosp anytime msmt per",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9830",null,"Her-2 pos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9846",null,"Pt died from cancer",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9875",null,"9 em core sessions",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9882",null,"2 em ongoing ms mo 13-15 wl",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9899",null,"Scrn mam perf rslts doc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9902",null,"Pt scrn tbco and id as user",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9912",null,"Hbv status assesed and int",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9925",null,"No scrn prov rsn nos",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9957",null,"Doc med rsn no combo thrpy",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9964",null,"Pt recv >=1 well-chld visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["G9977",null,"DIL MAC EXAM NO PERF RSN NOS ",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H0004",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"]
["H0016",null,"Alcohol and/or drug services",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H0019",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"]
["H0027",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"]
["H0039",null,"Asser com tx face-face/15min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H1000",null,"Prenatal care atrisk assessm",null,"By Report ",null,"By Report ",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["H1005",null,"Prenatalcare enhanced srv pk",null,"By Report ",null,"By Report ",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["H2017",null,"Psysoc rehab svc, per 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H2019",null,"Ther behav svc, per 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H2037",null,"Dev delay prev dp ch, 15 min",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["H2041",null,"Coord special care encounter",null,"By Report ",null,"By Report ",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC"]
["J0133",null,"Acyclovir injection",null,0.04,null,0.04,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0172",null,"Inj, aducanumab-avwa, 2 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0185",null,"Inj., aprepitant, 1 mg",null,1.71,null,1.71,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0211",null,"Inj, nithiodote, 3mg / 125mg",null,"Not Covered",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["J0270",null,"Alprostadil for injection",null,9.68,null,9.68,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0285",null,"Amphotericin b",null,50.07,null,50.07,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0300",null,"Amobarbital 125 mg inj",null,183.26,null,183.26,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0390",null,"Chloroquine injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0457",null,"Injection, aztreonam, 100 mg",null,2.48,null,2.48,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0558",null,"Peng benzathine/procaine inj",null,17.37,null,17.37,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0574",null,"Bupren/nal 6.1 to 10mg bupre",null,1.2,null,1.2,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J0592",null,"Buprenorphine hydrochloride",null,4.18,null,4.18,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0602",null,"Sevelamer carbonate pdr 20mg",null,"By report",null,"By report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["J0615",null,"Calcium acetate, oral, 23 mg",null,"By report",null,"By report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["J0651",null,"Inj, levothyroxine, freskabi",null,6.4,null,6.4,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0666",null,"Inj, bupivacaine liposome",null,1.42,null,1.42,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0694",null,"Cefoxitin sodium injection",null,5.01,null,5.01,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0713",null,"Inj ceftazidime per 500 mg",null,1.6,null,1.6,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0737",null,"Inj, clindamycin (baxter)",null,2.5299999999999998,null,2.5299999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0775",null,"Collagenase, clost hist inj",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J0872",null,"Daptomycin (xellia) unrefrig",null,0.05,null,0.05,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J0879",null,"Difelikefalin, esrd on dialy",null,0.13,null,0.13,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J0895",null,"Deferoxamine mesylate inj",null,8.2100000000000009,null,8.2100000000000009,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"]
["J1100",null,"Dexamethasone sodium phos",null,0.09,null,0.09,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1165",null,"Phenytoin sodium injection",null,0.52,null,0.52,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1203",null,"Inj, cipaglucosidase, 5 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1301",null,"Injection, edaravone, 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1307",null,"Inj, crovalimab-akkz, 10 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1380",null,"Estradiol valerate 10 mg inj",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1434",null,"Inj, focinvez, 1mg",null,3.02,null,3.02,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1444",null,"Fe pyro cit pow 0.1 mg iron",null,"By report",null,"By report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["J1448",null,"Injection, trilaciclib, 1mg",null,5.39,null,5.39,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J1556",null,"Inj, imm glob bivigam, 500mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1559",null,"Hizentra injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1575",null,"Hyqvia 100mg immuneglobulin",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1610",null,"Glucagon hydrochloride/1 mg",null,190.76,null,190.76,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"]
["J1726",null,"Makena, 10 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1743",null,"Idursulfase injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1747",null,"Inj, spesolimab-sbzo, 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["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"]
["J1921",null,"Inj labetalol hcl hikma, 5mg",null,1.38,null,1.38,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J1943",null,"Inj., aristada initio, 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J1955",null,"Inj levocarnitine per 1 gm",null,24.38,null,24.38,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2170",null,"Mecasermin injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2247",null,"Inj, micafungin (par pharm)",null,0.31,null,0.31,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J2260",null,"Inj milrinone lactate / 5 mg",null,1.57,null,1.57,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2305",null,"Inj, nitroglycerin, 5 mg",null,1.34,null,1.34,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["J2327",null,"Inj, nusinersen, 0.1mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2351",null,"Inj ocrelizumab 1mg hya-ocsq",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2360",null,"Orphenadrine injection",null,12.33,null,12.33,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2425",null,"Palifermin injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2501",null,"Paricalcitol",null,0.81,null,0.81,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2507",null,"Pegloticase injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2598",null,"Inj, vasopressin, 1 unit",null,"Facility Only",null,1.42,null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["J2650",null,"Prednisolone acetate inj",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2778",null,"Ranibizumab injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2782",null,"Inj avacincaptad pegol 0.1mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2798",null,"Inj., perseris, 0.5 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J2916",null,"Na ferric gluconate complex",null,1.94,null,1.94,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J2995",null,"Inj streptokinase /250000 iu",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J3095",null,"Telavancin injection",null,7.09,null,7.09,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J3101",null,"Tenecteplase injection",null,162.46,null,162.46,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J3244",null,"Inj. tigecycline (accord)",null,0.6,null,0.6,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J3304",null,"Inj triamcinolone ace xr 1mg",null,18.010000000000002,null,18.010000000000002,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J3315",null,"Triptorelin pamoate",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7356",null,"Inj foscarb/foslevodopa 5 mg",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["J3401",null,"Vyjuvek 5x10^9pfu/ml, 0.1 ml",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J3465",null,"Injection, voriconazole",null,1.06,null,1.06,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J3485",null,"Zidovudine",null,1.51,null,1.51,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J7060",null,"5% dextrose/water",null,1.82,null,1.82,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J7100",null,"Dextran 40 infusion",null,26.66,null,26.66,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J7181",null,"Factor xiii recomb a-subunit",null,17.34,null,17.34,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J7193",null,"Factor ix non-recombinant",null,1.38,null,1.38,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J7198",null,"Anti-inhibitor",null,2.4,null,2.4,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J7205",null,"Factor viii fc fusion recomb",null,2.3199999999999998,null,2.3199999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J7213",null,"Inj, ixinity, 1 i.u.",null,1.92,null,1.92,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["J7309",null,"Methyl aminolevulinate, top",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"]
["J7327",null,"Monovisc 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"]
["J7500",null,"Azathioprine oral 50mg",null,1.01,null,1.01,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J7503",null,"Tacrol envarsus ex rel oral",null,1.81,null,1.81,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J7520",null,"Sirolimus, oral",null,1.1399999999999999,null,1.1399999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J7599",null,"Immunosuppressive drug noc",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["J7614",null,"Levalbuterol non-comp unit",null,0.09,null,0.09,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J7635",null,"Atropine comp con",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7642",null,"Glycopyrrolate 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"]
["J7665",null,"Mannitol for inhaler",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J7683",null,"Triamcinolone comp con",null,0.56000000000000005,null,0.56000000000000005,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J8560",null,"Etoposide oral 50 mg",null,76.459999999999994,null,76.459999999999994,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["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,4.79,null,4.79,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9025",null,"Azacitidine injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9034",null,"Inj., bendeka 1 mg",null,13.58,null,13.58,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9045",null,"Carboplatin injection",null,2.93,null,2.93,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9065",null,"Inj cladribine per 1 mg",null,10.199999999999999,null,10.199999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9075",null,"Inj, cyclophosphamide, nos",null,"Facility Only",null,0.8,null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["J9165",null,"Diethylstilbestrol injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM"]
["J9174",null,"Inj, docetaxel (beizray) 1mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9200",null,"Floxuridine injection",null,3988.33,null,3988.33,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9209",null,"Mesna injection",null,1.36,null,1.36,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9223",null,"Inj. lurbinectedin, 0.1 mg",null,205.04,null,205.04,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["J9228",null,"Ipilimumab injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9269",null,"Inj. tagraxofusp-erzs 10 mcg",null,338.53,null,338.53,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["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"]
["J9292",null,"Inj, pemetrexed (avyxa) 10mg",null,"By report",null,"By report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["J9303",null,"Panitumumab injection",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9317",null,"Sacituzumab govitecan-hziy",null,35.799999999999997,null,35.799999999999997,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["J9324",null,"Inj, pemrydi rtu, 10 mg",null,81.06,null,81.06,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["J9348",null,"Inj. naxitamab-gqgk, 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9355",null,"Inj trastuzumab excl biosimi",null,75.69,null,75.69,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["J9376",null,"Inj pozelimab-bbfg, 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["J9395",null,"Injection, fulvestrant",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["K0007","NU","Extra heavy duty wheelchair",null,1853.35,null,1853.35,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0009","RR","Other manual wheelchair/base",null,104.91,null,105.91,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0012","NU","Ltwt portbl power whlchr",null,4585.1000000000004,null,4585.1000000000004,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0018","RR","Detach adjust armrst upper",null,3.37,null,3.37,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["K0040","RR","Adjustable angle footplate",null,7.99,null,7.99,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["K0044","RR","Ftrst upr hanger brac rep ea",null,2.0299999999999998,null,2.0299999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["K0052","RR","Swingaway detach ftrest repl",null,10.3,null,10.3,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["K0072","NU","Fr cstr semi-pne tire rep ea",null,85.75,null,85.75,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["K0455","RR","Pump uninterrupted infusion",null,373.76,null,373.76,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["K0601","NU","Repl batt silver oxide 1.5 v",null,1.56,null,1.56,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["K0730",null,"Ctrl dose inh drug deliv sys",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["K0746","NU","Absorp drg >48 suc pump",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["K0815","NU","Pwc gp 1 std seat/back",null,5203.72,null,5213.72,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0822","NU","Pwc gp 2 std seat/back",null,5640.75,null,5650.75,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0828","NU","Pwc gp 2 xtra hd seat/back",null,12303.32,null,12313.32,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0829","RR","Pwc gp 2 xtra hd cap chair",null,1157.3800000000001,null,1157.3800000000001,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0839","RR","Pwc gp2 vhd sing pow opt s/b",null,948.37,null,949.37,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0842","RR","Pwc gp2 std mult pow opt cap",null,642.59,null,643.59,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0850","NU","Pwc gp 3 hd seat/back",null,11183.12,null,11193.12,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0858","NU","Pwc gp3 hd sing pow opt s/b",null,12839.52,null,12849.52,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0862","RR","Pwc gp3 hd mult pow opt s/b",null,1283.95,null,1284.95,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["K0869","NU","Pwc gp 4 std cap chair",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["K0880","RR","Pwc gp4 vhd sing pow opt s/b",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["K0890","NU","Pwc gp5 ped sing pow opt s/b",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["K1035",null,"Mol diag reader self-admn",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["L0170",null,"Cervical collar molded to pt",null,1035.6099999999999,null,1035.6099999999999,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L0172",null,"Cerv col sr foam 2pc pre ots",null,186.91,null,186.91,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L0458",null,"Tlso 2mod symphis-xipho pre",null,1269.01,null,1269.01,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L0468",null,"Tlso rig fram pelvic pre cst",null,771.94,null,771.94,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L0623",null,"Sio rig pnl pelv/sac pre ots",null,206.68,null,206.68,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L0635",null,"Lso sagit rigid panel prefab",null,1503.61,null,1503.61,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L0648",null,"Lso sag r an/pos pnl pre ots",null,1200.1600000000001,null,1200.1600000000001,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L0861",null,"Halo repl liner/interface",null,306.69,null,306.69,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L0974",null,"Tlso full corset",null,252.55,null,252.55,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L1040",null,"Lumbar or lumbar rib pad",null,131.54,null,131.54,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L1085",null,"Outrigger bil w/ vert extens",null,224.02,null,224.02,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L1270",null,"Abdominal pad",null,105.62,null,105.62,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L1650",null,"Ho abduction hip adjustable",null,315.62,null,315.62,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L1690",null,"Combination bilateral ho",null,2751.61,null,2751.61,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L1812",null,"Ko elastic w/joints pre ots",null,128.19999999999999,null,128.19999999999999,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L1831",null,"Knee orth pos locking joint",null,418.81,null,418.81,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L1850",null,"Ko swedish type pre ots",null,367.25,null,367.25,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L1902",null,"Afo ankle gauntlet pre ots",null,133.43,null,133.43,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L1945",null,"Afo molded plas rig ant tib",null,1423.93,null,1423.93,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L2005",null,"Kafo sng/dbl mechanical act",null,5830.78,null,5830.78,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L2060",null,"Hkafo torsion ball bearing j",null,932.43,null,932.43,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L2114",null,"Afo tib fx semi-rigid",null,809.14,null,809.14,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L2192",null,"Pelvic band & belt thigh fla",null,486.04,null,486.04,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L2280",null,"Molded inner boot",null,618.20000000000005,null,618.20000000000005,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L2330",null,"Lacer molded to patient mode",null,633.28,null,633.28,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L2380",null,"Torsion straight knee joint",null,170.85,null,170.85,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L2510",null,"Th/wght bear quad-lat brim m",null,1126.3599999999999,null,1126.3599999999999,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L2550",null,"Thigh/wght bear high roll cu",null,427.17,null,427.17,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L2670",null,"Thorac cont paraspinal uprig",null,240.39,null,240.39,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L2830",null,"Soft interface above knee se",null,128.07,null,128.07,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L2861",null,"Torsion mechanism knee/ankle",null,597.79,null,597.79,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L3140",null,"Abduction rotation bar shoe",null,126.7,null,126.7,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L3203",null,"Oxford w/ supinator/pronator",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["L3209",null,"Surgical boot each child",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["L3224",null,"Woman's shoe oxford brace",null,80.16,null,80.16,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L3254",null,"Orth foot non-stndard size/w",null,36.450000000000003,null,36.450000000000003,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L3340",null,"Shoe wedge sach",null,121.3,null,121.3,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L3465",null,"Shoe heel thomas with wedge",null,83.22,null,83.22,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L3530",null,"Ortho shoe add half sole",null,45.21,null,45.21,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L3600",null,"Trans shoe calip plate exist",null,108.6,null,108.6,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L3677",null,"So hard plas stabili pre cst",null,218.71,null,218.71,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L3710",null,"Eo elas w/metal jnts pre ots",null,164.9,null,164.9,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L3809",null,"Whfo w/o joints pre ots",null,323.82,null,323.82,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L3906",null,"Who w/o joints cf",null,552.79999999999995,null,552.79999999999995,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L3925",null,"Fo pip dip jnt/sprng pre ots",null,82.78,null,82.78,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L3967",null,"Sewho airplane w/o jnts cf",null,2568.83,null,2568.83,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L3982",null,"Upper ext fx orthosis rad/ul",null,497.98,null,497.98,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L4055",null,"Replace non-molded calf lace",null,369.69,null,369.69,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L4090",null,"Repl met band kafo-afo calf/",null,164,null,164,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L4360",null,"Pneumat walking boot pre cst",null,503.26,null,503.26,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L5010",null,"Mold socket ank hgt w/ toe f",null,1841.15,null,1841.15,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5220",null,"No knee joint with artic ali",null,5561.75,null,5561.75,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5400",null,"Postop dress & 1 cast chg bk",null,2022.4,null,2022.4,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5505",null,"Init ak ischal plstr direct",null,2630.38,null,2630.38,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5600",null,"Hip disart sach laminat mold",null,8604.7900000000009,null,8604.7900000000009,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5628",null,"Test socket hemipelvectomy",null,914.33,null,914.33,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5637",null,"Below knee total contact",null,450.22,null,450.22,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5647",null,"Below knee suction socket",null,1202.99,null,1202.99,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5654",null,"Socket insert symes",null,585.91,null,585.91,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5668",null,"Bk molded distal cushion",null,169.68,null,169.68,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5686",null,"Bk back check",null,96.4,null,96.4,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5695",null,"Ak sleeve susp neoprene/equa",null,246.62,null,246.62,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5707",null,"Custom shape cvr hip disart",null,2133.14,null,2133.14,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L5781",null,"Lower limb pros vacuum pump",null,5940.24,null,5940.24,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5812",null,"Endo knee-shin frct swg & st",null,954.55,null,954.55,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5818",null,"Endo knee-shin frct swg & st",null,1452.3,null,1452.3,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5920",null,"Endo ak/hip alignable system",null,802.42,null,802.42,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L5926",null,"Endoskel posit rotat unit",null,1092.5,null,1092.5,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L5971",null,"Sach foot, replacement",null,370.96,null,370.96,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L5984",null,"Endoskeletal axial rotation",null,1092.5,null,1092.5,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6010",null,"Part hand little/ring",null,2981.49,null,2981.49,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6100",null,"Elb mold sock flex hinge pad",null,3536.58,null,3536.58,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6310",null,"Shoulder passive restor comp",null,5833.18,null,5833.18,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6360",null,"Thoracic passive restor comp",null,6422.61,null,6422.61,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6588",null,"Shdr fair lead cable molded",null,5322.67,null,5322.67,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6623",null,"Spring-ass rot wrst w/ latch",null,1089.02,null,1089.02,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6632",null,"Latex suspension sleeve each",null,98.25,null,98.25,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6645",null,"Shoulder flexion-abduction j",null,599.55999999999995,null,599.55999999999995,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6686",null,"Suction socket",null,1005.47,null,1005.47,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6695",null,"Elbow socket ins use w/o lck",null,902.71,null,902.71,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L6706",null,"Term dev mech hook vol open",null,602.83000000000004,null,602.83000000000004,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L6709",null,"Term dev mech hand vol close",null,2128.14,null,2128.14,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L6895",null,"Custom glove for term device",null,937.6,null,937.6,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6935",null,"Below elbow myoelectronic ct",null,13493.87,null,13493.87,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L6975",null,"Interscap-thor myoelectronic",null,24167.32,null,24167.32,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L7180",null,"Electronic elbow sequential",null,55407.35,null,55407.35,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM"]
["L7401",null,"Add ue prost a/e ultlite mat",null,509.42,null,509.42,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L7499",null,"Upper extremity prosthes nos",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N","Y","Y-CM"]
["L8030",null,"Breast prosthes w/o adhesive",null,477.1,null,477.1,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L8045",null,"Auricular prosthesis",null,3913.14,null,3913.14,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L8400",null,"Sheath below knee",null,28.07,null,28.07,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L8417",null,"Pros sheath/sock w gel cushn",null,111.66,null,111.66,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["L8511",null,"Indwelling trach insert",null,107.98,null,107.98,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["L8514",null,"Repl trach puncture dilator",null,139.97,null,139.97,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["L8613",null,"Ossicular implant",null,455.2,null,455.2,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y"]
["L8624",null,"Lith ion batt cid, ear level",null,239.43,null,239.43,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL"]
["L8659",null,"Interphalangeal joint repl",null,2864.86,null,2864.86,null,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-UR"]
["L8679",null,"Imp neurosti pls gn any type",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["L8695",null,"External recharg sys extern",null,24.71,null,24.71,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["L8701",null,"Pow ue rom dev ewh uprt cust",null,43198.39,null,43198.39,null,0,0,0,0,9,9,9,9,9,9,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"]
["M0301",null,"Fabric wrapping of aneurysm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1009",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"]
["M1018",null,"Pt dx hst cr pt sk lg cr scr",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"]
["M1043",null,"Fs no odi 9-15mo",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1070",null,"Pt not scrn fut fall no rsn",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"]
["M1125",null,"Oc ni pt selfdc 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"]
["M1141",null,"Fs no oks",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1159",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"]
["M1171",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"]
["M1176",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"]
["M1191",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"]
["M1194",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"]
["M1211",null,"Hemoglobin a1c level >9.0%",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1214",null,"Spiro results wth obs doc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1227",null,"Eb therapy prescribed",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1231",null,"Pt hcv tst no reactive res",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1247",null,"Pt resp true best int",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1254",null,"Pts deceased prior hu surv",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1260",null,"Pt no kd trnsplt wtlst lv do",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1271",null,"Pts dem any time/dur mo",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1287",null,"Calc bmi blw low param f/u",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1290",null,"Pt not eli d/t act dig htn",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1303",null,"Hospc serv dur meas pd",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1310",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"]
["M1319",null,"Pts csp doc contact",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1330",null,"Doc pts rsn no f/u xm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1342",null,"Pts died perf per",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"]
["M1362",null,"Pt died dur meas pd",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1365",null,"Hosp+pall care spec code 17",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1377",null,"Fu colscop 10 yr doc w/ disc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1385",null,"Pt rsn not seen 2nd pam",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1398",null,"Bslne and  fu promis doc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1403",null,"Bslne and fu promis doc",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1418",null,"Med rsn not up to date cov",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["M1421",null,"Dermatological care mvp",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["P3001",null,"Screening pap smear by phys",null,46.08,null,46.08,null,0,0,0,0,0,0,0,0,0,0,null,"R"]
["P9021",null,"Red blood cells unit",null,144.32,null,144.32,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["P9032",null,"Platelets, irradiated",null,135.78,null,135.78,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["P9046",null,"Albumin (human), 25%, 20 ml",null,21.23,null,21.23,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["P9059",null,"Plasma, frz between 8-24hour",null,71.09,null,71.09,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["P9603",null,"One-way allow prorated miles",null,1.19,null,1.19,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["Q0085",null,"Chemo by both infusion and o",null,"Facility Only",null,0,null,0,0,0,0,9,9,9,9,9,9,null,"O"]
["Q0114",null,"Fern test",null,13.73,null,13.73,null,0,0,0,0,9,9,9,9,9,9,null,"L"]
["Q0177",null,"Hydroxyzine pamoate 25mg",null,7.0000000000000007E-2,null,7.0000000000000007E-2,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["Q0244",null,"CASIRIVI AND IMDEVI 1200 MG",null,0,null,0,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["Q0477",null,"Pwr module pt cable lvad rpl",null,923.25,null,923.25,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["Q0489",null,"Pwr pck base combo vad, rep",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q0502",null,"Mobility cart pneum vad, rep",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q0510",null,"Dispens fee immunosupressive",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q2028",null,"Inj, sculptra, 0.5mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q2050",null,"Doxorubicin inj 10mg",null,150.41,null,150.41,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["Q3027",null,"Inj beta interferon im 1 mcg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4001",null,"Cast sup body cast plaster",null,61.75,null,61.75,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["Q4013",null,"Cast sup gauntlet plaster",null,19.88,null,19.88,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["Q4021",null,"Cast sup sht arm splint plst",null,8.5,null,8.5,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["Q4033",null,"Cast sup lng leg cylinder pl",null,34.020000000000003,null,34.020000000000003,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["Q4042",null,"Cast sup lng leg splnt fbrgl",null,43.07,null,43.07,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["Q4081",null,"Epoetin alfa, 100 units esrd",null,0.71,null,0.71,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["Q4105",null,"Integra drt or omnigraft",null,23.25,null,23.25,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["Q4117",null,"Hyalomatrix",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4124",null,"Oasis tri-layer wound matrix",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4133",null,"Grafix stravix prime pl sqcm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4151",null,"Amnioband, guardian 1 sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4159",null,"Affinity1 square cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4166",null,"Cytal, per square centimeter",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4181",null,"Amnio wound, per square 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"]
["Q4220",null,"Bellacell hd, surederm sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4221",null,"Amniowrap2 per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4234",null,"Xcellerate, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4249",null,"Amniply, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4262",null,"Dual layer impax, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4269",null,"Surgraft xt per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4282",null,"Cygnus dual per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4292",null,"Lamellas, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4302",null,"Complete aca, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4305",null,"Amer am ac tri-lay per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4321",null,"Renograft, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4325",null,"Acapatch, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4332",null,"Axolotl dualgraft, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4340",null,"Simpligraft, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4357",null,"Xwrap plus, per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4364",null,"Am bur xp mem xpl hy p sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4369",null,"Amnioplast 3 per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q4382",null,"Advograft dual per sq cm",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q5007",null,"Hospice in ltch",null,"By report",null,"By report",null,0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM"]
["Q5111",null,"Injection, udenyca 0.5 mg",null,163.6,null,163.6,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["Q5120",null,"Inj pegfilgrastim-bmez 0.5mg",null,24.71,null,24.71,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC"]
["Q5134",null,"Inj, tyruko, 1 mg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q5143",null,"Inj adalimumab-adbm, 1 mg",null,10.43,null,10.43,null,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM"]
["Q9002",null,"Va chaplain counsel individu",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["Q9960",null,"Hocm 200-249mg/ml iodine,1ml",null,0.2,null,0.2,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["Q9961",null,"Hocm 250-299mg/ml iodine,1ml",null,0.28999999999999998,null,0.28999999999999998,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["Q9992",null,"Buprenorphine xr over 100 mg",null,1925.23,null,1925.23,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["R0076",null,"Transport portable ekg",null,"Bundled",null,"Bundled",null,0,0,0,0,9,9,9,9,9,9,null,"B"]
["R0390",null,"Retraining child care licensd 6 hr/less",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S0080",null,"Injection, pentamidine iseth",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0119",null,"Ondansetron 4 mg",null,"By report",null,"By report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S0132",null,"Inj ganirelix acetat 250 mcg",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0174",null,"Dolasetron 50 mg",null,72.05,null,72.05,null,0,0,0,0,9,9,9,9,9,9,null,"D"]
["S0183",null,"Prochlorperazine 5 mg",null,0.28999999999999998,null,0.28999999999999998,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"]
["S0255",null,"Hospice refer visit nonmd",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0273",null,"Md home visit outside cap",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0342",null,"Lifestyle mod 4th stage",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0506",null,"Bifoc prscp lens",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0595",null,"New lenses in pts old frame",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S0622",null,"Phys exam for college",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S1034",null,"Art pancreas system",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S1037",null,"Art pancreas ext receiver",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S2083",null,"Adjustment gastric band",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S2112",null,"Knee arthroscp harv",null,"By Report",null,"By Report",null,0,0,0,0,9,9,9,9,9,9,null,"N"]
["S2207",null,"Minimally invasive direct co",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S2266",null,"Induced abortion 29-31 wks",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S2402",null,"Fetal surg cong cyst malf",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S3630",null,"Eosinophil blood count",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S3708",null,"Gastrointestinal fat absorpt",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S3844",null,"Dna analysis deafness",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S3902",null,"Ballistocardiogram",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S4021",null,"Ivf canc p aspir case rate",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S4031",null,"Sperm procure subs visit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S4990",null,"Nicotine patch legend",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S5101",null,"Adult day care per half day",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S5126",null,"Attendant care service /diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S5145",null,"Child fostercare th per diem",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S5180",null,"Hh respiratory thrpy in eval",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S5518",null,"Hit cath repair kit",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S5522",null,"Hit picc insert no supp",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,null,"X"]
["S8040",null,"Topographic brain mapping",null,"Not Covered",null,"Not Covered",null,0,0,0,0,9,9,9,9,9,9,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,0,0,0,0,9,9,9,9,9,9,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,43.43,null,43.43,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC"]
["S9123",null,"Nursing care in home rn",null,87.29,null,87.29,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,63.06,null,63.06,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,46.69,null,46.69,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,30.23,null,30.23,null,0,0,0,0,9,9,9,9,9,9,null,"F"]
["S9982",null,"Med record copy per page",null,0.6,null,0.6,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,50.65,null,50.65,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
["U0002",null,"Covid-19 lab test non-cdc",null,72.349999999999994,null,72.349999999999994,null,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM"]
["V0028",null,"Travel, vocational services, claimant",null,"State Rate",null,"State Rate",null,0,0,0,0,9,9,9,9,9,9,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,94.02,null,94.02,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,62.69,null,62.69,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,1780.27,null,1780.27,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,1067.05,null,1067.05,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,1067.05,null,1067.05,null,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM"]
["V5241",null,"Dispensing fee, monaural",null,890.13,null,890.13,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,1.1000000000000001,null,1.1000000000000001,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"]

{"sheet":"Updates and Corrections","index":3,"n_rows":21,"n_cols":4,"rows_kept":21,"cut":false,"hidden":false,"merged":[[0,0,0,2],[4,3,5,5]]}
["Updates and Corrections"]
["Payment policy updates"]
["Posting date","Policy Area","Description"]
[]
[null,null,null,"It may take up to 20 seconds for this page to fully load."]
[]
[]
["Fee schedule updates"]
["Posting date","Description","Updated Version"]
[]
[]
[]
[]
["Payment policy corrections"]
["Posting date","Policy Area","Description"]
[]
[]
[]
[]
["Fee schedule corrections"]
["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}}
["Professional Services Fee Schedule"]
[]
[]
[]
[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":21167,"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,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",58.65,58.65,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,12]
["01996",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",78.06,78.06,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,12]
["01999",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,12]
[10004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",95.08,76.41,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[10005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",242.65,128.33000000000001,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[10006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",107.91,87.5,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[10007,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",560.54999999999995,156.32,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[10008,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",260.14999999999998,90.41,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[10009,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",776.37,189.57,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[10010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",432.81,125.41,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[10011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,0,0,null,"N",null,"Y-CM",2,23]
[10012,null,{"$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",2,23]
[10021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,23]
[10030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1151.43,235.65,0,0,0,0,9,2,9,0,0,0,null,"R",null,"Y-CM",2,23]
[10035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,23]
[10036,null,{"$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,2,23]
[10040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",213.49,92.74,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[10060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",234.49,197.16,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[10061,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",390.81,335.4,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[10080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",455.56,192.49,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[10081,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",620.63,307.98,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[10120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",278.82,194.24,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[10121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",482.97,331.9,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
["10140",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",310.32,216.99,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[10160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",238.57,176.74,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[10180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",480.06,324.31,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",107.91,47.25,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49,26.25,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[11004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",986.94,986.94,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1335.76,1335.76,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[11006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1216.76,1216.76,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11008,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",470.14,470.14,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[11010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",806.7,495.22,10,0.1,0.8,0.1,0,2,2,1,0,0,null,"R",null,null,2,23]
[11011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",905.28,528.47,0,0,0,0,0,2,2,1,0,0,null,"R",null,null,2,23]
[11012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1169.52,735.54,0,0,0,0,0,2,2,1,0,0,null,"R",null,null,2,23]
[11042,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",237.4,108.49,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11043,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",421.14,272.98,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",558.79999999999995,396.64,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",71.75,43.16,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[11046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",130.08000000000001,95.08,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[11047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",215.24,169.16,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[11055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",130.08000000000001,26.83,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11056,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",151.07,39.08,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11057,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",163.91,49.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",182.57,67.08,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",90.99,38.5,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[11104,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",226.9,83.41,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",109.08,44.91,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[11106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",282.32,100.33,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",128.91,54.25,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[11200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",170.91,142.33000000000001,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",33.25,28.58,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",181.99,60.08,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",220.49,91.58,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",249.65,106.74,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11303,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",277.07,127.16,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",190.74,65.91,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",222.24,86.33,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",250.24,109.08,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11308,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",262.49,121.91,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",209.99,80.5,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11311,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",249.65,111.99,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",283.48,132.99,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",329.56,170.32,0,0,0,0,0,2,9,0,0,0,null,"R",null,null,2,23]
[11400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",235.65,155.74,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11401,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",285.82,194.24,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11402,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",316.14999999999998,212.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11403,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",363.4,275.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11404,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",411.81,302.14999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",582.13,450.31,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",232.74,151.66,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11421,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",292.23,200.07,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11422,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",328.98,250.82,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11423,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",377.98,289.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11424,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",436.89,331.9,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",599.04999999999995,487.06,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",262.49,198.91,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11441,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",317.89999999999998,244.99,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",354.65,270.64999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11443,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",418.23,328.4,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11444,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",518.54999999999995,412.98,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",701.71,576.88,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",783.96,479.47,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,null,2,23]
[11451,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",960.11,604.29999999999995,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,23]
[11462,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",771.71,460.81,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,23]
[11463,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",960.7,601.97,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,23]
[11470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",828.87,523.22,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[11471,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",989.28,638.13,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[11600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",361.65,222.24,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11601,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",418.81,269.48,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",449.14,293.39999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11603,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",510.39,349.4,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11604,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",568.72,383.81,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",814.29,564.04999999999995,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",362.81,223.99,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11621,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",420.56,271.82,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11622,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",463.14,306.82,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11623,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",540.14,377.4,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11624,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",613.63,426.98,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11626,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",737.29,519.72,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",372.73,230.99,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",433.98,282.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11642,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",490.56,328.98,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11643,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",575.72,410.06,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11644,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",708.13,505.14,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11646,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",914.03,692.96,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11719,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.25,12.83,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",60.66,25.08,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[11721,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",82.25,42,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[11730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",209.99,95.66,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11732,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",59.5,29.75,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[11740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",106.74,60.08,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",293.39999999999998,184.91,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",222.24,107.33,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[11760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",338.31,198.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11762,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",529.04999999999995,340.65,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11765,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",304.48,170.91,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[11770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",635.21,331.9,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11771,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1139.77,814.29,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11772,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1399.92,1049.94,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[11900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",105.58,52.5,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11901,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",127.74,80.5,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[11920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",366.9,205.32,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[11921,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",401.89,234.49,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[11922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",112.58,50.16,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[11950,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",150.49,92.74,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[11951,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",199.49,128.91,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[11952,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",265.39999999999998,180.82,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[11954,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",293.39999999999998,198.91,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[11960,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1868.31,1868.31,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[11970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1024.27,1024.27,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,null,2,23]
[11971,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1011.44,1011.44,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,null,2,23]
[11976,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,23]
[11980,null,{"$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,2,23]
[11981,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",182.57,110.83,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[11982,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",198.91,128.33000000000001,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[11983,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",254.32,181.99,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[12001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",171.49,78.16,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[12002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",207.65,102.66,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[12004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",240.9,127.74,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[12005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",319.64999999999998,163.32,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[12006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",370.4,201.82,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[12007,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",411.81,251.4,0,0,0,0,0,2,0,1,1,0,null,"R",null,null,2,23]
[12011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",204.16,97.41,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[12013,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",211.74,100.33,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[12014,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",256.64999999999998,128.33000000000001,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[12015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",312.07,162.16,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[12016,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",397.23,219.9,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[12017,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",265.98,265.98,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[12018,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",300.98,300.98,0,0,0,0,0,2,0,2,0,0,null,"R",null,null,2,23]
[12020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",547.14,342.4,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",320.82,254.9,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",480.06,275.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12032,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",557.04999999999995,347.06,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12034,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",610.13,371.56,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",710.46,435.14,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",790.95,506.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12037,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",884.87,585.04999999999995,10,0.1,0.8,0.1,0,2,0,0,1,0,null,"R",null,null,2,23]
[12041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",481.81,264.23,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12042,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",565.79999999999995,355.23,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",699.96,387.89,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",753.04,491.72,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",909.95,571.04999999999995,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[12047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",995.69,631.13,10,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,null,2,23]
[12051,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",516.22,306.82,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12052,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",575.72,361.65,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12053,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",662.05,389.64,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12054,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",694.71,394.89,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",912.86,540.72,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[12056,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1055.77,695.29,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[12057,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1098.3499999999999,757.12,10,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,null,2,23]
[13100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",620.04999999999995,361.65,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[13101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",720.96,444.47,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[13102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",209.99,126.58,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[13120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",645.71,416.48,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[13121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",772.29,463.72,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[13122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",228.07,145.24,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[13131,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",705.79,435.14,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[13132,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",853.95,541.89,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[13133,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",303.32,221.65,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[13151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",767.62,499.3,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[13152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",898.87,599.63,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[13153,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",334.23,242.07,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[13160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1436.08,1436.08,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[14000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1169.52,922.2,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[14001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1483.33,1184.68,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[14020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1294.3399999999999,1037.1099999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[14021,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1594.16,1290.26,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[14040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1395.84,1136.8499999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[14041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1695.07,1385.92,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[14060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1406.92,1210.93,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[14061,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1829.23,1486.83,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[14301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1969.8,1567.33,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R",null,null,2,23]
[14302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",379.15,379.15,0,0,0,0,0,0,0,2,0,0,null,"R",null,null,2,23]
[14350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1205.68,1205.68,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",618.88,390.23,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[15003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",123.66,77.58,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[15004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",710.46,463.14,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[15005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",208.24,156.91,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[15011,null,{"$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,null,2,23]
[15012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,1,0,0,null,"N",null,null,2,23]
[15013,null,{"$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,null,2,23]
[15014,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,1,0,0,null,"N",null,null,2,23]
[15015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",90,0.1,0.71,0.19,0,2,0,1,0,0,null,"N",null,null,2,23]
[15016,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,1,0,0,null,"N",null,null,2,23]
[15017,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",90,0.1,0.71,0.19,0,2,0,1,0,0,null,"N",null,null,2,23]
[15018,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,1,0,0,null,"N",null,null,2,23]
[15040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",477.72,225.15,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1072.69,839.37,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1574.33,1292.5899999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",333.65,194.82,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1493.83,1279.18,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",201.24,177.32,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1468.17,1258.76,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",271.23,240.9,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,23]
[15120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1535.83,1246.51,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",372.15,232.15,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,23]
[15130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1311.84,1089.02,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15131,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",174.99,158.66,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,23]
[15135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1581.91,1370.76,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15136,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",172.66,158.66,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,23]
[15150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1260.51,1141.52,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",208.24,188.41,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",272.39999999999998,253.74,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1440.17,1318.84,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15156,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",279.39999999999998,260.14999999999998,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,23]
[15157,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",311.48,283.48,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,23]
[15200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1531.16,1219.68,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",251.4,134.16,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1409.84,1110.02,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15221,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",231.57,121.33,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1701.49,1451.25,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15241,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",313.82,188.41,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1833.31,1540.5,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",369.81,239.15,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15271,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",279.39999999999998,149.32,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[15272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",43.75,29.75,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15273,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",549.47,340.06,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[15274,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",144.08000000000001,76.41,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",289.32,166.24,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[15276,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",58.91,43.75,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15277,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",614.21,391.98,0,0,0,0,0,2,0,1,1,0,null,"R",null,null,2,23]
[15278,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",169.74,97.41,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,23]
[15570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1647.82,1314.17,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15572,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1609.91,1335.76,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15574,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1564.99,1307.76,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15576,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1432,1179.43,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",620.63,390.81,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",682.46,453.22,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",824.2,602.54999999999995,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",853.95,633.46,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",999.19,741.96,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2564.77,1648.99,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,23]
[15731,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2037.47,1800.65,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15733,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1847.89,1847.89,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,23]
[15734,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2678.51,2678.51,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,23]
[15736,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2191.46,2191.46,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,23]
[15738,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2262.62,2262.62,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,23]
[15740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1854.89,1528.25,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1684.57,1684.57,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R",null,null,2,23]
[15756,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4062.1,4062.1,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R",null,null,2,23]
[15757,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4037.02,4037.02,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R",null,null,2,23]
[15758,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4021.85,4021.85,90,0.1,0.71,0.19,0,2,0,2,2,0,null,"R",null,null,2,23]
[15760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1545.16,1267.51,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15769,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",870.87,870.87,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[15770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1227.26,1227.26,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,23]
[15771,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,23]
[15772,null,{"$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,2,23]
[15773,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,23]
[15774,null,{"$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,2,23]
[15775,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",683.04,456.14,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[15776,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",922.2,622.96,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[15777,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",377.98,377.98,0,0,0,0,0,0,1,1,0,0,null,"R",null,null,2,23]
[15778,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",683.63,683.63,0,0,0,0,0,2,0,2,1,0,null,"R",null,null,2,23]
[15780,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1553.33,1214.43,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15781,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",962.45,768.79,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15782,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",895.95,682.46,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15783,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",832.37,656.8,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15786,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",418.23,244.99,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[15787,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",54.83,30.33,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[15788,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,1,0,0,null,"X",null,null,2,23]
[15789,null,{"$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,2,23]
[15792,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,0,0,0,0,null,"X",null,null,2,23]
[15793,null,{"$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,2,23]
[15820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1057.52,938.53,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[15821,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1131.02,999.78,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[15822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",841.7,725.04,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[15823,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1132.77,1000.36,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[15824,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1648.46,1648.46,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,23]
[15825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1417.39,1417.39,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,23]
[15826,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1340.35,1340.35,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,23]
[15828,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4591.07,4591.07,0,0,0,0,0,2,1,0,0,0,null,"F",null,"Y-CM",2,23]
[15829,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,1,0,0,0,null,"N",null,"Y-CM",2,23]
[15830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2115.63,2115.63,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[15832,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1681.65,1681.65,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[15833,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1593.58,1593.58,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[15834,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1622.74,1622.74,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[15835,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1688.65,1688.65,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[15836,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1450.67,1450.67,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[15837,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1588.33,1305.43,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[15838,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1187.02,1187.02,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[15839,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1627.41,1338.67,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[15840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1815.23,1815.23,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15841,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3200.57,3200.57,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,23]
[15842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4826.22,4826.22,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,23]
[15845,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1928.39,1928.39,90,0.1,0.71,0.19,0,2,0,2,0,0,null,"R",null,null,2,23]
[15847,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,2,1,0,null,"N",null,"Y-CM",2,23]
[15851,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",100.91,117.24,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[15852,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",78.16,78.16,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[15853,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",21,21,0,0,0,0,5,0,0,1,0,0,null,"R",null,null,2,23]
[15854,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.83,26.83,0,0,0,0,5,0,0,1,0,0,null,"R",null,null,2,23]
[15860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",186.66,186.66,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[15876,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,23]
[15877,null,{"$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,2,23]
[15878,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,0,0,0,null,"X",null,null,2,23]
[15879,null,{"$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,2,23]
[15920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1149.0999999999999,1149.0999999999999,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1452.42,1452.42,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,23]
[15931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1268.0899999999999,1268.0899999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15933,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1574.91,1574.91,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15934,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1783.15,1783.15,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2094.0500000000002,2094.0500000000002,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,23]
[15936,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1595.33,1595.33,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,23]
[15937,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1766.82,1766.82,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,23]
[15940,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1280.3399999999999,1280.3399999999999,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15941,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1722.48,1722.48,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15944,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1697.99,1697.99,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15945,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1851.39,1851.39,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,null,2,23]
[15946,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2871,2871,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,23]
[15950,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1162.52,1162.52,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,null,2,23]
[15951,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1634.99,1634.99,90,0.1,0.71,0.19,0,2,0,0,1,0,null,"R",null,null,2,23]
[15952,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1664.74,1664.74,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,23]
[15953,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1832.15,1832.15,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,23]
[15956,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2094.63,2094.63,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,23]
[15958,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2094.63,2094.63,90,0.1,0.71,0.19,0,2,0,1,1,0,null,"R",null,null,2,23]
[15999,null,{"$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,2,23]
[16000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",146.41,80.5,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[16020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",157.49,101.49,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[16025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",284.07,198.32,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[16030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",360.48,235.65,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[16035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",343.56,343.56,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[16036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",144.08000000000001,144.08000000000001,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[17000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",125.99,101.49,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",12.25,3.5,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17004,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",306.23,179.66,10,0.1,0.8,0.1,0,0,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",635.21,506.3,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",825.95,660.88,90,0.1,0.71,0.19,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17108,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1164.8499999999999,960.11,90,0.1,0.71,0.19,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[17110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",209.99,127.74,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",245.57,155.16,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",156.91,68.25,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[17260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",183.16,129.49,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",273.57,160.41,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17262,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",327.23,201.24,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",354.65,222.24,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17264,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",380.89,237.99,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17266,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",431.64,277.64999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",276.48,175.57,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17271,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",306.23,191.91,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",345.9,219.9,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17273,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",383.81,248.49,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17274,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",448.56,303.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17276,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",518.54999999999995,364.56,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",259.57,159.82,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17281,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",330.15,215.24,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",376.81,247.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17283,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",445.06,307.98,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",505.14,359.31,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",650.38,489.39,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17311,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1250.5999999999999,632.29999999999995,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",758.29,336.56,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1176.52,567.54999999999995,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17314,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",726.79,310.89999999999998,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",147.57,88.66,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,23]
[17340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,23]
[17360,null,{"$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,2,23]
[17380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,23]
[17999,null,{"$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,2,23]
[19000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",177.91,74.66,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[19001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",46.66,36.159999999999997,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,23]
[19020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",839.95,571.04999999999995,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,null,2,23]
[19030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",296.32,132.41,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[19081,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",897.7,285.23,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[19082,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",687.71,142.33000000000001,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[19083,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",888.37,267.73,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[19084,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",674.88,134.74,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[19085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1364.34,313.82,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[19086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1055.19,156.32,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[19100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",265.39999999999998,118.99,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[19101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",576.88,401.31,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[19105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2,23]
[19110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",873.2,642.21,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[19112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",827.7,592.63,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[19120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",944.95,754.79,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[19125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1040.02,832.95,90,0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM",2,23]
[19126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",277.07,277.07,0,0,0,0,0,0,0,1,1,0,null,"R",null,"Y-CM",2,23]
[19281,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",440.39,172.07,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[19282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",310.89999999999998,85.75,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[19283,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",469.56,173.24,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[19284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",340.06,86.33,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[19285,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",657.38,146.99,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[19286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",536.04999999999995,73.5,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[19287,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1133.94,219.32,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[19288,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",872.62,110.83,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[19294,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",285.23,285.23,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[19296,null,{"$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,2,23]
[19297,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,23]
[19298,null,{"$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,2,23]
[19300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,1,0,0,null,"X",null,null,2,23]
[19301,null,{"$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,2,23]
[19302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,23]
[19303,null,{"$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,2,23]
[19305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,23]
[19306,null,{"$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,2,23]
[19307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.71,0.19,0,2,1,2,1,0,null,"X",null,null,2,23]
[19316,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1434.33,1434.33,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[19318,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1972.72,1972.72,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[19325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1122.8499999999999,1122.8499999999999,90,0.1,0.71,0.19,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[19328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1010.28,1010.28,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[19330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1172.43,1172.43,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[19340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1377.17,1377.17,90,0.1,0.71,0.19,0,2,1,1,1,0,null,"R",null,"Y-CM",2,23]
[19342,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1383,1383,90,0.1,0.71,0.19,0,2,1,0,1,0,null,"R",null,"Y-CM",2,23]
[19350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1519.5,1225.51,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[19355,null,{"$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,2,23]
[19357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2113.88,2113.88,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[19361,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2799.26,2799.26,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[19364,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4850.1400000000003,4850.1400000000003,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[19367,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3177.24,3177.24,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[19368,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3874.28,3874.28,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[19369,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3601.29,3601.29,90,0.1,0.71,0.19,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[19370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1222.01,1222.01,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[19371,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1293.76,1293.76,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[19380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1465.83,1465.83,90,0.1,0.71,0.19,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[19396,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",492.31,256.07,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[19499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,23]
[20100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1059.8599999999999,1059.8599999999999,10,0.1,0.8,0.1,0,2,1,2,0,0,null,"R",null,null,2,23]
[20101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1019.03,371.56,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[20102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1090.19,455.56,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[20103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1020.19,617.71,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[20150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1812.9,1812.9,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[20200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",391.39,170.32,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[20205,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",548.29999999999995,274.14999999999998,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[20206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",395.48,102.08,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[20220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",418.81,153.99,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[20225,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",683.04,228.65,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[20240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",249.07,249.07,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[20245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",606.63,606.63,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[20250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",706.96,706.96,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[20251,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",775.79,775.79,10,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,null,2,23]
[20500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",230.99,164.49,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[20501,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",256.64999999999998,63.58,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[20520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",400.14,271.23,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[20525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",854.53,450.89,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[20526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",151.07,101.49,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[20527,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",160.41,118.41,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[20550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",105.58,68.83,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[20551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",104.41,68.25,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[20552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",95.08,64.75,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[20553,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",109.66,73.5,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[20555,null,{"$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,2,23]
[20560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",46.08,26.83,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,23]
[20561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",67.66,40.25,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-CM",2,23]
[20600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",97.99,63.58,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[20604,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",151.66,82.25,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[20605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",99.74,65.33,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[20606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",163.91,92.16,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[20610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",117.83,80.5,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[20611,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",180.24,104.41,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[20612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",119.58,73.5,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[20615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",455.56,290.48,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[20650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",429.89,307.98,10,0.1,0.8,0.1,0,2,0,1,1,0,null,"R",null,null,2,23]
[20660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",419.98,419.98,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[20661,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",950.2,950.2,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[20662,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",965.36,965.36,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[20663,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",890.7,890.7,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[20664,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1616.91,1616.91,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[20665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",219.9,181.99,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[20670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",648.04999999999995,266.57,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[20680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1093.0999999999999,764.71,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[20690,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1082.5999999999999,1082.5999999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[20692,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2054.9699999999998,2054.9699999999998,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20693,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",827.7,827.7,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[20694,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",797.95,633.46,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[20696,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2098.71,2098.71,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20697,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3191.23,3191.23,0,0,0,0,3,0,0,2,1,0,null,"R",null,null,2,23]
[20700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",147.57,147.57,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[20701,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",111.99,111.99,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[20702,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",250.82,250.82,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[20703,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",184.32,184.32,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[20704,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",264.23,264.23,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[20705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",218.15,218.15,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[20802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4894.47,4894.47,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[20805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5803.25,5803.25,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[20808,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6986.77,6986.77,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[20816,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3664.29,3664.29,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3177.82,3177.82,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20824,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3672.46,3672.46,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[20827,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3262.4,3262.4,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[20838,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4968.55,4968.55,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[20900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",697.04,320.82,0,0,0,0,0,2,0,2,1,0,null,"R",null,null,2,23]
[20902,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",485.89,485.89,0,0,0,0,0,2,0,2,1,0,null,"R",null,null,2,23]
[20910,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",883.12,883.12,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[20912,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",879.62,879.62,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[20920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",731.46,731.46,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,23]
[20922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1117.5999999999999,904.12,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20924,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.86,926.86,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,23]
[20931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",192.49,192.49,0,0,0,0,0,0,0,1,1,0,null,"R",null,null,2,23]
[20932,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1323.51,1323.51,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,23]
[20933,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1214.43,1214.43,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,23]
[20934,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1322.92,1322.92,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,23]
[20936,null,{"$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,2,23]
[20937,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",291.64999999999998,291.64999999999998,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,23]
[20938,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",317.89999999999998,317.89999999999998,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,23]
[20939,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",121.91,121.91,0,0,0,0,0,0,1,0,0,0,null,"R",null,"Y-UR",2,23]
[20950,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",475.39,160.41,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[20955,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4349.08,4349.08,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20956,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4704.8999999999996,4704.8999999999996,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20957,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4903.22,4903.22,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20962,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4795.3100000000004,4795.3100000000004,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20969,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4826.22,4826.22,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5075.88,5075.88,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[20972,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5059.54,5059.54,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[20973,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5338.94,5338.94,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[20974,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",158.66,93.91,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-ONC",2,23]
[20975,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",317.32,317.32,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-ONC",2,23]
[20979,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",102.08,54.83,0,0,0,0,0,0,0,1,0,0,null,"R",null,"Y-ONC",2,23]
[20982,null,{"$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,2,23]
[20983,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2,23]
[20985,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",254.32,254.32,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[20999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,23]
[21010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1348.01,1348.01,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[21011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",690.04,484.14,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21012,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",620.04999999999995,620.04999999999995,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21013,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.11,732.04,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21014,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",949.03,949.03,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1271.01,1271.01,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[21016,null,{"$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,2,23]
[21025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1470.5,1219.0999999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21026,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1009.69,804.95,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21029,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1420.92,1145.02,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,23]
[21030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",846.37,665.55,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[21031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",703.46,501.64,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[21032,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",691.21,482.97,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[21034,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2346.62,2024.63,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",854.53,668.46,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[21044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1560.33,1560.33,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2159.38,2159.38,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1793.65,1793.65,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR",2,23]
[21047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2187.38,2187.38,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21048,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1815.81,1815.81,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR",2,23]
[21049,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2074.8000000000002,2074.8000000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1571.99,1571.99,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[21060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1423.84,1423.84,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[21070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1108.27,1108.27,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[21073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",752.46,450.89,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[21076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1606.99,1284.43,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[21077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3891.19,3141.65,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[21079,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2689.6,2120.88,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3059.99,2385.11,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21081,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2819.67,2186.79,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21082,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2658.1,2029.3,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21083,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2519.86,1873.56,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21084,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2871,2164.63,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1255.8399999999999,876.12,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[21086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2888.5,2317.4499999999998,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[21087,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2888.5,2317.4499999999998,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21088,null,{"$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,2,23]
[21089,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,1,1,1,null,"N",null,null,2,23]
[21100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1150.27,664.96,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1572.58,1300.18,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",384.98,78.75,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[21120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1213.26,928.03,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,23]
[21121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1167.77,974.69,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1359.67,1359.67,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21123,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1530.58,1530.58,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4731.7299999999996,1222.5999999999999,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21127,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7308.17,1411.59,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21137,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1365.51,1365.51,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21138,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1656.57,1656.57,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21139,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1966.3,1966.3,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21141,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2410.7800000000002,2410.7800000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21142,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2472.61,2472.61,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21143,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2547.85,2547.85,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2794.01,2794.01,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2918.83,2918.83,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3067.57,3067.57,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2934,2934,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3226.23,3226.23,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21154,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3473.55,3473.55,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3849.2,3849.2,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21159,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4605.1499999999996,4605.1499999999996,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4990.71,4990.71,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21172,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3741.29,3741.29,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3944.86,3944.86,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21179,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2725.18,2725.18,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3040.74,3040.74,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21181,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1345.67,1345.67,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,23]
[21182,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3780.37,3780.37,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21183,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4108.7700000000004,4108.7700000000004,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21184,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4415.58,4415.58,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21188,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2848.84,2848.84,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21193,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2223.54,2223.54,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,23]
[21194,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2569.44,2569.44,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-UR",2,23]
[21195,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2418.9499999999998,2418.9499999999998,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,"Y-UR",2,23]
[21196,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2582.27,2582.27,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,23]
[21198,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1823.98,1823.98,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21199,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1832.15,1832.15,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1767.98,1767.98,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21208,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2991.16,1349.76,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21209,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1444.83,1103.5999999999999,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[21210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3230.32,1392.92,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7465.66,1448.33,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,23]
[21230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1346.84,1346.84,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1350.34,1042.94,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1903.31,1903.31,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[21242,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1837.4,1837.4,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[21243,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2926.42,2926.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[21244,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1819.9,1819.9,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2221.79,1716.65,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21246,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1537,1537,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21247,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2851.17,2851.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21248,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1798.31,1448.33,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21249,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2437.0300000000002,2017.63,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21255,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2417.7800000000002,2417.7800000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21256,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2241.62,2241.62,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,23]
[21261,null,{"$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,2,23]
[21263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,23]
[21267,null,{"$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,2,23]
[21268,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,23]
[21270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1869.48,1355.59,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1525.91,1525.91,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1075.6099999999999,1075.6099999999999,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[21282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",736.12,736.12,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[21295,null,{"$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,2,23]
[21296,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,0,0,null,"X",null,null,2,23]
[21299,null,{"$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,2,23]
[21315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",284.64999999999998,107.33,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[21320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",398.39,169.74,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[21325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",817.79,817.79,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",978.19,978.19,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1301.3399999999999,1301.3399999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21336,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1166.02,1166.02,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",768.21,558.79999999999995,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21338,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1233.0999999999999,1233.0999999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21339,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1388.84,1388.84,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1364.34,1364.34,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21343,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1973.3,1973.3,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2501.77,2501.77,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,23]
[21345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1469.33,1167.18,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21346,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1836.81,1836.81,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,23]
[21347,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1886.98,1886.98,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21348,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1964.55,1964.55,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,23]
[21355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",823.04,600.79999999999995,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[21356,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1006.19,739.04,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[21360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",958.95,958.95,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[21365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1956.39,1956.39,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21366,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2298.79,2298.79,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[21385,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1331.09,1331.09,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21386,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1258.18,1258.18,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[21387,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1389.42,1389.42,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[21390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1450.08,1450.08,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21395,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1810.56,1810.56,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",410.06,320.23,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[21401,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",941.45,612.47,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[21406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1067.44,1067.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21407,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1181.77,1181.77,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21408,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1631.49,1631.49,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[21421,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1196.93,1009.11,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21422,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1150.8499999999999,1150.8499999999999,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21423,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1439,1439,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,23]
[21431,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1273.93,1273.93,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[21432,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1299.5899999999999,1299.5899999999999,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[21433,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3108.41,3108.41,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2539.1,2539.1,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[21436,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3659.04,3659.04,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,null,2,23]
[21440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1391.17,1110.5999999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1418.59,1146.18,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[21450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1093.0999999999999,888.37,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21451,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1421.5,1181.77,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21452,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1335.76,838.2,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21453,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1994.3,1693.9,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21454,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",906.45,906.45,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,23]
[21461,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3277.56,1909.14,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,23]
[21462,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3574.46,2117.96,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1466.42,1466.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2106.88,2106.88,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",258.39999999999998,55.41,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[21485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1751.65,1428.5,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[21490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1446,1446,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[21497,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1312.43,1088.44,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,23]
[21501,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",897.7,622.38,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",908.2,908.2,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[21510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",814.29,814.29,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[21550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",485.89,282.89999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[21552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",808.45,808.45,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21554,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1315.34,1315.34,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",792.7,563.47,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[21556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",960.11,960.11,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[21557,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1706.74,1706.74,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"X",null,null,2,23]
[21600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1042.94,1042.94,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21601,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2025.22,2025.22,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,23]
[21602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2745.59,2745.59,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,23]
[21603,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2967.25,2967.25,90,0.1,0.71,0.19,0,2,0,2,1,0,null,"R",null,null,2,23]
[21610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2159.96,2159.96,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1098.94,1098.94,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[21616,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1244.76,1244.76,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[21620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",901.78,901.78,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21627,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",991.61,991.61,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[21630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2368.7800000000002,2368.7800000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21685,null,{"$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,2,23]
[21700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",620.63,620.63,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[21705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",921.03,921.03,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[21720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.69,974.69,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",996.86,996.86,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1791.9,1791.9,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[21742,null,{"$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",2,23]
[21743,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",90,0.1,0.69,0.21,0,2,0,2,1,0,null,"N",null,"Y-UR",2,23]
[21750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1187.5999999999999,1187.5999999999999,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21811,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1028.3599999999999,1028.3599999999999,0,0,0,0,0,2,1,2,0,0,null,"R",null,null,2,23]
[21812,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1246.51,1246.51,0,0,0,0,0,2,1,2,0,0,null,"R",null,null,2,23]
[21813,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1702.65,1702.65,0,0,0,0,0,2,1,2,0,0,null,"R",null,null,2,23]
[21820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",288.73,286.39999999999998,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",996.86,996.86,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[21899,null,{"$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",2,23]
[21920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",466.64,281.73,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[21925,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",908.2,695.29,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",917.53,664.96,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[21931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",849.28,849.28,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[21932,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1199.26,1199.26,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[21933,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1324.67,1324.67,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[21935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1816.4,1816.4,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,23]
[21936,null,{"$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,2,23]
[22010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1760.4,1760.4,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[22015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1720.15,1720.15,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[22100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1717.24,1717.24,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1614.57,1614.57,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1380.67,1380.67,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",232.74,232.74,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1903.31,1903.31,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2051.4699999999998,2051.4699999999998,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22114,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2051.4699999999998,2051.4699999999998,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",246.74,246.74,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4346.75,4346.75,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22207,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4247.59,4247.59,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22208,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1024.8599999999999,1024.8599999999999,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3197.07,3197.07,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22212,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2726.93,2726.93,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22214,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2723.43,2723.43,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22216,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",632.29999999999995,632.29999999999995,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2917.67,2917.67,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22222,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3152.15,3152.15,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22224,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2848.84,2848.84,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22226,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",627.63,627.63,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",577.47,551.22,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[22315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1664.74,1429.67,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[22318,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2940.42,2940.42,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22319,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3257.15,3257.15,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2660.43,2660.43,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22326,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2702.43,2702.43,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22327,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2761.34,2761.34,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",489.39,489.39,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",267.73,267.73,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[22510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,23]
[22511,null,{"$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,2,23]
[22512,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,1,0,0,null,"X",null,null,2,23]
[22513,null,{"$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,2,23]
[22514,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,23]
[22515,null,{"$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,2,23]
[22526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,9,9,9,9,9,9,null,"X",null,null,2,23]
[22527,null,{"$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,2,23]
[22532,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3191.23,3191.23,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22533,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2973.08,2973.08,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22534,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",628.21,628.21,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22548,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3495.13,3495.13,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3018.58,3018.58,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",688.29,688.29,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22554,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2259.12,2259.12,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3002.25,3002.25,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2712.35,2712.35,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",562.88,562.88,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22586,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3612.38,3612.38,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2847.09,2847.09,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22595,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2721.68,2721.68,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2343.6999999999998,2343.6999999999998,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2309.87,2309.87,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2817.34,2817.34,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22614,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",679.54,679.54,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2784.09,2784.09,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",555.88,555.88,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22633,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3217.48,3217.48,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22634,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",841.7,841.7,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2455.69,2455.69,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3747.7,3747.7,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22804,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4297.75,4297.75,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22808,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3227.4,3227.4,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3586.13,3586.13,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22812,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3932.03,3932.03,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22818,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3829.36,3829.36,90,0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR",2,23]
[22819,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4408.58,4408.58,90,0.11,0.76,0.13,0,2,0,2,2,2,null,"R",null,"Y-UR",2,23]
[22830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1485.67,1485.67,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22836,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,0,2,1,null,"X",null,null,2,23]
[22837,null,{"$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,2,23]
[22838,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,0,2,1,null,"X",null,null,2,23]
[22840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1311.84,1311.84,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22841,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,"Y-UR",2,23]
[22842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1325.84,1325.84,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22843,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1420.34,1420.34,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22844,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1717.82,1717.82,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22845,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1259.93,1259.93,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22846,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1311.84,1311.84,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22847,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1401.09,1401.09,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22848,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",626.46,626.46,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22849,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2330.87,2330.87,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22850,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1332.84,1332.84,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22852,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1283.8399999999999,1283.8399999999999,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22853,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",447.39,447.39,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22854,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",582.13,582.13,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22855,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1980.3,1980.3,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22856,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2887.34,2887.34,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22857,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3124.74,3124.74,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22858,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",881.95,881.95,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22859,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",581.54999999999995,581.54999999999995,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,2,2,0,null,"X",null,null,2,23]
[22861,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4091.85,4091.85,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22862,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4102.3500000000004,4102.3500000000004,90,0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR",2,23]
[22864,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3659.62,3659.62,90,0.1,0.69,0.21,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22865,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4007.27,4007.27,90,0.1,0.71,0.19,0,2,0,2,2,2,null,"R",null,"Y-UR",2,23]
[22867,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1900.39,1900.39,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[22868,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",419.98,419.98,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22869,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",779.87,779.87,90,0.1,0.8,0.1,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[22870,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",207.07,207.07,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-UR",2,23]
[22899,null,{"$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",2,23]
[22900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1023.69,1023.69,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22901,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1197.51,1197.51,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22902,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",860.37,609.54999999999995,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22903,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",795.62,795.62,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[22904,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,1,null,"X",null,null,2,23]
[22905,null,{"$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,2,23]
[22999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,"Y-UR",2,23]
[23000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1021.36,663.8,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1266.3399999999999,1266.3399999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[23030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",803.79,465.47,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[23031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",792.7,410.06,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[23035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1245.93,1245.93,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[23040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1312.43,1312.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1026.02,1026.02,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[23065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,1,1,0,0,null,"X",null,null,2,23]
[23066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1062.19,688.88,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[23071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",764.12,764.12,90,0.1,0.8,0.1,0,2,1,2,0,0,null,"R",null,null,2,23]
[23073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1260.51,1260.51,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[23075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",940.28,604.29999999999995,90,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[23076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",995.69,995.69,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,23]
[23078,null,{"$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,2,23]
[23100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",940.86,940.86,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",848.12,848.12,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[23105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1178.8499999999999,1178.8499999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",933.86,933.86,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[23107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1220.26,1220.26,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1086.0999999999999,1086.0999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1301.3399999999999,1301.3399999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1142.0999999999999,1142.0999999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[23140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1026.02,1026.02,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[23145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1276.26,1276.26,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1151.43,1151.43,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[23150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1226.0999999999999,1226.0999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1460,1460,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23156,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1248.8499999999999,1248.8499999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[23170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1043.52,1043.52,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[23172,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1054.02,1054.02,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[23174,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1405.17,1405.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1269.26,1269.26,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[23182,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1239.51,1239.51,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[23184,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1355.59,1355.59,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23190,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1061.6099999999999,1061.6099999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23195,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1369.59,1369.59,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,23]
[23210,null,{"$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,2,23]
[23220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,23]
[23330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",554.14,310.32,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[23333,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",878.45,878.45,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[23334,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1924.31,1924.31,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[23335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2280.12,2280.12,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[23350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",291.07,87.5,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[23395,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2323.87,2323.87,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[23397,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2053.8000000000002,2053.8000000000002,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[23400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1765.07,1765.07,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1124.02,1124.02,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[23406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1346.84,1346.84,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[23410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1495,1495,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23412,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1552.16,1552.16,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1286.76,1286.76,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[23420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1776.15,1776.15,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1360.84,1360.84,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1378.92,1378.92,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1713.74,1713.74,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1757.48,1757.48,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23460,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1972.14,1972.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23462,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1927.81,1927.81,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2021.13,2021.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23466,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2031.05,2031.05,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2158.21,2158.21,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23472,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2592.19,2592.19,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23473,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2879.17,2879.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23474,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3105.49,3105.49,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1495,1495,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[23485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1726.57,1726.57,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1566.16,1566.16,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[23491,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1842.64,1842.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[23500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",431.64,442.72,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",687.71,635.79999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1321.17,1321.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[23520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",465.47,461.97,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[23525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",762.37,694.13,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[23530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1062.77,1062.77,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[23532,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1155.52,1155.52,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[23540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",456.72,453.81,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",693.54,618.29999999999995,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[23550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1052.27,1052.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1185.8499999999999,1185.8499999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",453.22,469.56,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",782.79,720.96,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[23585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1767.98,1767.98,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[23600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",644.54999999999995,609.54999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",888.95,802.62,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1610.49,1610.49,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[23616,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2225.29,2225.29,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[23620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",523.79999999999995,500.47,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23625,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",725.63,660.88,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1432,1432,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[23650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",637.54999999999995,572.22,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23655,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",763.54,763.54,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1078.52,1078.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[23665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",827.12,755.96,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1591.83,1591.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[23675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1039.44,934.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[23680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1693.32,1693.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[23700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",360.48,360.48,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[23800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1860.73,1860.73,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2322.6999999999998,2322.6999999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2491.27,2491.27,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[23920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2033.38,2033.38,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[23921,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",875.53,875.53,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[23929,null,{"$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",2,23]
[23930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",655.63,393.73,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[23931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",553.54999999999995,297.48,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[23935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",951.95,951.95,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[24000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",888.37,888.37,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,"Y-UR",2,23]
[24006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1311.84,1311.84,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,"Y-UR",2,23]
[24065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",474.22,297.48,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[24066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1159.02,783.37,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",737.87,737.87,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[24073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1255.26,1255.26,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[24075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",968.28,607.22,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1002.11,1002.11,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24077,null,{"$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,2,23]
[24079,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,23]
[24100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",783.37,783.37,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",935.03,935.03,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1136.27,1136.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",678.96,678.96,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1091.94,1091.94,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[24115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1349.76,1349.76,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1563.83,1563.83,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[24120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",989.28,989.28,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[24125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1149.0999999999999,1149.0999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1198.68,1198.68,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[24130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",952.53,952.53,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[24134,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1369.59,1369.59,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[24136,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1164.8499999999999,1164.8499999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24138,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1272.76,1272.76,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[24140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1289.68,1289.68,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[24145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1096.02,1096.02,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[24147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1163.0999999999999,1163.0999999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[24149,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2152.96,2152.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24150,null,{"$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,2,23]
[24152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,23]
[24155,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1549.24,1549.24,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2265.54,2265.54,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[24164,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1327.01,1327.01,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[24200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",410.06,263.64999999999998,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[24201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1136.27,745.46,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",344.15,116.66,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,23]
[24300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",837.04,837.04,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1371.92,1371.92,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[24305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1072.1099999999999,1072.1099999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,23]
[24310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",871.45,871.45,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,23]
[24320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1425.59,1425.59,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[24330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1315.92,1315.92,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24331,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1434.33,1434.33,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1138.5999999999999,1138.5999999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[24340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1115.8499999999999,1115.8499999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24341,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1381.84,1381.84,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24342,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1413.92,1413.92,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24343,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1322.92,1322.92,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2012.97,2012.97,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1309.51,1309.51,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24346,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2012.97,2012.97,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",768.79,768.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[24358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",985.19,985.19,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[24359,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1219.68,1219.68,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[24360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1642.57,1642.57,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24361,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1829.23,1829.23,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24362,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1921.39,1921.39,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24363,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2606.77,2606.77,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1178.27,1178.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24366,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1250.01,1250.01,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2763.68,2763.68,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24371,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3162.65,3162.65,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1511.91,1511.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,23]
[24420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1934.22,1934.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1914.97,1914.97,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1966.3,1966.3,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1236.01,1236.01,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24495,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1680.49,1680.49,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[24498,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1570.83,1570.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",697.63,640.46,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",953.7,848.7,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1606.99,1606.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24516,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1561.49,1561.49,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[24530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",734.96,670.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1170.0999999999999,1069.19,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24538,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1448.33,1448.33,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1690.99,1690.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1884.64,1884.64,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[24560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",641.04999999999995,565.79999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1024.27,931.53,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24566,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1332.84,1332.84,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1350.34,1350.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24576,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",678.96,603.13,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24577,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1053.44,956.03,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24579,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1530,1530,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24582,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1508.41,1508.41,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24586,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1962.22,1962.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24587,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1968.64,1968.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",716.29,646.29999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",890.12,890.12,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1306.5899999999999,1306.5899999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1095.44,1095.44,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[24635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1250.01,1250.01,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24640,null,{"$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,2,23]
[24650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",513.89,477.72,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24655,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",855.12,766.46,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1216.76,1216.76,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24666,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1343.92,1343.92,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",565.79999999999995,515.04999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",870.28,785.12,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[24685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1206.26,1206.26,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[24800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1523.58,1523.58,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24802,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1819.9,1819.9,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1399.34,1399.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1340.42,1340.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[24925,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1052.8599999999999,1052.8599999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24930,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1411,1411,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1688.07,1688.07,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[24935,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2211.87,2211.87,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[24940,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2095.27,2095.27,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"F",null,"Y-UR",2,23]
[24999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,"Y-UR",2,23]
[25000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",653.88,653.88,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[25001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",659.13,659.13,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[25020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1354.42,1354.42,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[25023,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2384.5300000000002,2384.5300000000002,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[25024,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1419.17,1419.17,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[25025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2217.12,2217.12,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[25028,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1268.0899999999999,1268.0899999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25031,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",690.04,690.04,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1087.8499999999999,1087.8499999999999,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1031.27,1031.27,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",467.81,288.73,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[25066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",694.13,694.13,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",774.62,774.62,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25073,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",985.78,985.78,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",946.7,584.47,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",958.95,958.95,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25077,null,{"$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,2,23]
[25078,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,null,2,23]
[25085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",835.29,835.29,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",656.21,656.21,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",760.04,760.04,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",908.2,908.2,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,23]
[25107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1152.02,1152.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[25109,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",995.69,995.69,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[25110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",648.63,648.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[25111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",614.21,614.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",732.62,732.62,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1397,1397,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1123.44,1123.44,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,23]
[25118,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",718.63,718.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25119,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",933.28,933.28,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",932.7,932.7,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,23]
[25125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1101.27,1101.27,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1108.27,1108.27,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",845.79,845.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1041.19,1041.19,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25136,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",925.7,925.7,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",967.11,967.11,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1050.52,1050.52,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[25151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1081.44,1081.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25170,null,{"$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,2,23]
[25210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",918.7,918.7,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,23]
[25215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1145.5999999999999,1145.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",809.04,809.04,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[25240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",803.2,803.2,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,23]
[25246,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",349.98,127.74,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[25248,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",772.29,772.29,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",989.28,989.28,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25251,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1318.26,1318.26,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25259,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",795.62,795.62,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1177.68,1177.68,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[25263,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1172.43,1172.43,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[25265,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1382.42,1382.42,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[25270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",919.86,919.86,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[25272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1034.77,1034.77,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[25274,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1228.43,1228.43,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,23]
[25275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1240.68,1240.68,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,23]
[25280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1048.19,1048.19,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,23]
[25290,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",814.29,814.29,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[25295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",978.19,978.19,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[25300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1272.76,1272.76,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1186.43,1186.43,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1317.09,1317.09,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[25312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1318.84,1318.84,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[25315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1405.75,1405.75,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25316,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1667.07,1667.07,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1826.31,1826.31,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[25332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1547.49,1547.49,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25335,null,{"$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,2,23]
[25337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1636.74,1636.74,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1241.26,1241.26,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1399.92,1399.92,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25360,null,{"$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,null,2,23]
[25365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1668.24,1668.24,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1842.64,1842.64,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25375,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1733.57,1733.57,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1408.67,1408.67,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25391,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1807.65,1807.65,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25392,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1838.56,1838.56,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25393,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2039.8,2039.8,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25394,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1435.5,1435.5,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1465.83,1465.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1885.23,1885.23,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1757.48,1757.48,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2107.46,2107.46,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1749.32,1749.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2028.13,2028.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1346.26,1346.26,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25431,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1440.75,1440.75,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1408.67,1408.67,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25441,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1706.15,1706.15,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1485.08,1485.08,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25443,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1437.83,1437.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25444,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1517.16,1517.16,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1323.51,1323.51,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[25446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2122.63,2122.63,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25447,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1472.25,1472.25,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25448,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1623.32,1623.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25449,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1877.06,1877.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1140.3499999999999,1140.3499999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[25455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1341.59,1341.59,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[25490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1318.26,1318.26,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25491,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1353.84,1353.84,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25492,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1651.32,1651.32,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",551.79999999999995,498.72,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",961.86,867.37,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1237.18,1237.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1087.27,1022.52,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1451.83,1451.83,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[25526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1746.4,1746.4,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[25530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",516.22,473.06,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",936.2,860.37,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1158.43,1158.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",562.29999999999995,501.05,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",980.53,868.53,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25574,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1247.68,1247.68,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[25575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1655.99,1655.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",657.38,629.96,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1016.69,956.03,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1241.26,1241.26,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1369.59,1369.59,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25608,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1523,1523,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25609,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1927.81,1927.81,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25622,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",596.13,548.29999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25624,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",938.53,846.95,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25628,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1325.26,1325.26,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",589.72,547.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",889.53,803.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1055.77,1055.77,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",632.88,586.22,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25651,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",916.36,916.36,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25652,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1155.52,1155.52,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[25660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",848.7,848.7,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1117.02,1117.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25671,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",998.03,998.03,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",871.45,782.21,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25676,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1163.68,1163.68,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",995.11,995.11,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1346.84,1346.84,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25690,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",922.78,922.78,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25695,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1166.5999999999999,1166.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[25800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1342.17,1342.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[25805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1546.91,1546.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[25810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1590.66,1590.66,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[25820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1199.26,1199.26,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[25825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1461.17,1461.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[25830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1880.56,1880.56,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[25900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1322.92,1322.92,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25905,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1285.01,1285.01,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25907,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1132.77,1132.77,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25909,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1257.5899999999999,1257.5899999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25915,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2102.8000000000002,2102.8000000000002,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25920,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1338.67,1338.67,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1188.18,1188.18,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25924,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1306.5899999999999,1306.5899999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25927,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1577.24,1577.24,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[25929,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1104.77,1104.77,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[25931,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1460,1460,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[25999,null,{"$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,2,23]
[26010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",620.63,260.14999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[26011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",867.37,341.23,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[26020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1033.02,1033.02,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",776.96,776.96,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[26030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",911.7,911.7,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[26034,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1027.19,1027.19,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1579.58,1579.58,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26037,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1036.52,1036.52,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[26040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",596.72,596.72,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[26045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",881.95,881.95,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[26055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1085.52,550.04999999999995,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",476.56,476.56,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",605.47,605.47,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[26075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",635.21,635.21,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[26080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",749.54,749.54,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",638.71,638.71,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[26105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",642.79999999999995,642.79999999999995,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[26110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",611.88,611.88,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",769.96,769.96,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26113,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1013.19,1013.19,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1013.19,621.79999999999995,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.69,974.69,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26117,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,23]
[26118,null,{"$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,2,23]
[26121,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1110.02,1110.02,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[26123,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1546.91,1546.91,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[26125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",474.81,474.81,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[26130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",874.95,874.95,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[26135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1028.3599999999999,1028.3599999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",944.95,944.95,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",960.7,960.7,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1132.19,593.79999999999995,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",762.37,762.37,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",843.45,843.45,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26185,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1041.77,1041.77,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[26200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",838.79,838.79,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26205,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1115.27,1115.27,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",838.2,838.2,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1047.02,1047.02,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",928.03,928.03,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",915.2,915.2,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26236,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",823.62,823.62,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1933.06,1933.06,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1453.58,1453.58,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26262,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1162.52,1162.52,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",655.04999999999995,655.04999999999995,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",686.54,686.54,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[26341,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",217.57,144.08000000000001,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[26350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1377.17,1377.17,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26352,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1526.5,1526.5,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26356,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1471.67,1471.67,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1638.49,1638.49,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1801.81,1801.81,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26370,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1440.75,1440.75,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26372,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1672.32,1672.32,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26373,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1611.07,1611.07,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1601.74,1601.74,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26392,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1823.98,1823.98,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1109.44,1109.44,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26412,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1313.01,1313.01,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1555.08,1555.08,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26416,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1681.65,1681.65,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26418,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1156.68,1156.68,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1359.09,1359.09,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26426,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",937.36,937.36,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26428,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1461.75,1461.75,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26432,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1009.11,1009.11,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26433,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1053.44,1053.44,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26434,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1279.18,1279.18,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26437,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1230.18,1230.18,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1198.68,1198.68,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1822.23,1822.23,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1117.02,1117.02,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26449,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1300.18,1300.18,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",862.12,862.12,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",855.7,855.7,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26460,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",838.79,838.79,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26471,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1219.68,1219.68,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26474,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1201.01,1201.01,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26476,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1186.43,1186.43,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26477,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1160.77,1160.77,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,23]
[26478,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1215.5999999999999,1215.5999999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26479,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1244.18,1244.18,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26480,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1318.26,1318.26,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26483,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1596.49,1596.49,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1535.83,1535.83,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26489,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1759.23,1759.23,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1537.58,1537.58,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26492,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1696.82,1696.82,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26494,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1543.41,1543.41,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26496,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1655.41,1655.41,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26497,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1653.66,1653.66,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26498,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2140.71,2140.71,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1595.33,1595.33,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1266.3399999999999,1266.3399999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1385.92,1385.92,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26508,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1245.3499999999999,1245.3499999999999,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[26510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1182.93,1182.93,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26516,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1368.42,1368.42,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[26517,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1586.58,1586.58,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[26518,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1605.24,1605.24,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[26520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1253.51,1253.51,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1262.26,1262.26,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,23]
[26530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1007.94,1007.94,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26531,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1171.8499999999999,1171.8499999999999,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",823.62,823.62,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26536,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1381.25,1381.25,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1288.51,1288.51,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,null,2,23]
[26541,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1535.25,1535.25,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26542,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1329.92,1329.92,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1348.59,1348.59,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1919.06,1919.06,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[26548,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1469.92,1469.92,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2973.66,2973.66,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[26551,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5880.83,5880.83,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[26553,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5841.17,5841.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[26554,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6792.53,6792.53,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[26555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2507.02,2507.02,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6080.9,6080.9,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1171.27,1171.27,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1790.15,1790.15,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26562,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2504.11,2504.11,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1312.43,1312.43,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26567,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1323.51,1323.51,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26568,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1698.57,1698.57,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26580,null,{"$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,2,23]
[26587,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,23]
[26590,null,{"$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,2,23]
[26591,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",908.2,908.2,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26593,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1191.0999999999999,1191.0999999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26596,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1497.91,1497.91,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",584.47,557.04999999999995,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",634.04999999999995,569.88,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",940.28,940.28,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26608,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",900.62,900.62,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1071.52,1071.52,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",801.45,727.96,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[26645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",823.62,747.21,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[26650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",905.86,905.86,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[26665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1166.5999999999999,1166.5999999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[26670,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",674.29,599.63,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",879.03,799.12,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26676,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",956.61,956.61,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1076.19,1076.19,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,23]
[26686,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1146.18,1146.18,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[26700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",649.79999999999995,596.13,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",833.54,752.46,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26706,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",841.12,841.12,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1066.8599999999999,1066.8599999999999,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",392.56,367.48,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",655.04999999999995,580.97,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26727,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",889.53,889.53,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26735,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1104.77,1104.77,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",453.81,428.73,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26742,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",711.63,635.21,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26746,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1366.67,1366.67,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",366.31,370.4,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",618.29999999999995,525.54999999999995,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26756,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",797.37,797.37,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26765,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",940.86,940.86,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",555.29999999999995,502.8,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26775,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",755.96,675.46,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26776,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",845.2,845.2,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26785,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1023.69,1023.69,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1521.83,1521.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[26841,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1421.5,1421.5,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,23]
[26842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1525.91,1525.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[26843,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1433.75,1433.75,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26844,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1575.49,1575.49,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26850,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1351.51,1351.51,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26852,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1532.33,1532.33,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1133.3499999999999,1133.3499999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26861,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",179.66,179.66,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[26862,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1409.84,1409.84,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[26863,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",400.14,400.14,0,0,0,0,0,0,0,2,0,0,null,"R",null,null,2,23]
[26910,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1400.5,1400.5,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26951,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1302.51,1302.51,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26952,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1261.0899999999999,1261.0899999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26989,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,1,1,1,null,"N",null,null,2,23]
[26990,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1243.5999999999999,1243.5999999999999,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[26991,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1279.76,958.36,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[26992,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1822.81,1822.81,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[27000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",717.46,717.46,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",989.86,989.86,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1104.19,1104.19,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1320.01,1320.01,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27006,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1308.93,1308.93,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1706.15,1706.15,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,23]
[27027,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1597.66,1597.66,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1694.49,1694.49,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27033,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1762.15,1762.15,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2064.3000000000002,2064.3000000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[27036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1849.64,1849.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",618.29999999999995,361.65,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[27041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1285.01,1285.01,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27043,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",847.53,847.53,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1322.34,1322.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",898.28,657.96,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27048,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1113.52,1113.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27049,null,{"$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,2,23]
[27050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",758.87,758.87,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,23]
[27052,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1070.94,1070.94,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27054,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1262.8399999999999,1262.8399999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27057,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1818.73,1818.73,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27059,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,23]
[27060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",864.45,864.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27062,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",838.2,838.2,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",968.28,968.28,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27066,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1495.58,1495.58,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27067,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1879.39,1879.39,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1592.41,1592.41,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1759.23,1759.23,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3713.87,3713.87,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[27076,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4475.66,4475.66,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[27077,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4984.88,4984.88,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[27078,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3663.12,3663.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",925.7,925.7,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[27086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",572.79999999999995,312.64999999999998,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[27087,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1117.02,1117.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27090,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1506.08,1506.08,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27091,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2855.25,2855.25,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27093,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",413.56,120.16,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[27095,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",555.88,144.08000000000001,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[27096,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",300.98,148.74,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[27097,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1252.93,1252.93,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27098,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1276.8399999999999,1276.8399999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1517.16,1517.16,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1587.16,1587.16,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1762.15,1762.15,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1644.32,1644.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2338.4499999999998,2338.4499999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1991.97,1991.97,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2042.72,2042.72,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2305.1999999999998,2305.1999999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27132,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2991.75,2991.75,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27134,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3393.06,3393.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27137,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2623.1,2623.1,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27138,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2723.43,2723.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1629.74,1629.74,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2306.37,2306.37,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2627.18,2627.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27151,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2835.42,2835.42,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27156,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3051.24,3051.24,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27158,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2514.61,2514.61,90,0.1,0.69,0.21,0,2,2,2,0,0,null,"R",null,null,2,23]
[27161,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2201.96,2201.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27165,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2466.19,2466.19,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2106.88,2106.88,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1216.76,1216.76,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[27176,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1677.57,1677.57,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[27177,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2019.38,2019.38,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[27178,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1677.57,1677.57,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[27179,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1774.98,1774.98,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,23]
[27181,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2027.55,2027.55,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,23]
[27185,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1315.92,1315.92,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM",2,23]
[27187,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1807.06,1807.06,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[27197,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",242.65,242.65,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[27198,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",569.29999999999995,569.29999999999995,0,0,0,0,0,2,0,0,2,0,null,"R",null,null,2,23]
[27200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",362.23,367.48,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[27202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",965.94,965.94,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[27215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1086.69,1086.69,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,23]
[27216,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1605.82,1605.82,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,23]
[27217,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1509.58,1509.58,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,23]
[27218,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2065.4699999999998,2065.4699999999998,90,0.1,0.69,0.21,9,9,9,9,9,9,null,"R",null,null,2,23]
[27220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",770.54,760.62,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27222,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1778.48,1778.48,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27226,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1900.39,1900.39,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27227,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2958.5,2958.5,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27228,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3353.39,3353.39,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",906.45,890.12,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27232,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1312.43,1312.43,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1644.32,1644.32,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27236,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2152.38,2152.38,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27238,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",870.87,870.87,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1731.82,1731.82,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27244,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2213.62,2213.62,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27245,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2210.71,2210.71,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27246,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",728.54,722.13,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27248,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1350.34,1350.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",310.89999999999998,310.89999999999998,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[27252,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1352.09,1352.09,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27253,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1701.49,1701.49,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27254,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2288.87,2288.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27256,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",578.04999999999995,427.56,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[27257,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",652.13,652.13,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[27258,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2008.89,2008.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27259,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2773.59,2773.59,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27265,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",779.29,779.29,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27266,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1067.44,1067.44,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27267,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",816.04,816.04,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27268,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1005.61,1005.61,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27269,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2228.79,2228.79,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27275,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",340.06,340.06,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[27278,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,0,0,null,"X",null,null,2,23]
[27279,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1448.33,1448.33,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2433.5300000000002,2433.5300000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1567.91,1567.91,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[27284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2865.17,2865.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2942.75,2942.75,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27290,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2914.17,2914.17,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[27295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2243.37,2243.37,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27299,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,2,1,1,null,"N",null,"Y-UR",2,23]
[27301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1232.51,932.11,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27303,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1176.52,1176.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",894.2,894.2,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",638.71,638.71,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",760.04,760.04,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,null,2,23]
[27310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1341.01,1341.01,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27323,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",501.05,321.39999999999998,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[27324,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",758.29,758.29,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1042.3599999999999,1042.3599999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,23]
[27326,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",968.86,968.86,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[27327,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",910.53,578.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27328,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1130.44,1130.44,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27329,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1865.98,1865.98,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",787.46,787.46,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[27331,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",885.45,885.45,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27332,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1190.52,1190.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27333,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1089.02,1089.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27334,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1261.68,1261.68,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1400.5,1400.5,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",763.54,763.54,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27339,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1363.17,1363.17,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",701.71,701.71,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[27345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",905.28,905.28,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27347,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",976.44,976.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1203.3499999999999,1203.3499999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1122.27,1122.27,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27356,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1355.59,1355.59,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1490.33,1490.33,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",481.22,481.22,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-UR",2,23]
[27360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1644.32,1644.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27364,null,{"$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,2,23]
[27365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3664.29,3664.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27369,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",319.07,70.58,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[27372,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1079.1099999999999,737.87,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1144.43,1144.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27381,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1498.5,1498.5,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27385,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1119.3499999999999,1119.3499999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27386,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1564.41,1564.41,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",838.2,838.2,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[27391,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1069.19,1069.19,90,0.1,0.69,0.21,0,2,0,0,1,0,null,"R",null,"Y-UR",2,23]
[27392,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1308.3399999999999,1308.3399999999999,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,23]
[27393,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",928.03,928.03,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27394,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1203.93,1203.93,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[27395,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1607.57,1607.57,90,0.1,0.69,0.21,0,2,2,2,1,0,null,"R",null,"Y-UR",2,23]
[27396,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1139.18,1139.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27397,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1669.99,1669.99,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[27400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1277.43,1277.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27403,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1186.43,1186.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1240.0999999999999,1240.0999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27407,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1458.83,1458.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27409,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1756.32,1756.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27412,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2962,2962,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2479.61,2479.61,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27416,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1778.48,1778.48,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[27418,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1490.33,1490.33,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1366.09,1366.09,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27422,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1360.26,1360.26,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27424,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1371.34,1371.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",846.95,846.95,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[27427,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1296.0899999999999,1296.0899999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27428,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2033.38,2033.38,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27429,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2292.37,2292.37,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1356.17,1356.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1477.5,1477.5,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27437,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1213.26,1213.26,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[27438,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1531.75,1531.75,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1456.5,1456.5,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27441,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1502.58,1502.58,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1585.99,1585.99,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27443,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1489.16,1489.16,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2259.12,2259.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2068.38,2068.38,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27447,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2302.29,2302.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27448,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1509,1509,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1823.4,1823.4,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27454,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2331.4499999999998,2331.4499999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1743.48,1743.48,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27457,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1728.32,1728.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2247.4499999999998,2247.4499999999998,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27466,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2140.13,2140.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27468,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2414.2800000000002,2414.2800000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2131.96,2131.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27472,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2279.54,2279.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27475,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,"Y-UR",2,23]
[27477,null,{"$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",2,23]
[27479,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,"Y-UR",2,23]
[27485,null,{"$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",2,23]
[27486,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2525.11,2525.11,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27487,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3135.24,3135.24,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27488,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2167.54,2167.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27495,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2040.97,2040.97,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27496,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1019.03,1019.03,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27497,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1067.44,1067.44,90,0.1,0.69,0.21,0,2,1,0,2,0,null,"R",null,null,2,23]
[27498,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1210.93,1210.93,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27499,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1287.93,1287.93,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",971.78,887.78,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27501,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",933.28,921.03,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1365.51,1365.51,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27503,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1458.83,1458.83,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27506,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2414.2800000000002,2414.2800000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27507,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1744.65,1744.65,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27508,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",983.44,928.03,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27509,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1243.5999999999999,1243.5999999999999,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1239.51,1239.51,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27511,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1787.81,1787.81,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27513,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2207.79,2207.79,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27514,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1737.65,1737.65,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27516,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",978.19,912.28,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27517,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1272.18,1272.18,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27519,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1605.24,1605.24,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",627.04999999999995,577.47,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27524,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1376.59,1376.59,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",594.38,557.04999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27532,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1155.52,1073.8599999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1615.16,1615.16,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27536,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2145.96,2145.96,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27538,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",914.03,848.12,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1486.83,1486.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",960.7,876.7,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1171.8499999999999,1171.8499999999999,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1577.83,1577.83,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27557,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1874.14,1874.14,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2127.3000000000002,2127.3000000000002,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27560,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",709.29,644.54999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27562,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",916.36,916.36,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27566,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1622.74,1622.74,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",286.39999999999998,286.39999999999998,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[27580,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2655.18,2655.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1367.84,1367.84,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27591,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1747.57,1747.57,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27592,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1191.0999999999999,1191.0999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27594,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",908.2,908.2,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[27596,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1258.76,1258.76,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[27598,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1231.93,1231.93,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27599,null,{"$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",2,23]
[27600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",722.71,722.71,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27601,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",798.54,798.54,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",839.37,839.37,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27603,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",951.36,709.29,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27604,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",843.45,607.79999999999995,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",599.63,334.23,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[27606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",492.89,492.89,10,0.1,0.8,0.1,0,2,1,1,1,0,null,"R",null,null,2,23]
[27607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1088.44,1088.44,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1178.8499999999999,1178.8499999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[27612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1054.02,1054.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27613,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",463.14,295.14999999999998,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[27614,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1066.8599999999999,755.37,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,0,1,0,null,"X",null,null,2,23]
[27616,null,{"$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,2,23]
[27618,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",885.45,561.72,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27619,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",849.87,849.87,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",827.7,827.7,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27625,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1042.3599999999999,1042.3599999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27626,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1118.19,1118.19,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[27630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",992.78,662.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",743.71,743.71,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27634,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1211.51,1211.51,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1056.94,1056.94,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27637,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1371.34,1371.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27638,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1357.92,1357.92,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1502,1502,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1196.3499999999999,1196.3499999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3163.24,3163.24,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27646,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2755.51,2755.51,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27647,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1780.23,1780.23,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27648,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",379.15,90.41,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,23]
[27650,null,{"$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",2,23]
[27652,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1213.8499999999999,1213.8499999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[27654,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1312.43,1312.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27656,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",958.36,624.13,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27658,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",683.63,683.63,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[27659,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",865.03,865.03,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[27664,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",659.13,659.13,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,"Y-UR",2,23]
[27665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",768.21,768.21,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[27675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",910.53,910.53,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27676,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1115.8499999999999,1115.8499999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[27680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",779.87,779.87,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,23]
[27681,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",935.03,935.03,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[27685,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1201.01,856.28,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27686,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",971.78,971.78,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[27687,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",835.87,835.87,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27690,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1173.02,1173.02,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27691,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1359.67,1359.67,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27692,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",180.24,180.24,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,23]
[27695,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",894.78,894.78,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[27696,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1001.53,1001.53,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[27698,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1163.0999999999999,1163.0999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1301.93,1301.93,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27702,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1739.4,1739.4,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27703,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2009.47,2009.47,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[27704,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1034.77,1034.77,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[27705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1352.67,1352.67,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27707,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",753.62,753.62,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[27709,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2057.3000000000002,2057.3000000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27712,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1996.64,1996.64,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1938.89,1938.89,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1588.91,1588.91,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27722,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1630.32,1630.32,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27724,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2249.79,2249.79,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2203.12,2203.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27726,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1732.98,1732.98,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27727,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,23]
[27730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1083.77,1083.77,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-CM",2,23]
[27732,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",844.62,844.62,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[27734,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1208.5999999999999,1208.5999999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[27740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1297.26,1297.26,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-CM",2,23]
[27742,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1422.09,1422.09,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[27745,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1336.92,1336.92,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",666.71,615.96,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27752,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1001.53,910.53,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27756,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1086.69,1086.69,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27758,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1631.49,1631.49,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27759,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1806.48,1806.48,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",642.21,590.29999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27762,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",912.28,819.54,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27766,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1114.69,1114.69,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27767,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",561.13,562.29999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27768,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",843.45,843.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27769,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1325.84,1325.84,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27780,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",596.72,547.72,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27781,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",830.62,762.37,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27784,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1299.5899999999999,1299.5899999999999,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27786,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",600.22,547.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27788,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",805.54,724.46,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27792,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1179.43,1179.43,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27808,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",646.88,586.79999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",895.95,801.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27814,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1392.34,1392.34,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27816,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",636.38,562.88,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27818,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",929.78,822.45,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1590.08,1590.08,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27823,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1787.23,1787.23,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27824,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",602.54999999999995,582.72,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1023.11,915.78,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27826,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1555.08,1555.08,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27827,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2036.88,2036.88,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27828,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2395.61,2395.61,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27829,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1290.8399999999999,1290.8399999999999,90,0.1,0.69,0.21,0,2,1,2,2,0,null,"R",null,null,2,23]
[27830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",743.12,684.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27831,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",770.54,770.54,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27832,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1391.17,1391.17,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",725.63,725.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27842,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",911.7,911.7,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27846,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1320.01,1320.01,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27848,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1446,1446,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27860,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",300.39999999999998,300.39999999999998,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[27870,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1821.65,1821.65,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27871,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1257.5899999999999,1257.5899999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27880,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1571.41,1571.41,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27881,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1462.33,1462.33,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[27882,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1038.8599999999999,1038.8599999999999,90,0.1,0.69,0.21,0,2,1,0,1,0,null,"R",null,"Y-UR",2,23]
[27884,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1031.8599999999999,1031.8599999999999,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[27886,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1152.02,1152.02,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27888,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",998.03,998.03,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[27889,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1130.44,1130.44,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[27892,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",981.11,981.11,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27893,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1132.19,1132.19,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[27894,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1470.5,1470.5,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[27899,null,{"$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,2,23]
[28001,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",309.73,170.91,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[28002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",443.89,250.24,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[28003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",675.46,455.56,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[28005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1040.02,1040.02,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28008,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",780.46,541.29999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",433.39,386.14,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28011,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",583.88,516.79999999999995,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.69,664.38,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,23]
[28022,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",888.95,602.54999999999995,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[28024,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",849.28,572.22,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[28035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",974.69,665.55,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[28039,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",858.03,612.47,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[28041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",820.12,820.12,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28043,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",695.29,478.31,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",880.2,639.88,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28046,null,{"$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,2,23]
[28047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,23]
[28050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",758.87,513.29999999999995,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[28052,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",708.71,469.56,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[28054,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",669.63,432.81,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",711.63,711.63,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28060,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",942.03,660.3,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28062,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1064.52,746.62,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[28070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",932.11,634.63,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28072,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",896.53,599.04999999999995,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",988.11,708.13,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[28086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",947.28,638.13,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28088,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",848.7,544.22,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28090,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",850.45,568.72,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28092,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",772.29,503.97,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1124.02,770.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28102,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1126.94,1126.94,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[28103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",706.38,706.38,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[28104,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",965.36,654.46,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[28106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",776.96,776.96,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[28107,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.28,635.21,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,null,2,23]
[28108,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",795.04,533.14,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",848.12,544.22,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[28111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",862.12,582.13,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[28112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",880.78,576.88,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[28113,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1071.52,789.79,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[28114,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1951.14,1536.41,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28116,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1238.3499999999999,949.03,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[28118,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1109.44,778.71,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28119,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",958.95,669.05,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[28120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1220.26,906.45,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[28122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1080.27,805.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28124,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",873.2,617.71,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[28126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",711.04,459.06,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1146.18,1146.18,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1024.27,767.62,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,23]
[28150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",762.37,514.47,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28153,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",735.54,485.89,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",745.46,492.89,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28171,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,2,0,0,null,"X",null,null,2,23]
[28173,null,{"$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,2,23]
[28175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,1,0,null,"X",null,null,2,23]
[28190,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",436.31,241.49,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[28192,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",836.45,571.04999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28193,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",946.7,666.71,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",903.53,601.38,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,23]
[28202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1096.5999999999999,788.04,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[28208,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",881.37,589.72,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,23]
[28210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1069.19,768.79,90,0.1,0.69,0.21,0,2,0,2,0,0,null,"R",null,"Y-UR",2,23]
[28220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",816.62,559.38,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[28222,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",977.61,676.63,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[28225,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",756.54,489.97,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[28226,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1132.77,741.96,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[28230,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",789.79,524.97,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,"Y-UR",2,23]
[28232,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",687.13,444.47,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[28234,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",753.04,502.22,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[28238,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1209.76,883.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",806.12,540.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1076.19,758.29,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1313.59,978.78,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1969.8,1544.58,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28262,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2505.86,2011.22,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28264,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1627.41,1250.01,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,null,2,23]
[28270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",889.53,616.54999999999995,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28272,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",696.46,461.39,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",907.03,624.13,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28285,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",989.86,715.71,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[28286,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",800.29,542.47,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28288,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1100.69,802.04,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28289,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1255.26,848.12,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28291,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1239.51,869.7,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28292,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1276.8399999999999,893.62,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28295,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1888.73,1094.8499999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28296,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1609.32,943.2,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28297,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1843.81,1092.52,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28298,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1514.25,926.86,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28299,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1840.89,1089.5999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1186.43,1186.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1310.68,1310.68,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28304,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1508.41,1121.0999999999999,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1222.01,1222.01,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1108.8499999999999,745.46,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1437.83,956.03,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[28308,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1043.52,714.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28309,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1640.82,1640.82,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[28310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1005.61,672.54,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[28312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1027.19,655.04999999999995,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,"Y-UR",2,23]
[28313,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",972.94,669.63,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[28315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",873.78,599.63,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,null,2,23]
[28320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1121.69,1121.69,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28322,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1430.25,1053.44,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[28340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,0,1,0,0,null,"X",null,null,2,23]
[28341,null,{"$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,2,23]
[28344,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,1,1,0,null,"X",null,null,2,23]
[28345,null,{"$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,2,23]
[28360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,0,0,null,"X",null,null,2,23]
[28400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",473.06,438.64,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",855.12,765.29,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28406,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1094.8499999999999,1094.8499999999999,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2034.55,2034.55,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2351.2800000000002,2351.2800000000002,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",458.47,401.89,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",705.79,622.96,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28436,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.28,926.28,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1894.56,1894.56,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28446,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.69,0.21,0,2,1,2,1,0,null,"X",null,null,2,23]
[28450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",403.64,364.56,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28455,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",480.06,429.31,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[28456,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",698.79,698.79,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1181.77,1181.77,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28470,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",415.89,391.98,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28475,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",492.31,431.06,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28476,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",733.79,733.79,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[28485,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1035.94,1035.94,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,23]
[28490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",272.98,239.74,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28495,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",345.31,285.82,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28496,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",936.78,519.14,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1185.27,908.78,90,0.1,0.69,0.21,0,2,1,1,0,0,null,"R",null,null,2,23]
[28510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",232.15,232.15,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",313.23,272.98,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1027.19,741.96,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[28530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",226.32,197.74,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28531,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",607.22,337.73,90,0.1,0.69,0.21,0,2,1,1,2,0,null,"R",null,null,2,23]
[28540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",372.15,333.65,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",594.38,518.54999999999995,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1088.44,666.71,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28555,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1538.75,1186.43,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",456.72,380.89,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",722.13,645.71,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28576,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",730.29,730.29,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,null,2,23]
[28585,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1652.49,1302.51,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,null,2,23]
[28600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",418.23,355.23,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[28605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",656.8,585.04999999999995,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[28606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",739.04,739.04,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28615,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1517.75,1517.75,90,0.1,0.69,0.21,0,2,0,2,1,0,null,"R",null,null,2,23]
[28630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",286.98,202.41,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[28635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",317.89999999999998,240.32,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[28636,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",655.63,412.98,10,0.1,0.8,0.1,0,2,0,1,2,0,null,"R",null,null,2,23]
[28645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1187.5999999999999,891.87,90,0.1,0.69,0.21,0,2,0,1,1,0,null,"R",null,null,2,23]
[28660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",235.65,172.66,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[28665,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",279.39999999999998,230.99,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[28666,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",318.48,318.48,10,0.1,0.8,0.1,0,2,0,1,2,0,null,"R",null,null,2,23]
[28675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1051.69,762.37,90,0.1,0.69,0.21,0,2,0,1,0,0,null,"R",null,null,2,23]
[28705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2195.54,2195.54,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1713.74,1713.74,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1418.59,1418.59,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28730,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1320.59,1320.59,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28735,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1415.09,1415.09,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28737,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1246.51,1246.51,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1499.66,1121.69,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1415.09,1048.77,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[28755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.86,618.88,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[28760,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1398.17,1039.44,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",955.45,955.45,90,0.1,0.69,0.21,0,2,1,2,1,0,null,"R",null,"Y-UR",2,23]
[28805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1264.01,1264.01,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[28810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",762.37,762.37,90,0.1,0.69,0.21,0,2,0,0,0,0,null,"R",null,null,2,23]
[28820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",534.29999999999995,314.98,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[28825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",524.39,307.39999999999998,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[28890,null,{"$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,2,23]
[28899,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,0,1,1,null,"N",null,null,2,23]
[29000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",685.96,359.31,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",532.54999999999995,293.98,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29015,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",568.13,329.56,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",503.39,264.82,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",572.22,318.48,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29044,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",561.13,307.39999999999998,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29046,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",612.47,344.73,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29049,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",190.16,128.33000000000001,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29055,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",433.39,252.57,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29058,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",233.32,170.91,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29065,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",183.74,124.83,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",167.41,115.49,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29085,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",183.16,124.24,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",148.16,90.99,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",155.74,72.91,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",127.74,74.08,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",149.91,90.41,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",78.75,51.33,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29131,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",102.66,62.41,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",57.75,31.5,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[29240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",53.66,31.5,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",52.5,33.25,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",53.66,35,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",478.31,290.48,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",527.29999999999995,325.48,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[29345,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",254.32,180.24,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",264.82,191.32,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29358,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",307.98,187.24,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",234.49,158.66,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29405,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",151.66,107.33,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",142.33000000000001,99.16,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",233.9,157.49,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",79.91,49.58,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",234.49,175.57,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29450,null,{"$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",2,23]
[29505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",173.24,96.24,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29515,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",137.08000000000001,90.99,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",63,32.659999999999997,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,23]
[29530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",53.66,32.08,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",51.33,30.91,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",35.58,19.25,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[29720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",165.07,78.75,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[29805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",867.95,867.95,90,0.1,0.69,0.21,0,2,1,1,1,0,null,"R",null,"Y-UR",2,23]
[29822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",997.44,997.44,90,0.1,0.69,0.21,0,3,1,2,0,0,29805,"R",null,"Y-UR",2,23]
[29843,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",900.62,900.62,90,0.1,0.69,0.21,0,3,1,2,1,0,29840,"R",null,null,2,23]
[29862,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1479.83,1479.83,90,0.1,0.69,0.21,0,3,1,2,1,0,29860,"R",null,"Y-UR",2,23]
[29867,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2315.12,2315.12,90,0.1,0.69,0.21,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[29877,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1139.18,1139.18,90,0.1,0.69,0.21,0,3,1,0,0,0,29870,"R",null,"Y-UR",2,23]
[29891,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1233.0999999999999,1233.0999999999999,90,0.1,0.69,0.21,0,2,1,2,0,0,null,"R",null,"Y-UR",2,23]
[29914,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1800.65,1800.65,90,0.1,0.69,0.21,0,3,1,2,1,0,29860,"R",null,"Y-UR",2,23]
[30020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",488.81,224.57,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[30160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1473.42,1473.42,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,null,2,23]
[30210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",278.23,190.16,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[30545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,2,0,0,null,"X",null,null,2,23]
[30600,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",958.36,710.46,90,0.1,0.76,0.14000000000000001,0,2,0,0,0,0,null,"R",null,null,2,23]
[30906,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",692.38,232.15,0,0,0,0,0,2,2,1,0,0,null,"R",null,null,2,23]
[31051,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1261.0899999999999,1261.0899999999999,90,0.1,0.76,0.14000000000000001,0,2,1,1,0,0,null,"R",null,null,2,23]
[31086,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2129.63,2129.63,90,0.1,0.76,0.14000000000000001,0,2,1,2,0,0,null,"R",null,null,2,23]
[31235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",566.38,286.98,0,0,0,0,0,3,1,0,0,0,31231,"R",null,null,2,23]
[31276,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",668.46,668.46,0,0,0,0,0,3,1,1,0,0,31231,"R",null,null,2,23]
[31294,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2185.04,2185.04,10,0.1,0.8,0.1,0,3,1,0,0,0,31231,"R",null,null,2,23]
[31360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,23]
[31502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",60.66,60.66,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[31511,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",380.89,240.32,0,0,0,0,0,3,0,1,0,0,31505,"R",null,null,2,23]
[31536,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",373.31,373.31,0,0,0,0,0,3,0,1,0,0,31526,"R",null,null,2,23]
[31553,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.76,0.14000000000000001,0,2,0,0,1,0,null,"X",null,null,2,23]
[31578,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",556.47,267.14999999999998,0,0,0,0,0,3,0,0,0,0,31575,"R",null,null,2,23]
[31601,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,2,1,0,null,"X",null,null,2,23]
[31623,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",500.47,229.82,0,0,0,0,0,3,0,1,0,0,31622,"R",null,null,2,23]
[31635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",532.54999999999995,305.07,0,0,0,0,0,3,0,1,0,0,31622,"R",null,null,2,23]
[31638,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",428.14,428.14,0,0,0,0,0,3,0,1,0,0,31622,"R",null,null,2,23]
[31649,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",120.16,120.16,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[31755,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3150.4,3150.4,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,null,2,23]
[31800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1282.0899999999999,1282.0899999999999,90,0.1,0.76,0.14000000000000001,0,2,0,0,0,0,null,"R",null,null,2,23]
[32100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1418,1418,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,null,2,23]
[32225,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1734.15,1734.15,90,0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[32442,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5210.04,5210.04,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[32540,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2978.33,2978.33,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[32556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1327.59,215.82,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[32607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",530.22,530.22,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[32655,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1663.57,1663.57,90,0.1,0.76,0.14000000000000001,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[32664,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1475.17,1475.17,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[32815,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4811.6400000000003,4811.6400000000003,90,0.1,0.76,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[32854,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8286.36,8286.36,90,0.1,0.76,0.14000000000000001,0,2,2,2,1,2,null,"R",null,"Y-CM",2,23]
[33016,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",400.14,400.14,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[33140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,0,0,null,"X",null,null,2,23]
[33212,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",566.38,566.38,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[33215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",541.29999999999995,541.29999999999995,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[33234,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",842.87,842.87,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[33237,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1468.17,1468.17,90,0.09,0.84,7.0000000000000007E-2,0,2,0,0,2,0,null,"R",null,"Y-CM",2,23]
[33257,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1016.11,1016.11,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-CM",2,23]
[33268,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",219.9,219.9,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-CM",2,23]
[33279,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",601.38,601.38,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,0,0,null,"R",null,null,2,23]
[33320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1849.06,1849.06,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[33362,null,{"$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,2,23]
[33366,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,2,1,null,"X",null,null,2,23]
[33416,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3471.22,3471.22,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[33430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4798.8100000000004,4798.8100000000004,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[33474,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3736.04,3736.04,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[33501,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1927.22,1927.22,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-CM",2,23]
[33517,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",316.14999999999998,316.14999999999998,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-CM",2,23]
[33536,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4509.49,4509.49,90,0.09,0.82,0.09,0,2,0,2,0,0,null,"R",null,"Y-CM",2,23]
[33606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3061.74,3061.74,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[33645,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2966.66,2966.66,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[33681,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3181.32,3181.32,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[33690,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2089.38,2089.38,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[33726,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3471.8,3471.8,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[33766,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"X",null,null,2,23]
[33781,null,{"$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,2,23]
[33800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"X",null,null,2,23]
[33853,null,{"$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,2,23]
[33863,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5354.11,5354.11,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[33901,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1322.92,1322.92,0,0,0,0,0,2,2,0,0,0,null,"R",null,"Y-UR",2,23]
[33904,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",504.55,504.55,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-UR",2,23]
[33929,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,0,0,2,0,0,null,"N",null,"Y-UR",2,23]
[33954,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",807.87,807.87,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[33962,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",396.06,396.06,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[33969,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,23]
[33976,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2668.01,2668.01,0,0,0,0,0,2,2,2,0,0,null,"R",null,"Y-CM",2,23]
[33986,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",890.7,890.7,0,0,0,0,0,2,0,0,1,1,null,"R",null,"Y-CM",2,23]
[34201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1727.73,1727.73,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[34421,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1180.5999999999999,1180.5999999999999,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[34705,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2573.52,2573.52,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[34712,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1114.69,1114.69,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[34813,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",392.56,392.56,0,0,0,0,0,0,0,2,2,0,null,"R",null,"Y-CM",2,23]
[34844,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,2,0,null,"N",null,null,2,23]
[35045,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1648.99,1648.99,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[35103,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3644.46,3644.46,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[35188,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2276.04,2276.04,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[35201,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1592.41,1592.41,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,null,2,23]
[35256,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1737.65,1737.65,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,null,2,23]
[35302,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1886.39,1886.39,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[35363,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2738.01,2738.01,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[35500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",533.14,533.14,0,0,0,0,0,0,0,2,1,0,null,"R",null,"Y-CM",2,23]
[35526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2959.08,2959.08,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[35535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3203.48,3203.48,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[35566,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2798.09,2798.09,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[35606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1986.14,1986.14,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[35647,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2592.19,2592.19,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[35661,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1834.48,1834.48,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[35694,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1674.07,1674.07,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[35800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1299.5899999999999,1299.5899999999999,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[35884,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2089.38,2089.38,90,0.09,0.84,7.0000000000000007E-2,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[36002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",277.64999999999998,180.82,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[36221,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1737.07,339.48,0,0,0,0,0,2,2,1,0,0,null,"R",null,null,2,23]
[36228,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2390.36,430.48,0,0,0,0,0,0,1,1,0,0,null,"R",null,null,2,23]
[36400,null,{"$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,2,23]
[36410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",32.659999999999997,15.75,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[36468,null,{"$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,2,23]
[36478,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1735.32,475.97,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[36522,null,{"$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,2,23]
[36561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1711.4,580.97,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[36581,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1364.34,321.39999999999998,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[36584,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",580.38,102.66,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[36620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",75.83,75.83,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[36818,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1175.93,1175.93,90,0.09,0.84,7.0000000000000007E-2,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[36837,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",16982.78,788.62,0,0,0,0,0,2,0,2,1,0,null,"R",null,null,2,23]
[36906,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9469.2900000000009,872.62,0,0,0,0,0,2,0,1,1,0,null,"R",null,"Y-CM",2,23]
[37184,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3007.49,735.54,0,0,0,0,0,2,1,1,2,0,null,"R",null,null,2,23]
[37193,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2647.02,593.22,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[37218,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1419.75,1419.75,90,0.09,0.84,7.0000000000000007E-2,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[37224,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5090.46,747.79,0,0,0,0,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[37241,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8105.54,730.29,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[37252,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1659.49,151.07,0,0,0,0,0,0,0,0,1,0,null,"R",null,null,2,23]
[37607,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",649.21,649.21,90,0.09,0.84,7.0000000000000007E-2,0,2,0,1,1,0,null,"R",null,null,2,23]
[37650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",788.62,788.62,90,0.09,0.84,7.0000000000000007E-2,0,2,1,1,1,0,null,"R",null,"Y-CM",2,23]
[37799,null,{"$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,2,23]
[38129,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,1,1,null,"N",null,null,2,23]
[38214,null,{"$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]
[38300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",617.71,384.39,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[38520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",844.04,844.04,90,0.11,0.73,0.16,0,2,1,1,0,0,null,"R",null,null,2,23]
[38531,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",801.45,801.45,90,0.11,0.73,0.16,0,2,1,0,0,0,null,"R",null,"Y-UR",2,23]
[38724,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2596.85,2596.85,90,0.11,0.73,0.16,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[38770,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1436.08,1436.08,90,0.11,0.73,0.16,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[39402,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",694.71,694.71,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[40490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2,23]
[40700,null,{"$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,2,23]
[40720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,1,0,0,0,null,"X",null,null,2,23]
[40830,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",414.73,269.48,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[40843,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2187.38,1571.99,90,0.09,0.81,0.1,0,2,2,2,0,0,null,"R",null,"Y-CM",2,23]
[41007,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",608.38,410.64,90,0.09,0.81,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[41120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,23]
[41155,null,{"$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,2,23]
[41530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1653.07,692.38,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[41820,null,{"$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,2,23]
[42100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,23]
[42210,null,{"$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,2,23]
[42220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,0,0,null,"X",null,null,2,23]
[42300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",392.56,286.39999999999998,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[42415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,1,2,1,0,null,"X",null,null,2,23]
[42507,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",899.45,899.45,90,0.09,0.81,0.1,0,2,2,2,0,0,null,"R",null,null,2,23]
[42800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",289.89999999999998,215.82,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[42831,null,{"$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,2,23]
[42900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",597.29999999999995,597.29999999999995,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[42972,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",918.11,918.11,90,0.09,0.81,0.1,0,2,0,2,0,0,null,"R",null,null,2,23]
[43020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1016.69,1016.69,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,23]
[43112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5866.83,5866.83,90,0.09,0.81,0.1,0,2,0,2,2,0,null,"R",null,"Y-CM",2,23]
[43192,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",303.89999999999998,303.89999999999998,0,0,0,0,0,3,0,1,0,0,43191,"R",null,null,2,23]
[43206,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",552.97,235.65,0,0,0,0,0,3,0,1,0,0,43200,"R",null,"Y-CM",2,23]
[43213,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2169.29,454.39,0,0,0,0,0,3,0,1,0,0,43200,"R",null,null,2,23]
[43239,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",680.13,243.82,0,0,0,0,0,3,0,1,0,0,43235,"R",null,"Y-CM",2,23]
[43246,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",350.56,350.56,0,0,0,0,0,3,0,0,2,0,43235,"R",null,null,2,23]
[43252,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",618.29999999999995,295.73,0,0,0,0,0,3,0,1,0,0,43235,"R",null,"Y-CM",2,23]
[43264,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",636.96,636.96,0,0,0,0,0,3,0,1,0,0,43260,"R",null,"Y-CM",2,23]
[43276,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",839.95,839.95,0,0,0,0,0,3,0,1,0,0,43260,"R",null,null,2,23]
[43288,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6461.21,6461.21,90,0.09,0.81,0.1,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[49596,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1791.9,1791.9,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[43330,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2355.37,2355.37,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[43340,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2431.19,2431.19,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[43425,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2501.19,2501.19,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[43605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1496.75,1496.75,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[43631,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2556.02,2556.02,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[43640,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2105.71,2105.71,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[43754,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",429.89,69.41,0,0,0,0,0,0,0,2,0,0,null,"R",null,null,2,23]
[43771,null,{"$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,2,23]
[43840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2397.9499999999998,2397.9499999999998,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,23]
[43882,null,{"$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,2,23]
[44005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1922.56,1922.56,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,23]
[44127,null,{"$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,2,23]
[44132,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,23]
[44146,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3682.96,3682.96,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[44180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1626.82,1626.82,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,23]
[44205,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2344.2800000000002,2344.2800000000002,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[44314,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1778.48,1778.48,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[44366,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",420.56,420.56,0,0,0,0,0,3,0,1,0,0,44360,"R",null,null,2,23]
[44378,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",671.96,671.96,0,0,0,0,0,3,0,0,0,0,44376,"R",null,"Y-CM",2,23]
[44390,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",733.21,370.4,0,0,0,0,0,3,0,1,0,0,44388,"R",null,"Y-CM",2,23]
[44407,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,3,0,1,0,0,44388,"X",null,null,2,23]
[44602,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2457.44,2457.44,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,23]
[44715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,1,0,null,"N",null,null,2,23]
[44800,null,{"$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,2,23]
[45020,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1035.3599999999999,1035.3599999999999,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[45126,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4801.7299999999996,4801.7299999999996,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[45172,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.81,0.1,0,2,0,2,1,0,null,"X",null,null,2,23]
[45327,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",207.65,207.65,0,0,0,0,0,3,0,1,0,0,45300,"R",null,"Y-CM",2,23]
[45335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",530.79999999999995,120.16,0,0,0,0,0,3,0,1,0,0,45330,"R",null,"Y-CM",2,23]
[45342,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",299.23,299.23,0,0,0,0,0,3,0,1,0,0,45330,"R",null,"Y-CM",2,23]
[45385,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",819.54,445.06,0,0,0,0,0,3,0,1,0,0,45378,"R",null,"Y-CM",2,23]
[45400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2001.89,2001.89,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[45550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2570.02,2570.02,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[45825,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2717.01,2717.01,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[46080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",522.04999999999995,283.48,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[46261,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",964.19,964.19,90,0.09,0.81,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[46320,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",389.06,205.32,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[46612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",595.54999999999995,169.16,0,0,0,0,0,3,0,1,0,0,46600,"R",null,"Y-CM",2,23]
[46706,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",327.23,327.23,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[46735,null,{"$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,2,23]
[46924,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,1,0,0,null,"X",null,null,2,23]
[46942,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",460.81,234.49,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[47122,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5991.66,5991.66,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[47135,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9496.1200000000008,9496.1200000000008,90,0.09,0.81,0.1,0,2,0,2,1,2,null,"R",null,"Y-CM",2,23]
[47379,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,1,1,null,"N",null,null,2,23]
[47382,null,{"$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,2,23]
[47532,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1503.75,365.73,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[47542,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",886.62,233.32,0,0,0,0,0,0,0,1,0,0,null,"R",null,null,2,23]
[47570,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1376,1376,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,23]
[47721,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2390.36,2390.36,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[47800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2746.76,2746.76,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[48145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2869.84,2869.84,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[48500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2035.13,2035.13,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[48510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1944.14,1944.14,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[49014,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",660.3,660.3,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[49040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1780.23,1780.23,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,23]
[49250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1070.3599999999999,1070.3599999999999,90,0.09,0.81,0.1,0,2,0,1,1,0,null,"R",null,null,2,23]
[49325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",727.96,727.96,10,0.1,0.8,0.1,0,3,0,2,2,0,49320,"R",null,null,2,23]
[49407,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1346.84,356.98,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[49441,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1721.32,421.73,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,null,2,23]
[49465,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",248.49,52.5,0,0,0,0,0,2,0,0,0,0,null,"R",null,null,2,23]
[49500,null,{"$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,2,23]
[49610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1238.93,1238.93,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[49614,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",999.19,999.19,0,0,0,0,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[49900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1478.67,1478.67,90,0.09,0.81,0.1,0,2,0,2,1,0,null,"R",null,null,2,23]
[50060,null,{"$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,2,23]
[50220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1874.73,1874.73,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,null,2,23]
[50290,null,{"$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,2,23]
[50380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3656.12,3656.12,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[50385,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1801.81,377.4,0,0,0,0,0,2,1,0,0,0,null,"R",null,null,2,23]
[50431,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",576.88,117.83,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[50526,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2775.34,2775.34,90,0.08,0.83,0.09,0,2,0,2,0,0,null,"R",null,"Y-CM",2,23]
[50553,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",700.54,550.64,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[50574,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",986.94,986.94,0,0,0,0,0,3,1,0,0,0,50570,"R",null,null,2,23]
[50650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1844.39,1844.39,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[50694,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1988.47,462.56,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[50728,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1255.26,1255.26,90,0.08,0.83,0.09,0,2,0,2,2,0,null,"R",null,"Y-CM",2,23]
[50783,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1998.39,1998.39,90,0.08,0.83,0.09,0,2,1,2,2,0,null,"R",null,"Y-CM",2,23]
[50947,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2444.0300000000002,2444.0300000000002,90,0.08,0.83,0.09,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[50957,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",779.87,620.63,0,0,0,0,0,3,1,0,0,0,50951,"R",null,"Y-CM",2,23]
[51050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.08,0.83,0.09,0,2,0,2,1,0,null,"X",null,null,2,23]
[51500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1145.02,1145.02,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,null,2,23]
[51590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3404.72,3404.72,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,null,2,23]
[51701,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",79.91,44.33,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[51726,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",365.73,365.73,0,0,0,0,1,2,0,1,0,0,null,"R",null,null,2,23]
[51729,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",441.56,441.56,0,0,0,0,1,2,0,0,0,0,null,"R",null,null,2,23]
[51785,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",728.54,728.54,0,0,0,0,1,2,0,0,0,0,null,"R",null,null,2,23]
[51792,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",468.39,468.39,0,0,0,0,1,2,0,0,0,0,null,"R",null,null,2,23]
[51845,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1045.8599999999999,1045.8599999999999,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[51980,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1276.8399999999999,1276.8399999999999,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[52234,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",432.23,432.23,0,0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,23]
[52276,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",464.31,464.31,0,0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,23]
[52310,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",551.79999999999995,267.73,0,0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,23]
[52318,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",827.7,827.7,0,0,0,0,0,3,0,1,0,0,52000,"R",null,null,2,23]
[52352,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",621.21,621.21,0,0,0,0,0,3,1,1,0,0,52351,"R",null,"Y-CM",2,23]
[52402,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",463.14,463.14,0,0,0,0,0,3,0,1,0,0,52000,"R",null,"Y-CM",2,23]
[53040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",709.29,709.29,90,0.08,0.83,0.09,0,2,0,0,0,0,null,"R",null,null,2,23]
[53220,null,{"$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,"Y-CM",2,23]
[53400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1432.58,1432.58,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[53431,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2044.47,2044.47,90,0.08,0.83,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[53454,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2,23]
[53502,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",876.12,876.12,90,0.08,0.83,0.09,0,2,0,1,0,0,null,"R",null,null,2,23]
[53855,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,23]
[54050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",268.32,197.74,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[54112,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,23]
[54125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1478.08,1478.08,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[54240,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",113.74,113.74,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[54250,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",27.42,27.42,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[54336,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,23]
[54400,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",956.03,956.03,90,0.1,0.8,0.1,0,2,0,1,1,0,null,"R",null,"Y-CM",2,23]
[54430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1147.3499999999999,1147.3499999999999,90,0.1,0.8,0.1,0,2,2,2,0,0,null,"R",null,null,2,23]
[54440,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",90,0.1,0.8,0.1,0,2,0,2,1,0,null,"N",null,null,2,23]
[54660,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",652.13,652.13,90,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[54699,null,{"$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,2,23]
[55041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",922.2,922.2,90,0.1,0.8,0.1,0,2,2,1,0,0,null,"R",null,"Y-CM",2,23]
[55500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",707.54,707.54,90,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[55605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",944.95,944.95,90,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,"Y-CM",2,23]
[55725,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1073.8599999999999,1073.8599999999999,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[55867,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1861.31,1861.31,90,0.1,0.8,0.1,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[55873,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.08,0.83,0.09,0,2,0,1,0,0,null,"X",null,null,2,23]
[56605,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",173.24,104.41,0,0,0,0,0,2,0,1,2,0,null,"R",null,"Y-CM",2,23]
[56606,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",67.66,50.75,0,0,0,0,0,0,0,1,2,0,null,"R",null,"Y-CM",2,23]
[56700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",10,0.1,0.8,0.1,0,2,0,2,1,0,null,"X",null,null,2,23]
[57061,null,{"$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,2,23]
[57110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1606.99,1606.99,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[57220,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",627.04999999999995,627.04999999999995,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[57284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1489.75,1489.75,90,0.08,0.83,0.09,0,2,0,2,2,0,null,"R",null,"Y-CM",2,23]
[57289,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1415.09,1415.09,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[57415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",316.14999999999998,316.14999999999998,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[57423,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1648.41,1648.41,90,0.08,0.83,0.09,0,2,0,2,2,0,null,"R",null,"Y-CM",2,23]
[57522,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,0,1,0,0,null,"X",null,null,2,23]
[57545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1483.33,1483.33,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[58145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"X",null,null,2,23]
[58152,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2193.21,2193.21,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[58300,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[58322,null,{"$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,2,23]
[58410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1451.25,1451.25,90,0.12,0.74,0.14000000000000001,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[58552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1747.57,1747.57,90,0.12,0.74,0.14000000000000001,0,2,0,2,2,0,null,"R",null,"Y-CM",2,23]
[58561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,3,0,0,2,0,58555,"X",null,null,2,23]
[58580,null,{"$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,2,23]
[58700,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,2,2,1,0,null,"X",null,null,2,23]
[58800,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,2,1,0,0,null,"X",null,null,2,23]
[58940,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.12,0.74,0.14000000000000001,0,2,2,2,1,0,null,"X",null,null,2,23]
[58976,null,{"$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,2,23]
[59030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,0,0,0,null,"X",null,null,2,23]
[59074,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",677.79,536.04999999999995,0,0,0,0,0,2,0,2,0,0,null,"R",null,"Y-CM",2,23]
[59136,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1581.33,1581.33,90,0.17,0.6,0.23,0,2,0,2,0,0,null,"R",null,"Y-CM",2,23]
[59410,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1884.06,1884.06,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[59612,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1564.99,1564.99,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[59840,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",445.64,394.31,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[59898,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,2,1,1,null,"N",null,null,2,23]
[60200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1202.76,1202.76,90,0.09,0.82,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[60505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.09,0.82,0.09,0,2,0,2,1,0,null,"X",null,null,2,23]
[60521,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1963.39,1963.39,90,0.09,0.82,0.09,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[60699,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,0,2,1,1,null,"N",null,null,2,23]
[61108,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1633.24,1633.24,90,0.11,0.76,0.13,0,2,0,1,0,0,null,"R",null,null,2,23]
[61305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3548.21,3548.21,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,23]
[61321,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3753.54,3753.54,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,23]
[61510,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,0,2,1,0,null,"X",null,null,2,23]
[61520,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,0,2,2,0,null,"X",null,null,2,23]
[61535,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1809.4,1809.4,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,23]
[61543,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3840.45,3840.45,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[61556,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,0,2,1,0,null,"X",null,null,2,23]
[61583,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5192.54,5192.54,90,0.11,0.76,0.13,0,2,0,2,1,2,null,"R",null,"Y-CM",2,23]
[61591,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5470.77,5470.77,90,0.11,0.76,0.13,0,2,1,2,1,2,null,"R",null,"Y-CM",2,23]
[61611,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",806.12,806.12,0,0,0,0,0,0,0,2,1,2,null,"R",null,"Y-CM",2,23]
[61641,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,23]
[61686,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7846.55,7846.55,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[61715,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2,23]
[61781,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",406.56,406.56,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[61783,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",401.31,401.31,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,23]
[61867,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,1,2,1,0,null,"X",null,null,2,23]
[62010,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2735.09,2735.09,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[62143,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1872.39,1872.39,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,23]
[62192,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1777.9,1777.9,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[62252,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",158.66,158.66,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,23]
[62273,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",303.89999999999998,201.24,0,0,0,0,0,2,0,1,0,0,null,"R",null,null,2,23]
[62291,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",556.47,251.99,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-UR",2,23]
[62323,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",470.14,176.74,0,0,0,0,0,2,9,1,0,0,null,"R",null,"Y-UR",2,23]
[62329,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",477.14,183.16,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[62365,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",541.29999999999995,541.29999999999995,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-UR",2,23]
[63035,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",404.23,404.23,0,0,0,0,0,0,1,2,2,0,null,"R",null,"Y-UR",2,23]
[63050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2651.1,2651.1,90,0.11,0.76,0.13,0,2,0,2,2,0,null,"R",null,"Y-UR",2,23]
[63064,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3128.24,3128.24,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[63091,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",304.48,304.48,0,0,0,0,0,0,0,2,2,2,null,"R",null,"Y-UR",2,23]
[63185,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2203.71,2203.71,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[63197,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3041.33,3041.33,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[63270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3674.79,3674.79,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[63283,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3380.81,3380.81,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[63306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4336.84,4336.84,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[63621,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",434.56,434.56,0,0,0,0,0,0,0,2,0,0,null,"R",null,"Y-CM",2,23]
[63709,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1999.55,1999.55,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-UR",2,23]
[64418,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",155.74,97.99,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[64448,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",125.99,125.99,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[64450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",135.33000000000001,74.08,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[64474,null,{"$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,2,23]
[64505,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",264.23,190.16,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[64553,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6959.35,800.87,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-UR",2,23]
[64575,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",90,0.11,0.76,0.13,0,2,0,1,0,0,null,"X",null,"Y-CM",2,23]
[64590,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",750.12,526.14,10,0.1,0.8,0.1,0,2,0,1,1,0,null,"R",null,"Y-UR",2,23]
[64630,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",467.22,345.9,10,0.1,0.8,0.1,0,2,0,0,0,0,null,"R",null,"Y-CM",2,23]
[64642,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",278.23,190.16,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[64646,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",292.23,205.9,0,0,0,0,0,2,0,1,0,0,null,"R",null,"Y-CM",2,23]
[64716,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",930.36,930.36,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,"Y-CM",2,23]
[64732,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",834.7,834.7,90,0.11,0.76,0.13,0,2,1,2,0,0,null,"R",null,"Y-CM",2,23]
[64763,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",926.86,926.86,90,0.11,0.76,0.13,0,2,1,2,1,0,null,"R",null,"Y-CM",2,23]
[64786,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1780.23,1780.23,90,0.11,0.76,0.13,0,2,1,2,0,0,null,"R",null,null,2,23]
[64822,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1280.3399999999999,1280.3399999999999,90,0.11,0.76,0.13,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[64837,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",635.79999999999995,635.79999999999995,0,0,0,0,0,0,0,2,0,0,null,"R",null,null,2,23]
[64874,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",302.73,302.73,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,23]
[64886,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2304.04,2304.04,90,0.11,0.76,0.13,0,2,0,2,1,0,null,"R",null,null,2,23]
[64901,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1038.27,1038.27,0,0,0,0,0,0,0,2,1,0,null,"R",null,null,2,23]
[65101,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1535.25,1535.25,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,23]
[65175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1409.25,1409.25,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,23]
[65260,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1760.98,1760.98,90,0.1,0.7,0.2,0,2,1,2,0,0,null,"R",null,null,2,23]
[65430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",208.82,181.99,0,0,0,0,0,2,1,1,0,0,null,"R",null,null,2,23]
[65765,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4868.33,4868.33,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,23]
[65771,null,{"$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]
[65785,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3794.95,804.37,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,"Y-CM",2,23]
[66030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",322.56,202.41,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[66170,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1969.22,1969.22,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,23]
[66500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",711.63,711.63,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,23]
[66680,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1072.1099999999999,1072.1099999999999,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,23]
[66820,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",844.62,844.62,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,23]
[66986,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1617.49,1617.49,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,23]
[67005,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",864.45,864.45,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,23]
[67036,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1606.41,1606.41,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,23]
[67115,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",901.2,901.2,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,23]
[67141,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",489.39,390.81,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[67311,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",823.04,823.04,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[67331,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",223.99,223.99,0,0,0,0,0,0,1,1,1,0,null,"R",null,"Y-CM",2,23]
[67413,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1730.65,1730.65,90,0.1,0.7,0.2,0,2,1,2,0,0,null,"R",null,null,2,23]
[67450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2500.02,2500.02,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,23]
[67801,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",296.89999999999998,236.24,10,0.1,0.8,0.1,0,2,0,1,0,0,null,"R",null,null,2,23]
[67810,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",333.65,121.91,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[67903,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1091.3499999999999,865.03,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,23]
[67914,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",884.28,599.04999999999995,90,0.1,0.7,0.2,0,2,1,1,0,0,null,"R",null,null,2,23]
[67961,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1068.6099999999999,820.7,90,0.1,0.7,0.2,0,2,1,0,0,0,null,"R",null,null,2,23]
[68110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",428.73,269.48,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[68335,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1164.8499999999999,1164.8499999999999,90,0.1,0.7,0.2,0,2,1,1,1,0,null,"R",null,null,2,23]
[68420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",597.88,299.23,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[68720,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1460,1460,90,0.1,0.7,0.2,0,2,1,2,1,0,null,"R",null,null,2,23]
[68761,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",263.07,212.9,10,0.1,0.8,0.1,0,2,1,0,0,0,null,"R",null,null,2,23]
[69105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",262.49,117.83,0,0,0,0,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[69209,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",29.17,29.17,0,0,0,0,5,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[69399,null,{"$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,2,23]
[69450,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",995.69,995.69,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,0,0,0,null,"R",null,null,2,23]
[69610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",694.71,517.39,10,0.1,0.8,0.1,0,2,1,1,0,0,null,"R",null,null,2,23]
[69635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2326.1999999999998,2326.1999999999998,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R",null,null,2,23]
[69662,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",2072.46,2072.46,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R",null,null,2,23]
[69717,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1013.19,1013.19,90,7.0000000000000007E-2,0.79,0.14000000000000001,0,2,1,1,0,0,null,"R",null,"Y-CM",2,23]
[69730,null,{"$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,2,23]
[69799,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,2,1,0,1,1,null,"N",null,null,2,8]
[69990,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",375.06,375.06,0,0,0,0,0,0,0,2,0,0,null,"R",null,null,2,8]
[70030,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",45.5,45.5,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[70130,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",86.33,86.33,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[70160,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",70,70,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[70200,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",88.66,88.66,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[70210,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",60.08,60.08,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[70300,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",8.75,8.75,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[70310,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",14.58,14.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[70350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",32.08,32.08,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[70370,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",165.07,165.07,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[70380,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",55.41,55.41,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[70450,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",71.75,71.75,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,8]
[70470,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",106.74,106.74,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,8]
[70487,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",190.74,190.74,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[70492,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",279.39999999999998,279.39999999999998,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[70496,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",374.48,374.48,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[70545,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",429.89,429.89,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[70546,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",623.54999999999995,623.54999999999995,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[70549,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",652.71,652.71,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[70553,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",193.07,193.07,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,8]
[70558,"TC",{"$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,2,8]
[71047,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",23.33,23.33,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[71101,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",55.41,55.41,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[71110,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",56.58,56.58,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2,8]
[71130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",76.41,76.41,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[71271,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,4,0,0,0,0,null,"X",null,null,2,8]
[71552,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",886.03,886.03,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[71555,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",150.49,150.49,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[72070,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",17.5,17.5,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[72080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",64.16,64.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[72082,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",104.41,104.41,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[72100,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",54.25,54.25,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[72126,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",102.08,102.08,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[72128,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",243.82,243.82,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[72130,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",267.73,267.73,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[72141,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",232.74,232.74,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,8]
[72147,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",149.91,149.91,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,8]
[72157,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",602.54999999999995,602.54999999999995,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,8]
[72190,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",78.16,78.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[72192,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",158.07,158.07,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[72196,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",144.66,144.66,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[72197,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",184.91,184.91,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[72202,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",19.25,19.25,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[72265,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",128.91,128.91,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[73000,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",46.08,46.08,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[73020,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",26.83,26.83,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[73070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",54.25,54.25,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[73080,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",60.66,60.66,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[73100,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",62.41,62.41,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[73115,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",48.41,48.41,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[73140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",71.75,71.75,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[73206,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",150.49,150.49,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[73221,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",269.48,269.48,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR",2,8]
[73223,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",181.41,181.41,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR",2,8]
[73503,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",89.24,89.24,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[73523,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",88.66,88.66,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[73560,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",49,49,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[73565,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",74.66,74.66,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2,8]
[73580,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",199.49,199.49,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[73610,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",67.66,67.66,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[73650,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",13.42,13.42,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[73700,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",83.41,83.41,0,0,0,0,1,4,3,0,0,0,null,"R",null,null,2,8]
[73718,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",113.16,113.16,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR",2,8]
[73721,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",382.64,382.64,0,0,0,0,1,4,3,0,0,0,null,"R",null,"Y-UR",2,8]
[74018,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",40.25,40.25,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[74019,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",49,49,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[74160,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",106.74,106.74,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[74175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",576.29999999999995,576.29999999999995,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[74177,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",415.31,415.31,0,0,0,0,1,4,0,9,0,0,null,"R",null,null,2,8]
[74185,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",485.31,485.31,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[74220,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",50.75,50.75,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[74235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,8]
[74250,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",222.24,222.24,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[74251,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",556.47,556.47,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[74262,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",211.15,211.15,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM",2,8]
[74300,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",23.33,23.33,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[74301,"TC",{"$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,2,8]
[74340,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,8]
[74360,null,{"$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,2,8]
[74420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",144.66,144.66,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[74445,null,{"$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,2,8]
[74445,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",95.08,95.08,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[74470,"TC",{"$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,2,8]
[74740,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,8]
[75561,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",460.22,460.22,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM",2,8]
[75565,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",63.58,63.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[75600,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",283.48,283.48,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[75635,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",774.62,774.62,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[75716,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",294.57,294.57,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,8]
[75731,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",189.57,189.57,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[75733,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",211.74,211.74,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,8]
[75746,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",92.16,92.16,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[75801,null,{"$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,2,8]
[75807,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,2,0,0,0,null,"N",null,null,2,8]
[75825,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",114.91,114.91,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[75831,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",89.83,89.83,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[75840,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",96.24,96.24,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[75880,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",139.99,139.99,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[75885,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",136.49,136.49,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[75893,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",151.07,151.07,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[75901,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",415.89,415.89,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[75958,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,8]
[75959,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",281.73,281.73,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[76010,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,8]
[76016,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,4,0,0,0,0,null,"X",null,null,2,8]
[76018,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,4,0,0,0,0,null,"X",null,null,2,8]
[76145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1848.48,1848.48,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,8]
[76390,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",126.84,126.84,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-CM",2,8]
[76497,26,{"$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,2,8]
[76510,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",69.41,69.41,0,0,0,0,1,7,3,0,0,0,null,"R",null,null,2,8]
[76512,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",33.25,33.25,0,0,0,0,1,7,3,0,0,0,null,"R",null,null,2,8]
[76519,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",125.99,125.99,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2,8]
[76642,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",156.32,156.32,0,0,0,0,1,0,1,0,0,0,null,"R",null,"Y-CM",2,8]
[76705,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",111.41,111.41,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[76770,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",61.83,61.83,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[76800,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",110.24,110.24,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[76805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",247.9,247.9,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[76813,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",109.08,109.08,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[76815,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",54.83,54.83,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[76819,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",64.75,64.75,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[76826,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",285.82,285.82,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[76830,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",159.82,159.82,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[76831,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,4,0,0,0,0,null,"X",null,null,2,8]
[76872,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",309.73,309.73,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[76882,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",117.83,117.83,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[76932,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",61.83,61.83,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[76940,"TC",{"$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,2,8]
[76946,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",32.08,32.08,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[76977,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",8.75,8.75,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[76979,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",156.91,156.91,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[76982,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",171.49,171.49,0,0,0,0,1,4,0,0,0,0,null,"R",null,null,2,8]
[76999,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,8]
[77003,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",190.74,190.74,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[77012,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",122.49,122.49,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[77021,null,{"$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,null,2,8]
[77048,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",177.32,177.32,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-UR",2,8]
[77061,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,9,0,0,null,"X",null,null,2,8]
[77063,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,2,9,0,0,null,"X",null,null,2,8]
[77072,null,{"$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,2,8]
[77075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",183.74,183.74,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[77076,null,{"$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,2,8]
[77084,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",134.74,134.74,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[77085,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",25.08,25.08,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[77280,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",433.98,433.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77293,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",190.74,190.74,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3452.55,3452.55,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",276.48,276.48,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77321,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",90.41,90.41,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77331,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",36.159999999999997,36.159999999999997,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77338,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",467.81,467.81,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77402,null,{"$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",2,8]
[77427,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",348.23,348.23,0,0,0,0,2,9,9,9,9,9,null,"R",null,"Y-CM",2,8]
[77470,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",73.5,73.5,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77610,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",1139.18,1139.18,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77610,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",124.83,124.83,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77763,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1462.92,1462.92,90,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77763,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",634.63,634.63,90,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77778,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",884.28,884.28,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[77789,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",109.08,109.08,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78012,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",135.91,135.91,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78016,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",405.98,405.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78071,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",487.64,487.64,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78075,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",743.71,743.71,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78110,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",130.08000000000001,130.08000000000001,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78111,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",171.49,171.49,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78140,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",42.58,42.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78185,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",28.58,28.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78201,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",35.58,35.58,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78215,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",335.98,335.98,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78231,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",156.32,156.32,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78232,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",156.91,156.91,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78262,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",57.16,57.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78267,null,{"$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,2,13]
[78299,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,8]
[78300,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",51.91,51.91,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[78351,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.25,26.25,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2,8]
[78428,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",317.89999999999998,317.89999999999998,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78431,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-UR",2,8]
[78434,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",51.33,51.33,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR",2,8]
[78453,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",81.66,81.66,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-UR",2,8]
[78456,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",82.25,82.25,0,0,0,0,1,6,9,9,9,9,null,"R",null,"Y-CM",2,8]
[78468,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",271.82,271.82,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78469,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",303.89999999999998,303.89999999999998,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-UR",2,8]
[78483,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",282.89999999999998,282.89999999999998,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78494,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",388.48,388.48,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-UR",2,8]
[78580,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",397.81,397.81,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78582,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",87.5,87.5,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78601,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",42,42,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[78605,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",44.91,44.91,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[78610,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",274.73,274.73,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[78645,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",496.97,496.97,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[78700,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",256.07,256.07,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[78708,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",325.48,325.48,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[78740,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",390.81,390.81,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[78799,26,{"$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",2,8]
[78802,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",65.33,65.33,0,0,0,0,1,4,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78804,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",82.25,82.25,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78815,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",200.66,200.66,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-UR",2,8]
[78831,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1182.3499999999999,1182.3499999999999,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[78832,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",1329.34,1329.34,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[79101,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",164.49,164.49,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[79440,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",74.66,74.66,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[80047,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",14,14,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[80145,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[80163,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.72,18.72,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[80176,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.71,20.71,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[80179,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.28,26.28,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[80193,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",54.38,54.38,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[80202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.09,19.09,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[80307,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",87.62,87.62,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[80328,null,{"$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,2,13]
[80339,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[80346,null,{"$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,2,13]
[80357,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[80362,null,{"$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,2,13]
[80369,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[80416,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",295.14,295.14,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[80430,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[80503,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49,39.08,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,13]
[81099,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,13]
[81110,null,{"$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,2,13]
[81168,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81170,null,{"$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,2,13]
[81180,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81192,null,{"$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,2,13]
[81203,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81219,null,{"$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,2,13]
[81231,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81241,null,{"$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,2,13]
[81251,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81254,null,{"$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,2,13]
[81270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81274,null,{"$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,2,13]
[81284,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81292,null,{"$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,2,13]
[81309,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81316,null,{"$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,2,13]
[81321,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81332,null,{"$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,2,13]
[81339,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81350,null,{"$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,2,13]
[81363,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81380,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",249.92,249.92,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[81404,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81417,null,{"$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,2,13]
[81435,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81437,null,{"$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,2,13]
[81451,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81471,null,{"$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,2,13]
[81506,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81520,null,{"$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,2,13]
[81541,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[81552,null,{"$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,2,13]
[82043,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8.15,8.15,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82103,null,{"$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,2,13]
[82120,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8.4499999999999993,8.4499999999999993,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82154,null,{"$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,2,13]
[82175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.75,26.75,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82270,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6.18,6.18,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.149999999999999,18.149999999999999,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82378,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.73,26.73,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[82415,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.86,17.86,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82523,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.34,26.34,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82530,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",23.56,23.56,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82608,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.190000000000001,20.190000000000001,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82633,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",43.68,43.68,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82671,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",45.54,45.54,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[82710,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",23.69,23.69,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82775,null,{"$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,2,13]
[82938,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",24.94,24.94,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82947,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5.54,5.54,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[82960,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[83009,null,{"$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,2,13]
[83030,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[83068,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",13.35,13.35,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[83884,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[83528,null,{"$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,2,13]
[83631,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",27.68,27.68,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[83664,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",27.24,27.24,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[83721,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",14.81,14.81,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[83789,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",34,34,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[83873,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",24.25,24.25,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[83951,null,{"$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,2,13]
[83993,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",27.68,27.68,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[84105,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8.15,8.15,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[84143,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[84154,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.93,25.93,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[84157,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",5.64,5.64,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[84210,null,{"$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,2,13]
[84235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[84305,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",29.98,29.98,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[84402,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",35.909999999999997,35.909999999999997,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[84436,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.69,9.69,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[84479,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.1199999999999992,9.1199999999999992,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[84512,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",14.23,14.23,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[84525,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7.23,7.23,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[84620,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.2,18.2,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[85008,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",4.84,4.84,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[85025,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",10.96,10.96,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[85048,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",3.58,3.58,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[85175,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",28.72,28.72,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[85290,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",23.04,23.04,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[85337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",24.35,24.35,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[85360,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",11.86,11.86,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[85420,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.2100000000000009,9.2100000000000009,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[85445,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[85549,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.44,26.44,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[85613,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",13.51,13.51,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.84,9.84,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86041,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,13]
[86063,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8.14,8.14,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[86079,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",94.49,85.75,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,13]
[86156,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",11.38,11.38,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86235,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.28,25.28,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86305,null,{"$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,2,13]
[86318,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.51,25.51,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86337,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",30.19,30.19,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86355,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",53.2,53.2,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86364,null,{"$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,2,13]
[86403,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",16.27,16.27,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86593,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6.2,6.2,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86609,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.16,18.16,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86644,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.29,20.29,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86651,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.600000000000001,18.600000000000001,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86674,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.76,20.76,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86695,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.600000000000001,18.600000000000001,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86710,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",19.11,19.11,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86735,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.399999999999999,18.399999999999999,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86768,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",18.600000000000001,18.600000000000001,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86774,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.87,20.87,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86794,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",23.76,23.76,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86816,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",42.54,42.54,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86835,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",455.37,455.37,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86886,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7.3,7.3,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86922,null,{"$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,2,13]
[86941,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.079999999999998,17.079999999999998,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[86976,null,{"$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,2,13]
[87040,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",14.55,14.55,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87106,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",14.55,14.55,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",7.85,7.85,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87164,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",15.14,15.14,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87181,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",6.7,6.7,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87209,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25.35,25.35,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87255,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",47.74,47.74,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87278,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",22,22,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87301,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",16.89,16.89,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87338,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",20.28,20.28,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87341,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",14.57,14.57,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87451,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",14.82,14.82,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87472,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",60.4,60.4,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87490,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",32.08,32.08,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[87500,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49.48,49.48,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87517,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",60.4,60.4,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87522,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",60.4,60.4,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[87537,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",30.91,30.91,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87550,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",28.27,28.27,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87561,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49.48,49.48,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87632,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",307.45999999999998,307.45999999999998,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[87651,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49.48,49.48,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87798,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49.48,49.48,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[87850,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",34.630000000000003,34.630000000000003,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[87900,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",183.79,183.79,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[88020,null,{"$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,2,13]
[88104,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",148.16,148.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,13]
[88104,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",99.74,99.74,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[88120,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",947.86,947.86,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[88125,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",23.92,23.92,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[88160,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",109.66,109.66,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[88172,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",103.24,103.24,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[88173,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",316.73,316.73,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[88199,26,{"$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]
[88233,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",198.43,198.43,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[88271,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",30.2,30.2,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[88280,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",47.19,47.19,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2,13]
[88304,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",79.33,79.33,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[88311,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",37.33,37.33,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[88313,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",21,21,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[88321,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",174.99,146.41,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[88325,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",282.32,237.4,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,13]
[88334,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",65.33,65.33,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[88342,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",60.66,60.66,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[88350,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",205.32,205.32,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[88361,null,{"$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]
[88364,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",240.32,240.32,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[88366,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",392.56,392.56,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[88372,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",36.97,36.97,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2]
[88380,null,{"$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]
[88381,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",323.14999999999998,323.14999999999998,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[88399,"TC",{"$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]
[89125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",8.2899999999999991,8.2899999999999991,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2,13]
[89250,null,{"$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,2,13]
[89281,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
[89335,null,{"$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,2,12]
[89343,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
[90376,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",479.72,479.72,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
[90384,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,12]
[90471,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",37.909999999999997,37.909999999999997,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,12]
[90611,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,12]
[90634,null,{"$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,2,12]
[90657,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
[90675,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",317.67,317.67,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
[90687,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
[90698,null,{"$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]
[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]
[90832,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",145.83000000000001,125.99,0,0,0,0,0,0,0,9,0,0,null,"R",null,"Y-CM",2,17]
[90839,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",274.14999999999998,238.57,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,17]
[90870,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",312.64999999999998,184.91,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,17]
[90913,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",58.33,42,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,8]
[90954,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
[90966,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",526.72,526.72,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[90970,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",17.5,17.5,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[91010,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",113.16,113.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[91030,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",81.08,81.08,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[91038,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",723.29,723.29,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[91110,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",1105.94,1105.94,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[91120,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",85.16,85.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[91133,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",822.45,822.45,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
[91304,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",161.54,161.54,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2]
[92002,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",153.99,80.5,0,0,0,0,0,0,2,0,0,0,null,"R",null,null,2]
[92025,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",34.409999999999997,34.409999999999997,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92071,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",65.33,57.16,0,0,0,0,0,0,1,0,0,0,null,"R",null,null,2]
[92082,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",36.75,36.75,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92136,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",32.659999999999997,32.659999999999997,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92228,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",29.17,29.17,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92240,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",440.97,440.97,0,0,0,0,1,7,2,0,0,0,null,"R",null,"Y-CM",2]
[92265,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",79.33,79.33,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92283,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",15.75,15.75,0,0,0,0,1,7,2,0,0,0,null,"R",null,"Y-CM",2]
[92285,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",37.33,37.33,0,0,0,0,1,7,2,0,0,0,null,"R",null,null,2]
[92342,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",78.16,46.08,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2]
[92353,null,{"$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]
[92508,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",44.33,44.33,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2]
[92524,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",199.49,199.49,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2]
[92538,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",40.25,40.25,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2]
[92544,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",32.659999999999997,32.659999999999997,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[92546,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",26.25,26.25,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[92548,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",59.5,59.5,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,23]
[92558,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",16.920000000000002,15.17,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2]
[92583,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",111.99,111.99,0,0,0,0,3,0,2,0,0,0,null,"R",null,null,2,23]
[92588,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",51.33,51.33,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2,8]
[92595,null,{"$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,2,8]
[92614,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",277.64999999999998,116.66,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[92625,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",121.33,108.49,0,0,0,0,9,0,2,0,0,0,null,"R",null,"Y-CM",2,8]
[92651,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",144.66,144.66,0,0,0,0,0,0,2,0,0,0,null,"R",null,"Y-CM",2,8]
[92700,null,{"$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,2,8]
[92961,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",417.64,417.64,0,0,0,0,0,9,9,9,9,9,null,"R",null,"Y-CM",2,8]
[92972,null,{"$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,2,8]
[92979,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,8]
[93016,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",37.33,37.33,0,0,0,0,2,0,0,0,0,0,null,"R",null,null,2,8]
[93050,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",29.75,29.75,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,8]
[93225,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",33.83,33.83,0,0,0,0,3,6,0,0,0,0,null,"R",null,null,2,8]
[93260,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",72.91,72.91,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93261,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",63,63,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93281,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",79.33,79.33,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93282,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",72.33,72.33,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93286,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",56.58,56.58,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93288,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",102.66,102.66,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93293,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",76.41,76.41,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93304,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",219.9,219.9,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93306,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",358.73,358.73,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[93312,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",427.56,427.56,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[93318,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",177.91,177.91,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[93320,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",30.91,30.91,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[93351,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",144.66,144.66,0,0,0,0,1,6,0,9,9,9,null,"R",null,null,2,8]
[93452,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",1581.33,1581.33,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93455,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",1301.93,1301.93,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93458,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",500.47,500.47,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93464,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",394.89,394.89,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93563,null,{"$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,2,8]
[93573,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,8]
[93580,null,{"$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,2,8]
[93593,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,8]
[93595,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,2,0,0,0,0,null,"X",null,null,2,8]
[93600,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",197.74,197.74,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93603,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",195.41,195.41,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93616,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,8]
[93618,null,{"$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",2,8]
[93622,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,8]
[93624,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",406.56,406.56,0,0,0,0,1,2,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93650,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",993.94,993.94,0,0,0,0,0,2,0,0,0,0,null,"R",null,"Y-UR",2,8]
[93657,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",523.22,523.22,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-UR",2,8]
[93724,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",414.14,414.14,0,0,0,0,1,6,0,0,0,0,null,"R",null,"Y-CM",2,8]
[93770,null,{"$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,2,8]
[93799,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,8]
[93882,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",187.82,187.82,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[93895,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,6,0,0,0,0,null,"N",null,null,2,8]
[93923,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",204.74,204.74,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,8]
[93930,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",299.82,299.82,0,0,0,0,1,6,2,0,0,0,null,"R",null,null,2,8]
[93931,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",187.24,187.24,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[93978,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",332.48,332.48,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[93980,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",214.65,214.65,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[93990,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",269.48,269.48,0,0,0,0,1,6,0,0,0,0,null,"R",null,null,2,8]
[94011,null,{"$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]
[94070,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",116.66,116.66,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[94150,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,1,9,9,9,9,9,null,"B",null,null,2,8]
[94452,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",68.83,68.83,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[94618,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",62.41,62.41,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2]
[94662,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",60.66,60.66,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[94681,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",16.920000000000002,16.920000000000002,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[94728,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",82.25,82.25,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[94761,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,3,0,0,0,0,0,null,"B",null,null,2]
[94799,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,null,2,8]
[95017,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",15.17,6.42,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[95125,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
[95147,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",116.66,5.83,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2]
[95249,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
[95708,null,{"$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]
[95723,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",454.39,445.06,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2]
[95782,"TC",{"$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,2,8]
[95803,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",168.57,168.57,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[95805,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",820.12,820.12,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[95812,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",649.79999999999995,649.79999999999995,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95813,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",827.7,827.7,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95819,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",99.74,99.74,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95851,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",44.91,13.42,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
[95864,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",408.31,408.31,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95867,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",73.5,73.5,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95870,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",35,35,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95872,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",71.16,71.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95887,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",85.16,85.16,0,0,0,0,1,0,3,0,0,0,null,"R",null,null,2,8]
[95905,"TC",{"$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,2,8]
[95908,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",85.75,85.75,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95911,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",148.74,148.74,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95923,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",78.16,78.16,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95926,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",261.89999999999998,261.89999999999998,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2,8]
[95928,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",438.06,438.06,0,0,0,0,1,0,2,0,0,0,null,"R",null,null,2,8]
[95933,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",92.74,92.74,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95955,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",337.15,337.15,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95957,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",538.39,538.39,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95961,"TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",319.64999999999998,319.64999999999998,0,0,0,0,1,0,0,0,0,0,null,"R",null,null,2,8]
[95967,26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"See CPT",302.73,302.73,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2,8]
[95982,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
[96020,null,{"$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,2,8]
[96130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",216.4,194.24,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,17]
[96132,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",232.15,188.41,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,17]
[96202,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,17]
[96361,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",22.17,22.17,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,17]
[96372,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",26.25,26.25,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,17]
[96411,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",97.41,97.41,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,17]
[96521,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",219.9,219.9,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2,17]
[96548,null,{"$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]
[96922,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2]
[96999,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",77.33,77.33,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2]
[97024,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",13.42,13.42,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,20]
[97039,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",21.67,21.67,0,0,0,0,7,0,0,0,0,0,null,"F",null,null,2,20]
[97130,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",38.5,38.5,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,20]
[97162,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",149.44999999999999,149.44999999999999,0,0,0,0,7,5,0,0,0,0,null,"F",null,null,2,20]
[97533,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",115.49,115.49,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,20]
[97551,null,{"$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,2,20]
[97750,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",63,63,0,0,0,0,7,5,0,0,0,0,null,"R",null,null,2,20]
[97811,null,{"$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,2,20]
[98009,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,5]
[98016,null,{"$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,2,5]
[98928,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",129.49,103.24,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,20]
[98970,null,{"$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,2,20]
[99000,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
[99060,null,{"$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]
[99140,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
[99157,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",100.33,100.33,0,0,0,0,9,9,9,9,9,9,null,"R",null,"Y-CM",2]
[99199,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,null,2]
[99204,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",303.32,236.82,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,5]
[99233,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",209.4,209.4,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,5]
[99244,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",289.32,237.99,0,0,0,0,9,9,9,9,9,9,null,"R",null,null,2,5]
[99282,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",73.5,73.5,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,5]
[99315,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",145.24,145.24,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,5]
[99359,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Bundled","Bundled",0,0,0,0,0,0,0,0,0,0,null,"B",null,null,2,5]
[99377,null,{"$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,2,5]
[99391,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
[99403,null,{"$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,2,5]
[99407,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",49,43.75,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2,9]
[99437,null,{"$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,2,5]
[99447,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,5]
[99459,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",40.25,40.25,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2,5]
[99474,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,5]
[99480,null,{"$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,2,5]
[99495,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,5]
[99502,null,{"$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,2,5]
[99506,null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,5]
["0001A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",40,40,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2]
["0011U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0014F",null,{"$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]
["0021U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0522U",null,{"$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]
["0055T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report ","By Report ",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-UR",2]
["0076T",null,{"$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]
["0091U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["0094U",null,{"$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]
["0099U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0105U",null,{"$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]
["0112U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0124A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",40,40,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2]
["0128U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0142U",null,{"$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]
["0144U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0154U",null,{"$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]
["0161U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0202U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",587.66,587.66,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2]
["0212T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["0215T",null,{"$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]
["0221T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0221U",null,{"$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]
["0230U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0237U",null,{"$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]
["0263T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0278T",null,{"$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]
["0291U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0300U",null,{"$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]
["0333T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0348T",null,{"$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]
["0354T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0378R",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",10.55,10.55,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,25]
["0380R",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["0401A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","State Rate","State Rate",0,0,0,0,9,9,9,9,9,9,null,"S",null,null,2,18]
["0408A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","State Rate","State Rate",0,0,0,0,9,9,9,9,9,9,null,"S",null,null,2,18]
["0414T",null,{"$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]
["0420U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0429U",null,{"$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]
["0432U",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0441A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",37.65,37.65,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,18]
["0449T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["0486T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,9,2,9,9,9,null,"X",null,null,2]
["0501F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["0514F",null,{"$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]
["0518T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2]
["0525F",null,{"$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]
["0528T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,9,9,9,9,9,null,"X",null,null,2]
["0550F",null,{"$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]
["0556T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0565T",null,{"$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]
["0573T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0582T",null,{"$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]
["0587T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0625T",null,{"$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]
["0635T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,3,0,0,0,null,"X",null,null,2]
["0676T",null,{"$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]
["0679T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,0,1,0,0,null,"X",null,null,2]
["0695T",null,{"$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,2,20]
["0699T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,2,1,1,0,0,null,"X",null,null,2]
["0713T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,2,9,9,9,9,9,null,"X",null,null,2]
["0746T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0757T",null,{"$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]
["0760T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["0778T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,2,0,0,0,null,"X",null,null,2]
["0783T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0819T",null,{"$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]
["0827T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["0835T",null,{"$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]
["0842T",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]
["0858T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2]
["0908T",null,{"$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]
["0919T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["0928T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,2,0,0,0,0,0,null,"X",null,null,2]
["0931T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,1,2,0,0,0,0,null,"X",null,null,2]
["0938T",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","Not Covered","Not Covered",0,0,0,0,3,6,0,0,0,0,null,"X",null,null,2]
["0803V",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",9.08,9.08,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,25]
["0840V",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",10.65,10.65,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,25]
["0844V",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",10.65,10.65,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,25]
["1005F",null,{"$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]
["1008F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1032F",null,{"$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]
["1036F",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]
["1068M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Assess impediments to rtrn to wrk, app","Contracted","Contracted",0,0,0,0,9,9,9,9,9,9,null,"C",null,null,2]
["1077M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Opioid req for subacute pain w/doc",69.72,69.72,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,21]
["1090F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1101F",null,{"$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]
["1119F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1130M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ime - terminated examination",431.85,431.85,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,11]
["1135F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1151M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Omd requested consultation","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["1157F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1170F",null,{"$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]
["1200F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1245M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Utilization review physical medicine","Contracted","Contracted",0,0,0,0,9,9,9,9,9,9,null,"C",null,null,2]
["1250M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"UR, advanced imaging goldcard providers","Contracted","Contracted",0,0,0,0,9,9,9,9,9,9,null,"C",null,null,2]
["1280M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"CCM, POST-RECOVERY PHASE, 15 MIN","Contracted","Contracted",0,0,0,0,9,9,9,9,9,9,null,"C",null,null,2]
["1295M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"NCM Progress Report",32.880000000000003,32.880000000000003,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,5]
["1304W",null,{"$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]
["1493F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["1729M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"PGAP Coach Mileage","State Rate","State Rate",0,0,0,0,9,9,9,9,9,9,null,"S",null,null,2,15]
["2004F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["2025F",null,{"$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]
["2028F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["2051A",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",64.81,64.81,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,3]
["3018F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3027F",null,{"$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]
["3051F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3078F",null,{"$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]
["3088F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3110F",null,{"$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]
["3120F",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]
["3267F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3272F",null,{"$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]
["3292F",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]
["3341F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3374F",null,{"$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]
["3384F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3490F",null,{"$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]
["3493F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3512F",null,{"$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]
["3555F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["3756F",null,{"$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]
["3775F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4014F",null,{"$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]
["4030F",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]
["4052F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4062F",null,{"$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]
["4100F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,10]
["4124F",null,{"$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,2,10]
["4148F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4168F",null,{"$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]
["4177F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4191F",null,{"$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]
["4221F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4230F",null,{"$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]
["4267F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["4301F",null,{"$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,2,7]
["4450F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2,7]
["4552F",null,{"$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]
["4561F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["5091V",null,{"$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,2,12]
["5094V",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",25,25,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,4]
["6030F",null,{"$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,2,7]
["6101F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["8880H",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",866.1,866.1,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2]
["8915H",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["8971H",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",10.86,10.86,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,28]
["9007F",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"See CPT",0,0,0,0,0,0,9,9,9,9,9,9,null,"T",null,null,2]
["9917M",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"IND HYGIENIST CONSULTATION",391.88,391.88,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2]
["A0110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nonemergency transport bus","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,15]
["A0140",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nonemergency transport air","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,15]
["A0384",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bls defibrillation supplies",50.22,50.22,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,15]
["A0426",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Als 1",778.53,778.53,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,15]
["A0998",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ambulance response/treatment","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,15]
["A2006",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Novosorb synpath per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["A2019",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Kerecis marigen shld sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["A2031",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mirodry, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["A4210",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nonneedle injection device",2081.52,2081.52,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["A4211",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Supp for self-adm injections","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4225",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sup/ext insulin inf pump syr",3.55,3.55,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,7]
["A4234",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"J-cell batt for glucose mon",5.61,5.61,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A4256",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Calibrator solution/chips",3.41,3.41,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4269",null,{"$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,2,7]
["A4280",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brst prsths adhsv attchmnt",7.31,7.31,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A4314",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cath w/drainage 2-way latex",35.67,35.67,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4327",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fem urinary collect dev cup",59.64,59.64,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4333",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urinary cath anchor device",3.13,3.13,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4349",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disposable male external cat",2.84,2.84,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4357",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bedside drainage bag",13.71,13.71,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4371",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Skin barrier powder per oz",5.07,5.07,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4381",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urinary plastic pouch w/o fp",6.52,6.52,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4394",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ostomy pouch liq deodorant",3.66,3.66,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4405",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nonpectin based ostomy paste",4.82,4.82,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4417",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ost pch w bar/bltinconv/fltr",5.26,5.26,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4420",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ost pch clsd for bar w lk fl",3.26,3.26,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4434",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ost pch urine w lock flng/ft",5.3,5.3,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4452",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Waterproof tape",0.54,0.54,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4470",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gravlee jet washer","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4510",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Full length surg stocking",158.27000000000001,158.27000000000001,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A4557",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lead wires, pair",19.559999999999999,19.559999999999999,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4580",null,{"$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,2,7]
["A4595",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tens suppl 2 lead per month","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["A4606",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oxygen probe used w oximeter",73.849999999999994,73.849999999999994,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["A4627",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spacer bag/reservoir",34.869999999999997,34.869999999999997,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A4635",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Underarm crutch pad",7.21,7.21,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A4650",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant radiation dosimeter","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,7]
["A4670",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Automatic bp monitor, dial",112.07,112.07,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A4719",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"\"y set\" tubing",15.03,15.03,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A4750",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Art or venous blood tubing",22.89,22.89,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A4772",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Blood glucose test strips",7.34,7.34,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A4918",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Venous pressure clamp","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["A5055",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Stoma cap",2.0299999999999998,2.0299999999999998,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A5061",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pouch drainable w barrier at",4.99,4.99,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A5120",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Skin barrier, wipe or swab",0.32,0.32,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A5200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Percutaneous catheter anchor",15.94,15.94,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A5514",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mult den insert dir carv/cam",54.62,54.62,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,7]
["A6198",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alginate dressing > 48 sq in",74.7,74.7,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6209",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Foam drsg <=16 sq in w/o bdr",10.54,10.54,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6212",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Foam drg <=16 sq in w/border",13.71,13.71,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6229",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gauze >16<=48 sq in watr/sal",5.08,5.08,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6235",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hydrocolld drg >16<=48 w/o b",23.74,23.74,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6247",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hydrogel drg > 48 sq in w/b",33.56,33.56,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6259",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transparent film > 48 sq in",15.43,15.43,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sterile eye pad",0.53,0.53,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6444",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Conform band n/s w>=5\"/yd",0.79,0.79,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6457",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tubular dressing",1.61,1.61,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6501",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Compres burngarment bodysuit","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["A6518",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Grad com wrap w strap arm cu","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["A6528",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"G com garment bra nighttime",655.39,655.39,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6534",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gc stocking thighlngth 30-40",61.61,61.61,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A6541",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gc stocking waistlngth 40-50",135.93,135.93,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A6563",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"G com stckng waist30-40 cust",998.57,998.57,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6567",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"G com garment neck/head cust",787.17,787.17,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6579",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom grad com glove med",308.07,308.07,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6582",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gradient comp gauntlet",47.87,47.87,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6600",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"G com bandge hgh dn foam sht",3.02,3.02,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A6603",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"G com bandge low dn foamchnl",2.3199999999999998,2.3199999999999998,0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A7000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disposable canister for pump",34.450000000000003,34.450000000000003,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,7]
["A7012",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nebulizer water collec devic",6.33,6.33,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A7027",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Combination oral/nasal mask",281.81,281.81,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A7039",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Filter, non disposable w pap",18.25,18.25,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A7049",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Epap nasal valve","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["A7503",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hmes filter holder or cap",16.010000000000002,16.010000000000002,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A8003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hard protect helmet custom","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["A9150",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Misc/exper non-prescript dru","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2]
["A9279",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Monitoring feature/devicenoc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"B",null,"Y-CM",2,7]
["A9280",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alert device, noc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,7]
["A9504",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tc99m apcitide","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-PHL",2,7]
["A9512",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tc99m pertechnetate",31.04,31.04,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,7]
["A9524",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"I131 serum albumin, dx","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-PHL",2,7]
["A9537",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tc99m mebrofenin",297.10000000000002,297.10000000000002,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,7]
["A9556",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ga67 gallium",177.46,177.46,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,7]
["A9560",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tc99m labeled rbc",352.69,352.69,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-PHL",2,7]
["A9577",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj multihance",6.64,6.64,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["A9580",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sodium fluoride f-18",705.38,705.38,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,7]
["A9590",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Iodine i-131 iobenguane 1mci",349.67,349.67,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,7]
["A9601",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flortaucipir inj 1 millicuri","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["A9698",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-rad contrast materialnoc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["A9800",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gallium locametz 1 millicuri",1893.35,1893.35,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["B4148",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Enteral feed elastomer daily",11.91,11.91,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,7]
["B4152",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ef calorie dense>/=1.5kcal",0.57999999999999996,0.57999999999999996,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["B4162",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ef ped specmetabolic inherit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,7]
["B4197",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Parenteral sol 74-100 gm pro",409.78,409.78,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["B9004","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Parenteral infus pump portab",585.30999999999995,585.30999999999995,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["C1062",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intravertebral fx aug impl","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-UR",2]
["C1721",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Aicd, dual chamber","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C1729",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cath, drainage","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C1737",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Si&pelvis fusn&fixn dev","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["C1752",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cath,hemodialysis,short-term","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C1768",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Graft, vascular","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C1773",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ret dev, insertable","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C1786",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pmkr, single, rate-resp","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C1816",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Receiver/transmitter, neuro","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C1827",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gen, neuro, carot sinus baro","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["C1876",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Stent, non-coa/non-cov w/del","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C1889",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant/insert device, noc","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-CM",2]
["C1898",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lead, pmkr, other than trans","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C2620",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pmkr, single, non rate-resp","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C2623",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cath, translumin, drug-coat","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["C2635",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brachytx, non-str, ha, p-103","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["C2645",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Brachytx planar, p-103","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["C7501",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Perc bx breast lesions stero","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR",2]
["C7508",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Perq lumb&thor vert aug","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2]
["C7521",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"R hrt angio w/ ivus or oct","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR",2]
["C7524",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"L hrt angio w/flow resrv","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR",2]
["C7538",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Insrt vent pm w/l vent lead","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR",2]
["C7545",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Exch bil cath w/ rmv calculi","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR",2]
["C7552",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"R hrt art/grft ang hrt flow","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,"Y-UR",2]
["C8000",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Suprt dev, a-v fistula, imp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["C8905",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mri w/o fol w/cont, brst, un","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C8913",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mra w/o cont, lwr ext","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C8928",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tte w or w/o fol w/con,stres","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C8936",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mra, w/o&w/dye, upper extr","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C9059",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, meloxicam",2.11,2.11,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2]
["C9145",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, aponvie, 1 mg",1.86,1.86,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["C9175",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, treosulfan, 50 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["C9358",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surgimend, fetal","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["C9488",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Conivaptan hcl","By report","By report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["C9603",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Perc d-e cor stent ather br","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["C9734",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"U/S TRTMT, NOT LEIOMYOMATA","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["C9757",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spine/lumbar disk surgery","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-UR",2]
["C9772",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Revasc lithotrip tibi/perone","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["C9775",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Revasc lith-sten-ath tib/per","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["C9793",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pre-plan 3d model w/ccta","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["C9809",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cryo needle non-opioid dev","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["D0190",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Screening of a patient",107.2,107.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,6]
["D0274",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bitewings four images",84,84,0,0,0,0,1,0,0,0,0,0,null,"F",null,null,2,6]
["D0364",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cone beam ct capt & interp",378.4,378.4,0,0,0,0,1,0,0,0,0,0,null,"F",null,null,2,6]
["D0371",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sialoendoscopy capt & interp","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2,6]
["D0389",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Periopic image capture only","By Report","By Report",0,0,0,0,1,0,0,0,0,0,null,"N",null,"Y-CM",2,6]
["D0394",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Digital sub 2 or more images",340.8,340.8,0,0,0,0,1,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D0416",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Viral culture","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,6]
["D0470",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diagnostic casts",171.2,171.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,6]
["D0482",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Direct immunofluorescence","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,6]
["D0606",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Molecular testing for a public health related pathogen, including coronavirus","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,6]
["D0707",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intraoral periap radio image",47.2,47.2,0,0,0,0,1,0,0,0,0,0,null,"F",null,null,2,6]
["D1320",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tobacco counseling","Bundled","Bundled",0,0,0,0,0,0,0,0,0,0,null,"B",null,null,2,6]
["D1526",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Remove bilat space main, max",556,556,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D1552",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Recement space maint - man","Not Covered","Not Covered",0,0,0,0,5,0,0,0,0,0,null,"X",null,null,2,6]
["D1703",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Moderna Covid-19 vaccine administration - first dose","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,6]
["D2161",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amalgam 4 or > surfaces perm",368.8,368.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,6]
["D2530",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental inlay metl 3/more sur","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,6]
["D2620",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inlay porcelain/ceramic 2 su","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,6]
["D2712",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crown 3/4 resin-based compos",1252,1252,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D2721",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crown resin w/ base metal",1268.8,1268.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D2920",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Re-cement or re-bond crown",158.4,158.4,0,0,0,0,5,0,0,0,0,0,null,"F",null,null,2,6]
["D2929",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prefab porc/ceram crown pri",524,524,0,0,0,0,5,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D2950",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Core build-up incl any pins",350.4,350.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,6]
["D2975",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Coping",764,764,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D2990",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Resin infiltration of lesion",246.4,246.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D3310",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"End thxpy, anterior tooth",978.4,978.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,6]
["D3410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Apicoectomy - anterior",943.2,943.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,6]
["D3431",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Biological materials",695.2,695.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D3473",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surg rep root res molar",988.8,988.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,6]
["D4230",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ana crown exp 4 or> per quad",1158.4000000000001,1158.4000000000001,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,6]
["D4241",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gngvl flap w rootplan 1-3 th",809.6,809.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D4274",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mesial/distal wedge proc",844.8,844.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D4286",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Remove non-resorb barrier",616.79999999999995,616.79999999999995,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D5110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dentures complete maxillary",2402.4,2402.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D5223",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Immed max part dent metal",2245.6,2245.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,6]
["D5410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dentures adjust cmplt maxil",120.8,120.8,0,0,0,0,5,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D5640",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Replace part denture teeth",260.8,260.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D5670",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Replc tth&acrlc on mtl frmwk",932.8,932.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D5731",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Denture reln cmplt mand chr",490.4,490.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D5850",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Denture tiss conditn maxill",278.39999999999998,278.39999999999998,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D5876",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Add metal sub to acrylc dent",647.20000000000005,647.20000000000005,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D5924",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cranial prosthesis","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,6]
["D5932",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Postsurgical obturator",6394.4,6394.4,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D5958",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intraoral con def inter plt","By Report","By Report",0,0,0,0,0,0,0,0,0,0,null,"N",null,"Y-CM",2,6]
["D5996",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Peri medicament w/seal, mand",567.20000000000005,567.20000000000005,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-ONC",2,6]
["D6050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Odontics transosteal implnt",6477.6,6477.6,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D6061",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Abutment supported mtl crown",1648.8,1648.8,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D6069",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Abutment supported retainer",1724,1724,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D6076",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant supported retainer",1884.8,1884.8,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D6092",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Recement supp crown",202.4,202.4,0,0,0,0,0,9,9,9,9,9,null,"F",null,null,2,6]
["D6099",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Imp retainer for fpd",1904.8,1904.8,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-ONC",2,6]
["D6113",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Imp/abut rem dent part mand",3677.6,3677.6,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,6]
["D6180",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implnt maint proced","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,6]
["D6199",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant procedure",1036.8,1036.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D6211",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bridge base metal cast",1359.2,1359.2,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D6602",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cst hgh nble mtl inlay 2 srf","Not Covered","Not Covered",0,0,0,0,0,9,9,9,9,9,null,"X",null,null,2,6]
["D6605",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cst bse mtl inlay >= 3 surfa","Not Covered","Not Covered",0,0,0,0,0,9,9,9,9,9,null,"X",null,null,2,6]
["D6634",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onlay titanium","Not Covered","Not Covered",0,0,0,0,0,9,9,9,9,9,null,"X",null,null,2,6]
["D6780",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crown 3/4 high noble metal",1399.2,1399.2,0,0,0,0,0,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D6920",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental connector bar",1295.2,1295.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D7240",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Impact tooth remov comp bony",617.6,617.6,0,0,0,0,0,9,9,9,9,9,null,"F",null,null,2,6]
["D7261",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Primary closure sinus perf",989.6,989.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,6]
["D7282",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mobilize erupted/malpos toot","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,6]
["D7299",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rem anchorage device w/flap","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,6]
["D7411",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Excision benign lesion>1.25c",856.8,856.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D7450",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rem odontogen cyst to 1.25cm",807.2,807.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D7473",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Remove torus mandibularis",1113.5999999999999,1113.5999999999999,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D7640",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Clsd red simpl mandible fx",4087.2,4087.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D7750",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Open red comp malar/zygma fx",5144.8,5144.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D7830",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tmj manipulation under anest",1225.5999999999999,1225.5999999999999,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D7873",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tmj arthroscopy lysis adhesn",5124.8,5124.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D7910",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dent sutur recent wnd to 5cm",376,376,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,6]
["D7920",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental skin graft",3255.2,3255.2,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,6]
["D7945",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bone cutting body mandible",8707.2000000000007,8707.2000000000007,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D7961",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Buccal/labial frenectomy","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2,6]
["D7991",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dental coronoidectomy",4780,4780,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D8040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Limited dental tx adult",4132.8,4132.8,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D8671",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Periodic orth treat w surg","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,6]
["D8695",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Remove fixed ortho appliance",354.4,354.4,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,6]
["D9219",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eval mod/deep sed/gen anest",131.19999999999999,131.19999999999999,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,6]
["D9230",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Analgesia",115.2,115.2,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,6]
["D9612",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Thera par drugs 2 or > admin",224,224,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,6]
["D9938",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fab removable appliance",432,432,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,6]
["D9945",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Occ guard, soft, full arch",644.79999999999995,644.79999999999995,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D9952",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Complete occlusal adjustment",800.8,800.8,0,0,0,0,0,0,0,0,0,0,null,"F",null,"Y-CM",2,6]
["D9959",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Unspec sleep ap proc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,6]
["D9987",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cancelled appointment","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,6]
["E0114","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Crutch underarm pair no wood",62.79,62.79,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0118",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Crutch substitute",801.43,801.43,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0147","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Walker variable wheel resist",623.5,623.5,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0153","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Forearm crutch platform atta",96.92,96.92,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0157","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Walker crutch attachment",8.4600000000000009,8.4600000000000009,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0168","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Heavyduty/wide commode chair",185.1,185.1,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0184","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Dry pressure mattress",245.45,245.45,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0187","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Water pressure mattress",306.74,306.74,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0199","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Dry pressure pad for mattres",43.08,43.08,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0202",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Phototherapy light w/ photom","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E0225",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hydrocollator unit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E0246",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transfer tub rail attachment",72.849999999999994,72.849999999999994,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0260","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hosp bed semi-electr w/ matt",1266.04,1276.04,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["E0265","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hosp bed total electr w/ mat",212.04,213.04,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["E0280","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Bed cradle",44.3,44.3,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0291","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hosp bed fx ht w/o rail w/o",628.32000000000005,638.32000000000005,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["E0296","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hosp bed total elect w/ matt",170.45,171.45,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["E0303","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hosp bed hvy dty xtra wide",294.45999999999998,295.45999999999998,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["E0352","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Disposable pack w/bowel syst","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["E0371","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Nonpower mattress overlay",399.51,400.51,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0440",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oxygen system liquid station","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E0446","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Topical ox deliver sys, nos","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["E0466","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Home vent non-invasive inter",11449.46,11449.46,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0471","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Rad w/backup non inv intrfc",5727.91,5737.91,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["E0491",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oral dv nm mouthpc hw remote","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["E0560","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Humidifier supplemental w/ i",208.6,208.6,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0580","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Nebulizer for use w/ regulat",163.04,163.04,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0600","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Suction pump portab hom modl",646.1,656.1,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0616","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Cardiac event recorder","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["E0620","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Cap bld skin piercing laser",123.37,123.37,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0635","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Patient lift electric",436.29,436.29,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["E0639","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Moveable patient lift system","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["E0655","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pneumatic appliance half arm",15.33,15.33,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0657","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Segmental pneumatic chest",766.09,766.09,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0669","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Seg pneumatic appli half leg",258.69,258.69,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0673","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pressure pneum appl half leg",378.42,378.42,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0691",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Uvl pnl 2 sq ft or less","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E0715",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intravag pelvic floor kegel","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E0737",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transcut tibial stim by app","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E0746","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Electromyograph biofeedback","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL",2,7]
["E0762",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Trans elec jt stim dev sys","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E0767",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intrabuc am rf emf cancer tx","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E0786","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Implantable pump replacement",11269.31,11269.31,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["E0840","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Tract frame attach headboard",23.04,23.04,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0850","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Traction stand free standing",148.24,148.24,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0890","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Traction frame attach pelvic",46.34,46.34,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0941",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gravity assisted traction de","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E0948","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Fracture frame attachmnts ce",82.75,82.75,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0956","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"W/c lateral trunk/hip suppor",11.05,11.05,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0966","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair head rest extensi",97.27,97.27,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0970","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair no. 2 footplates",56.03,56.03,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["E0973","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"W/ch access det adj armrest",94.76,94.76,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E0983","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Add pwr joystick",352.69,353.69,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["E0988","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Lever-activated wheel drive",3807.02,3807.02,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E1003","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwr seat recline",533.79,534.79,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["E1008","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwr seat combo pwr shear",1035.1099999999999,1035.1099999999999,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["E1017","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hd shck absrbr for hd man wc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["E1020","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Residual limb support system",26.67,26.67,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E1037",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Transport chair, ped size","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E1039","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Transport chair pt wt >300lb",45.93,46.93,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E1083","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Hemi-wheelchair fixed arms",1111.0999999999999,1121.0999999999999,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["E1093","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair wide w/ foot rest",1559.64,1569.64,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["E1130","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Whlchr stand fxd arm ft rest",78.45,78.45,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["E1161","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Manual adult wc w tiltinspac",3338.86,3348.86,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["E1171","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair amputee w/o leg r",113.1,114.1,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["E1222","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair spec size w/ leg",95.64,96.64,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["E1228","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair spec sz spec ht b",39.03,39.03,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["E1230","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Power operated vehicle",3191.79,3191.79,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["E1239",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped power wheelchair nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E1285","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair heavy duty fixed",166.98,166.98,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["E1297","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Wheelchair special seat dept",16.399999999999999,16.399999999999999,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E1358","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Dc power adapter, port conc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL",2,7]
["E1520","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Heparin infusion pump","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["E1600","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Deli/install chrg hemo equip","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["E1635","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Compact travel hemodialyzer","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["E1639","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Scale, each","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["E1802","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Adjst forearm pro/sup device",461.19,461.19,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E1814",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adjust knee flexion device","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC",2,7]
["E1829",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adjust toe flexion device","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-ONC",2,7]
["E1840","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Adj shoulder ext/flex device",540.08000000000004,540.08000000000004,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2203","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Frame depth less than 22 in",614.13,614.13,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2206","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Man wc whl lock comp repl ea",5.36,5.36,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2209","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Arm trough each",12.02,12.02,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2219","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Foam caster tire any size ea",56.12,56.12,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2227","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Gear reduction drive wheel",2640.04,2650.04,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2295",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped dynamic seating frame","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["E2312","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Mini-prop remote joystick",2845.68,2855.68,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2325","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sip and puff interface",1637.82,1647.82,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2329","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Head control nonproportional",214.81,215.81,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2343","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"W/c dpth 22-25 in seat frame",1011.5,1011.5,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2363","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Gr24 sealed leadacid battery",208.94,208.94,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2366","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Battery charger, single mode",263.38,263.38,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2368","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwr wc drivewheel motor repl",58.33,58.33,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2375","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Non-expandable controller",96.54,96.54,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2382","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Tube, pneum wheel drive tire",23.84,23.84,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2388","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Foam drive wheel tire",59.9,59.9,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2395","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Caster wheel excludes tire",61.84,61.84,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2397","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc acc, lith-based battery",58.45,58.45,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2510","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sgd w multi methods msg/accs",955.11,955.11,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2599","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Sgd accessory noc","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,7]
["E2607","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Skin pro/pos wc cus wd <22in",310.14,310.14,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2616","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pos back post/lat wdth>=22in",682.76,682.76,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E2624","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Adj skin pro/pos cus<22in",397.49,397.49,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["E8001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Upright gait trainer","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["G0023",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pin service 60m per month","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0033",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"2+ benzo seiz","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0043",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt mech pros ht valv","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0053",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adv rheum pt care mvp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0057",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Best pct pt safety em mvp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0077",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Care manag h vst new pt 30 m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0081",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Care man h v ext pt 20 mi","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0103",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Psa screening",27.23,27.23,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2]
["G0128",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Corf skilled nursing service","Not Covered","Not Covered",0,0,0,0,3,0,0,0,0,0,null,"X",null,null,2]
["G0138",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Iv cipaglucosidase alfa-atga","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0155",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hhcp-svs of csw,ea 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0162",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hhc rn e&m plan svs, 15 min",47.53,47.53,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,28]
["G0177",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Opps/php; train & educ serv","Facility Only","Facility Only",0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["G0204",26,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Dx mammo incl cad bi",100.44,100.44,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2]
["G0239",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oth resp proc, group",25.08,25.08,0,0,0,0,5,0,0,0,0,0,null,"R",null,null,2]
["G0252",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pet imaging initial dx","Not Covered","Not Covered",0,0,0,0,1,9,9,9,9,9,null,"X",null,null,2]
["G0260",null,{"$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]
["G0293",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non-cov surg proc,clin trial","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0316",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prolong inpt eval add15 m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0327",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Colon ca scrn;bld-bsd biomrk","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0364",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bone marrow aspirate &biopsy",26.01,18.059999999999999,0,0,0,0,9,9,9,9,9,9,null,"F",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]
["G0416",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prostate biopsy, any mthd","Not Covered","Not Covered",0,0,0,0,1,0,0,0,0,0,null,"X",null,null,2]
["G0420",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ed svc ckd ind per session",193.66,193.66,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2]
["G0436",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tobacco-use counsel 3-10 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0442",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Annual alcohol screen 15 min","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0464",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Colorec ca scr, sto bas dna","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0467",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fqhc visit, estab pt","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0494",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lpn care ea 15min hh/hospice","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0501",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Resource-inten svc during ov","Bundled","Bundled",0,0,0,0,0,0,0,0,0,0,null,"B",null,null,2]
["G0514",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prolong prev svcs, addl 30m",112.58,104.41,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
["G0528",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mgt est pt dem mod-hi cmplx","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0535",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt navigat svs direct/ref","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G0547",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Phone/internet svs 11-20 m","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0557",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adv prim care mgmt lvl 2","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G0558",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adv prim care mgmt lvl 3","Not Covered","Not Covered",0,0,0,0,0,0,0,0,0,0,null,"X",null,null,2]
["G1028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Take home supply 8mg per 0.1","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"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]
["G2020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hi inten serv for sip model","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2074",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med assist tx no drug","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2082",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Visit esketamine 56m or less",1601.74,61.83,0,0,0,0,0,0,0,0,0,0,null,"R",null,"Y-CM",2]
["G2106",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt 66+ lt ints > 90","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2121",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Psy dep anx ap and icd asse","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2128",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No aspirin med rsn","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2149",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No mpm med rsn","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2152",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Res change sc =0","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2179",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med doc rsn no low ex","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2188",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt 50 yrs w/clin ind hd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2202",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No rsn no brief couns","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G2207",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rsn no trtmt chem her2","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G4001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Diagnostic rad ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G4004",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Endocrinology ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G4014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nephrology ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G4024",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pediatric ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G4036",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Urgent care ss","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G6002","TC",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Stereoscopic x-ray guidance",103.83,103.83,0,0,0,0,1,0,0,0,0,0,null,"R",null,"Y-CM",2]
["G6014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Radiation treatment delivery",419.98,419.98,0,0,0,0,3,0,0,0,0,0,null,"R",null,"Y-CM",2]
["G8396",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lvef not performed","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8417",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Calc bmi abv up param f/u","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8430",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ec at doc medrec pt not elig","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8535",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eld maltreatment not doc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8543",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cur funct asses; no care pln","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8568",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt no ref otolo no spec","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8598",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Asa/antiplat ther used","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8654",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rafs crs hi no scor no surv","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8663",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Rafscrs si scor >= 0","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8711",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pres antibiotic","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8749",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No signs melanoma","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8807",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No ta tv ultrasnd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8816",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Statin med pres at disch","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8844",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No ahi or rdi initial dx","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8857",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No elig ref for oto eval","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8880",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sen lym p node biop not perf","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8912",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt doc with wrong event","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8937",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No rx ace/arb therapy","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G8946",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mibm but no dx of breast ca","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mccd, risk adj hi, initial","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9009",null,{"$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]
["G9059",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc prac mgmt pt opt alterna","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9066",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx nsclc stg3b-4 metasta","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9075",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx brst metastic/ recur","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9085",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx colon t4, n0 w/o prog","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9098",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx esophageal mets recur","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9105",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx pancreatc p r0 res no","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9117",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx ovarian unknown nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9133",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Onc dx prostate clinical met","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9156",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Evaluation for wheelchair","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9188",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Beta not given no reason","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9247",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"1 med visit in 24mo","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9274",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bp out of nrml limits","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9286",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Antibio rx w in 10d of sympt","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9295",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Non cutaneous loc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9311",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No surg site infection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9314",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Norsn not first line amox","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9353",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Medrsn >1 sinus ct w 90d dx","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9358",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pp eval/edu not perf","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9394",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dx bipol, death, nhres, hosp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9417",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt not 1 tdap betw 10-13 yrs","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9425",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spec rpt no doc class histo","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9432",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Asth controlled","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9478",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Othe therapist at hospice","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9480",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Admission to mccm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9515",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No reas, no ret or w/in 90d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9516",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Impr vis acuit w/in 90d","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9533",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Indic for head ct not valid","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9551",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Imag no les","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9580",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Door to punc time <2hrs","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9608",null,{"$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]
["G9630",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt no bwli srg 30 day srg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9643",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Elective surgery","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9664",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Taking statin or rec'd order","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9674",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt w/clin ascvd dx","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9702",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt use hosp during msmt per","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9706",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Low recur prost ca","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9721",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt not ambul/immob/wc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9724",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt w/doc use anticoag mst yr","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9746",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mit sten, valve or trans af","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9754",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Incid pulm nodule","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9765",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc pat declined therapy","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9777",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt no antiemet pre/intraop","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9786",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Path report not sent","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9797",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt currently on statin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9831",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ajcc stg brt ca dx ii or iii","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9843",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Kras or nras gene mutation","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9860",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt less 3d hospice","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9884",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"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]
["G9899",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Scrn mam perf rslts doc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9905",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No pt tbco scrn rng","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9913",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No hbv status assesd and int","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9930",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Com care","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9956",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Combo thrpy of >= 2 prophly","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9965",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No well-chld vist recv by pt","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["G9996",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc pt pal or hospice","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H0001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol and/or drug assess","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["H0017",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol and/or drug services","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["H0020",null,{"$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]
["H0030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol and/or drug hotline","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H0040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Assert comm tx pgm per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H0047",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alcohol/drug abuse svc nos","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,17]
["H1005",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prenatalcare enhanced srv pk","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["H2018",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Psysoc rehab svc, per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H2025",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Supp maint employ, 15 min","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["H2034",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"A/d halfway house, per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,27]
["J0120",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tetracyclin injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J0133",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Acyclovir injection",0.04,0.04,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0178",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Aflibercept injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J0190",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj biperiden lactate/5 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J0217",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj velmanase alfa-tycv 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J0270",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Alprostadil for injection",9.68,9.68,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0287",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amphotericin b lipid complex",10.3,10.3,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0364",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Apomorphine hydrochloride",38.46,38.46,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J0456",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Azithromycin",2.2200000000000002,2.2200000000000002,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0461",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Atropine sulfate injection",0.11,0.11,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0558",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Peng benzathine/procaine inj",17.37,17.37,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0583",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bivalirudin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J0593",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj., lanadelumab-flyo, 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J0605",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sucroferric oxyhydroxide 5mg","By report","By report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,12]
["J0616",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj metoprolol tartrate 1 mg","By report","By report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,12]
["J0652",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, levothyroxine, hikma",5.14,5.14,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0690",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cefazolin sodium injection",0.83,0.83,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0702",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Betamethasone acet&sod phosp",6.85,6.85,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0714",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ceftazidime and avibactam",100.5,100.5,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0736",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, clindamycin phosp 300mg",1.61,1.61,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0799",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hiv prep, fda approved, noc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["J0873",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, daptomycin (xellia)",0.03,0.03,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0882",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Darbepoetin alfa, esrd use",2.92,2.92,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J0896",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj luspatercept-aamt 0.25mg",41.24,41.24,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2,12]
["J1000",null,{"$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,2,12]
["J1071",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj testosterone cypionate",0.03,0.03,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J1160",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Digoxin injection",4.88,4.88,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J1205",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Chlorothiazide sodium inj",32.479999999999997,32.479999999999997,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J1299",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, eculizumab, 2 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["J1324",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Enfuvirtide injection",0.66,0.66,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J1410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj estrogen conjugate 25 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J1436",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Etidronate disodium inj","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J1447",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj tbo filgrastim 1 microg",0.37,0.37,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J1449",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj eflapegrastim-xnst 0.1mg",22.61,22.61,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J1551",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj cutaquig 100 mg",14.34,14.34,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J1571",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hepagam b im injection",65.150000000000006,65.150000000000006,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J1576",null,{"$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]
["J1600",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gold sodium thiomaleate inj","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J1628",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj., guselkumab, 1 mg",70.430000000000007,70.430000000000007,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J1729",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj hydroxyprogst capoat nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J1744",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Icatibant injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J1748",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, zymfentra, 10 mg","By report","By report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["J1813",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lyumjev for insulin pump use",15.33,15.33,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2,12]
["J1833",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, isavuconazonium",0.99,0.99,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J1939",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, bumetanide, 0.5 mg",0.56999999999999995,0.56999999999999995,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J1956",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Levofloxacin injection",1.03,1.03,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J2062",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Loxapine for inhalation 1 mg",15,15,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J2184",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, meropenem (b. braun)",2.09,2.09,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J2265",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Minocycline hydrochloride",2.59,2.59,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J2272",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, morphine (fresenius)",6.64,6.64,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J2312",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj naloxone hcl nos, 0.01mg","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["J2353",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Octreotide injection, depot",204.59,204.59,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J2402",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Chloroprocaine (clorotekal)","By report","By report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,12]
["J2410",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oxymorphone hcl injection",2.85,2.85,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J2502",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, pasireotide long acting",526.94000000000005,526.94000000000005,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J2547",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, peramivir",1.68,1.68,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J2561",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, sezaby, 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["J2670",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Totazoline hcl injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J2778",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ranibizumab injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J2785",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Regadenoson injection",4.41,4.41,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J2799",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, uzedy, 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["J2820",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sargramostim injection",59.88,59.88,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J2993",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Reteplase injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J3101",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tenecteplase injection",162.46,162.46,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J3240",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Thyrotropin injection",2078.71,2078.71,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J3260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tobramycin sulfate injection",1.6,1.6,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J3305",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj trimetrexate glucoronate","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J3316",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj., triptorelin xr 3.75 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J3385",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Velaglucerase alfa","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J3397",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj., vestronidase alfa-vjbk","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J3465",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, voriconazole",1.06,1.06,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J3485",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Zidovudine",1.51,1.51,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J7050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Normal saline solution infus",0.62,0.62,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J7100",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dextran 40 infusion",26.66,26.66,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J7178",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj human fibrinogen con nos",1.48,1.48,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J7186",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Antihemophilic viii/vwf comp",1.2,1.2,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J7198",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Anti-inhibitor",2.4,2.4,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J7209",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Factor viii nuwiq recomb 1iu",1.19,1.19,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J7298",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mirena, 52 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J7309",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Methyl aminolevulinate, top","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,12]
["J7323",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Euflexxa inj per dose","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,12]
["J7327",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Monovisc inj per dose","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,"Y-CM",2,12]
["J7500",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Azathioprine oral 50mg",1.01,1.01,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J7510",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prednisolone oral per 5 mg",0.48,0.48,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J7521",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tacrolim granules oral susp",1.33,1.33,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2]
["J7599",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Immunosuppressive drug noc","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,12]
["J7622",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Beclomethasone comp unit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J7629",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bitolterol mesylate comp unt","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J7642",null,{"$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,2,12]
["J7665",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mannitol for inhaler","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J7680",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Terbutaline sulf comp con","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J7683",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Triamcinolone comp con",0.56000000000000005,0.56000000000000005,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J8540",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oral dexamethasone",0.06,0.06,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["J8600",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Melphalan oral 2 mg",9.16,9.16,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9017",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Arsenic trioxide injection",4.79,4.79,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9029",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, adstiladrin, per tx dos",63235.61,63235.61,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2,12]
["J9041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj., velcade 0.1 mg",2.5,2.5,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2,12]
["J9045",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Carboplatin injection",2.93,2.93,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9071",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj cyclophosphamd auromedic",0.87,0.87,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9074",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, cyclophosphamd, sandoz","Facility Only",4.34,0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2,12]
["J9165",null,{"$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",2,12]
["J9185",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fludarabine phosphate inj",59.53,59.53,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9202",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Goserelin acetate implant",705.14,705.14,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9209",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mesna injection",1.36,1.36,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9215",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Interferon alfa-n3 inj",8.6,8.6,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9246",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj., evomela, 1 mg",18.5,18.5,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2,12]
["J9269",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj. tagraxofusp-erzs 10 mcg",338.53,338.53,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9272",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, dostarlimab-gxly, 10 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J9299",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, nivolumab","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J9303",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Panitumumab injection","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J9313",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj., lumoxiti, 0.01 mg",23.39,23.39,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9325",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj talimogene laherparepvec",70.38,70.38,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9348",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj. naxitamab-gqgk, 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["J9360",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vinblastine sulfate inj",5.14,5.14,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9390",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Vinorelbine tartrate inj",6.59,6.59,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["J9395",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, fulvestrant","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["K0003","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Lightweight wheelchair",863.45,873.45,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["K0008","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Cstm manual wheelchair/base","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["K0012","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Ltwt portbl power whlchr",4585.1000000000004,4585.1000000000004,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["K0017","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Detach adjust armrest base",6.01,6.01,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["K0041","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Large size footplate each",61.93,61.93,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["K0044","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Ftrst upr hanger brac rep ea",2.0299999999999998,2.0299999999999998,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["K0050","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Ratchet assembly replacement",39.229999999999997,39.229999999999997,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["K0056","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Seat ht <17 or >=21 ltwt wc",12.82,12.82,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["K0455","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pump uninterrupted infusion",373.76,373.76,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["K0602","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Repl batt silver oxide 3 v",8.85,8.85,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["K0609",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Repl electrode for aed","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["K0746","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Absorp drg >48 suc pump","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["K0814","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 1 std port cap chair",4626.1000000000004,4636.1000000000004,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["K0822","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 2 std seat/back",5640.75,5650.75,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["K0828","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 2 xtra hd seat/back",12303.32,12313.32,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["K0831","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp2 std seat elevate cap","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,7]
["K0841","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp2 std mult pow opt s/b",6429.56,6439.56,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["K0842","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp2 std mult pow opt cap",642.59,643.59,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["K0851","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 3 hd cap chair",10752.76,10762.76,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["K0856","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp3 std sing pow opt s/b",1034.8499999999999,1035.8499999999999,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["K0862","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp3 hd mult pow opt s/b",1283.95,1284.95,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["K0868","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp 4 std seat/back","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,7]
["K0880","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp4 vhd sing pow opt s/b","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,7]
["K0890","NU",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Pwc gp5 ped sing pow opt s/b","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["K1004","RR",{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"Y"},"Lo freq us diathermy device","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["L0113",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cranial cervical torticollis",421.55,421.55,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L0172",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cerv col sr foam 2pc pre ots",186.91,186.91,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L0462",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tlso 3mod sacro-scap pre",1776.67,1776.67,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L0486",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tlso rigidlined cust fab two",2570.19,2570.19,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L0623",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sio rig pnl pelv/sac pre ots",206.68,206.68,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L0634",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lso flexion control custom",1107.99,1107.99,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L0643",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lso sag ctr rigi pos pre ots",189.34,189.34,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L0861",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Halo repl liner/interface",306.69,306.69,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L0984",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Protect body sock ea pre ots",93.22,93.22,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L1001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ctlso infant immobilizer","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["L1085",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Outrigger bil w/ vert extens",224.02,224.02,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L1290",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lateral trochanteric pad",109.44,109.44,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L1610",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ho frejka cov only pre cst",59.85,59.85,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L1690",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Combination bilateral ho",2751.61,2751.61,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L1812",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ko elastic w/joints pre ots",128.19999999999999,128.19999999999999,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L1846",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ko w adj flex/ext rotat mold",1742.86,1742.86,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L1850",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ko swedish type pre ots",367.25,367.25,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L1930",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Afo plastic",376.62,376.62,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L1952",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Afo spiral prefab ots",1195.02,1195.02,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2]
["L2005",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Kafo sng/dbl mechanical act",5830.78,5830.78,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L2090",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hkafo unilat torsion ball br",796.99,796.99,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L2136",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Kafo femoral fx cast rigid",1612.1,1612.1,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L2192",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pelvic band & belt thigh fla",486.04,486.04,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L2280",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Molded inner boot",618.20000000000005,618.20000000000005,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L2330",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lacer molded to patient mode",633.28,633.28,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L2380",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Torsion straight knee joint",170.85,170.85,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L2550",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Thigh/wght bear high roll cu",427.17,427.17,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L2580",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pelvic control pelvic sling",747.7,747.7,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L2670",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Thorac cont paraspinal uprig",240.39,240.39,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L2768",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ortho sidebar disconnect",185.37,185.37,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L3003",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Foot insert silicone gel eac",247.98,247.98,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L3140",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Abduction rotation bar shoe",126.7,126.7,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L3204",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hightop w/ supp/pronator inf","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["L3208",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surgical boot each infant","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["L3224",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Woman's shoe oxford brace",80.16,80.16,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L3320",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoe lift elev heel/sole cor",211.42,211.42,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L3360",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoe sole wedge outside sole",50.67,50.67,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L3465",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoe heel thomas with wedge",83.22,83.22,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L3570",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"O shoe add instep extension",121.3,121.3,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L3649",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Orthopedic shoe modifica nos","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,7]
["L3677",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"So hard plas stabili pre cst",218.71,218.71,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L3710",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eo elas w/metal jnts pre ots",164.9,164.9,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L3808",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Whfo, rigid w/o joints",466.65,466.65,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L3906",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Who w/o joints cf",552.79999999999995,552.79999999999995,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L3921",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hfo w/joint(s) cf",415.97,415.97,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L3973",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sewho airplane w/jnt(s) cf",2568.83,2568.83,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L3982",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Upper ext fx orthosis rad/ul",497.98,497.98,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L4010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Replace trilateral socket br",1091.03,1091.03,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L4205",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ortho dvc repair per 15 min",51.73,51.73,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L4360",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pneumat walking boot pre cst",503.26,503.26,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L5010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mold socket ank hgt w/ toe f",1841.15,1841.15,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Kne sing axis fric shin sach",6160.29,6160.29,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5400",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Postop dress & 1 cast chg bk",2022.4,2022.4,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5460",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Postop app non-wgt bear dsg",883.45,883.45,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5610",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Above knee hydracadence",4016.91,4016.91,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5628",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Test socket hemipelvectomy",914.33,914.33,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5630",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Syme typ expandabl wall sckt",765.92,765.92,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5642",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Above knee leather socket",1249.3,1249.3,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5654",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Socket insert symes",585.91,585.91,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5670",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bk molded supracondylar susp",447.93,447.93,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5684",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bk fork strap",97.06,97.06,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5695",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ak sleeve susp neoprene/equa",246.62,246.62,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5705",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom shape cover ak",1514,1514,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L5782",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hd low limb pros vacuum pump",6262.35,6262.35,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5812",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Endo knee-shin frct swg & st",954.55,954.55,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5827",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Endo knee shin single axis",8528.1299999999992,8528.1299999999992,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2]
["L5856",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Elec knee-shin swing/stance",35639.760000000002,35639.760000000002,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5926",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Endoskel posit rotat unit",1092.5,1092.5,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L5972",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flexible keel foot",592.84,592.84,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L5980",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flex foot system",6130.9,6130.9,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L6010",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Part hand little/ring",2981.49,2981.49,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L6050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Wrst mld sck flx hng tri pad",3283.33,3283.33,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L6310",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoulder passive restor comp",5833.18,5833.18,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L6360",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Thoracic passive restor comp",6422.61,6422.61,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L6580",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Wrist/elbow bowden cable mol",2724.21,2724.21,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L6610",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Flexible metal hinge pair",264.45999999999998,264.45999999999998,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L6632",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Latex suspension sleeve each",98.25,98.25,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L6647",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Shoulder lock actuator",770.87,770.87,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L6680",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Test sock wrist disart/bel e",359.76,359.76,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L6695",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Elbow socket ins use w/o lck",902.71,902.71,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L6704",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Term dev, sport/rec/work att",947.72,947.72,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L6711",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ped term dev, hook, vol open","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["L6895",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Custom glove for term device",937.6,937.6,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L6935",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Below elbow myoelectronic ct",13493.87,13493.87,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L6975",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Interscap-thor myoelectronic",24167.32,24167.32,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L7180",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Electronic elbow sequential",55407.35,55407.35,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-CM",2,7]
["L7401",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Add ue prost a/e ultlite mat",509.42,509.42,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L7499",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Upper extremity prosthes nos","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N","Y","Y-CM",2,7]
["L8030",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Breast prosthes w/o adhesive",477.1,477.1,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L8045",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Auricular prosthesis",3913.14,3913.14,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L8400",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sheath below knee",28.07,28.07,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L8417",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pros sheath/sock w gel cushn",111.66,111.66,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["L8511",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Indwelling trach insert",107.98,107.98,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,7]
["L8514",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Repl trach puncture dilator",139.97,139.97,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,7]
["L8613",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ossicular implant",455.2,455.2,0,0,0,0,9,9,9,9,9,9,null,"F","Y",null,2,7]
["L8624",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lith ion batt cid, ear level",239.43,239.43,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-PHL",2,7]
["L8659",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Interphalangeal joint repl",2864.86,2864.86,0,0,0,0,9,9,9,9,9,9,null,"F","Y","Y-UR",2,7]
["L8679",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Imp neurosti pls gn any type","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,7]
["L8695",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"External recharg sys extern",24.71,24.71,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["L8701",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pow ue rom dev ewh uprt cust",43198.39,43198.39,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,7]
["M0222",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bebteleovimab injection","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2]
["M0301",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fabric wrapping of aneurysm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1009",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dc eoc doc med rec","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1018",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt dx hst cr pt sk lg cr scr","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1041",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt cr ft inf lm or pt id sl","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1043",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fs no odi 9-15mo","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1070",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt not scrn fut fall no rsn","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1107",null,{"$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]
["M1125",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oc ni pt selfdc 1-2 vis","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1128",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"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]
["M1141",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fs no oks","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1159",null,{"$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]
["M1171",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1176",null,{"$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]
["M1191",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"No neck fs prom incap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1194",null,{"$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]
["M1211",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hemoglobin a1c level >9.0%","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1214",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Spiro results wth obs doc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1227",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eb therapy prescribed","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1231",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt hcv tst no reactive res","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1247",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt resp true best int","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1254",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pts deceased prior hu surv","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt no kd trnsplt wtlst lv do","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1271",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pts dem any time/dur mo","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1287",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Calc bmi blw low param f/u","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1290",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt not eli d/t act dig htn","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1303",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospc serv dur meas pd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1310",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt scr tob & cess int","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1319",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pts csp doc contact","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1330",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doc pts rsn no f/u xm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1342",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pts died perf per","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1348",null,{"$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]
["M1362",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt died dur meas pd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1365",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hosp+pall care spec code 17","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1377",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fu colscop 10 yr doc w/ disc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1385",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt rsn not seen 2nd pam","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1398",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bslne and  fu promis doc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1403",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bslne and fu promis doc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1418",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med rsn not up to date cov","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["M1421",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dermatological care mvp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["P3001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Screening pap smear by phys",46.08,46.08,0,0,0,0,0,0,0,0,0,0,null,"R",null,null,2]
["P9021",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Red blood cells unit",144.32,144.32,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["P9032",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Platelets, irradiated",135.78,135.78,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["P9046",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Albumin (human), 25%, 20 ml",21.23,21.23,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["P9059",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Plasma, frz between 8-24hour",71.09,71.09,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["P9603",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"One-way allow prorated miles",1.19,1.19,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2]
["Q0085",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Chemo by both infusion and o","Facility Only",0,0,0,0,0,9,9,9,9,9,9,null,"O",null,null,2]
["Q0114",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fern test",13.73,13.73,0,0,0,0,9,9,9,9,9,9,null,"L",null,null,2]
["Q0177",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hydroxyzine pamoate 25mg",7.0000000000000007E-2,7.0000000000000007E-2,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,12]
["Q0244",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"CASIRIVI AND IMDEVI 1200 MG",0,0,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2,12]
["Q0477",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pwr module pt cable lvad rpl",923.25,923.25,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2]
["Q0489",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pwr pck base combo vad, rep","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,12]
["Q0502",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Mobility cart pneum vad, rep","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q0510",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dispens fee immunosupressive","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q2028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, sculptra, 0.5mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q2050",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Doxorubicin inj 10mg",150.41,150.41,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2]
["Q3027",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj beta interferon im 1 mcg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4001",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup body cast plaster",61.75,61.75,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["Q4013",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup gauntlet plaster",19.88,19.88,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["Q4021",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup sht arm splint plst",8.5,8.5,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["Q4033",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup lng leg cylinder pl",34.020000000000003,34.020000000000003,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["Q4042",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cast sup lng leg splnt fbrgl",43.07,43.07,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,7]
["Q4081",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Epoetin alfa, 100 units esrd",0.71,0.71,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,7]
["Q4105",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Integra drt or omnigraft",23.25,23.25,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2,7]
["Q4117",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hyalomatrix","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4124",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Oasis tri-layer wound matrix","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4133",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Grafix stravix prime pl sqcm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4151",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amnioband, guardian 1 sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4159",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Affinity1 square cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4166",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cytal, per square centimeter","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4181",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amnio wound, per square cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4206",null,{"$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]
["Q4220",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bellacell hd, surederm sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4221",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amniowrap2 per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4234",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Xcellerate, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4249",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amniply, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4262",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dual layer impax, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4269",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Surgraft xt per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4282",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Cygnus dual per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4292",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lamellas, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4302",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Complete aca, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4305",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amer am ac tri-lay per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4321",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Renograft, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4325",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Acapatch, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4332",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Axolotl dualgraft, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4340",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Simpligraft, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4357",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Xwrap plus, per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4364",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Am bur xp mem xpl hy p sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4369",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Amnioplast 3 per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q4382",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Advograft dual per sq cm","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q5007",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice in ltch","By report","By report",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,28]
["Q5111",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, udenyca 0.5 mg",163.6,163.6,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["Q5120",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj pegfilgrastim-bmez 0.5mg",24.71,24.71,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-ONC",2]
["Q5134",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj, tyruko, 1 mg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q5143",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj adalimumab-adbm, 1 mg",10.43,10.43,0,0,0,0,9,9,9,9,9,9,null,"D",null,"Y-CM",2]
["Q9002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Va chaplain counsel individu","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["Q9960",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hocm 200-249mg/ml iodine,1ml",0.2,0.2,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["Q9961",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hocm 250-299mg/ml iodine,1ml",0.28999999999999998,0.28999999999999998,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["Q9992",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Buprenorphine xr over 100 mg",1925.23,1925.23,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["R0076",null,{"$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,2,8]
["R0390",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Retraining child care licensd 6 hr/less","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S0080",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Injection, pentamidine iseth","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0119",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ondansetron 4 mg","By report","By report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S0132",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Inj ganirelix acetat 250 mcg","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0174",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dolasetron 50 mg",72.05,72.05,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["S0183",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prochlorperazine 5 mg",0.28999999999999998,0.28999999999999998,0,0,0,0,9,9,9,9,9,9,null,"D",null,null,2]
["S0197",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Prenatal vitamins 30 day","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0255",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hospice refer visit nonmd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0273",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Md home visit outside cap","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0342",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Lifestyle mod 4th stage","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0506",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Bifoc prscp lens","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0595",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"New lenses in pts old frame","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S0622",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Phys exam for college","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S1034",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Art pancreas system","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S1037",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Art pancreas ext receiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S2083",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adjustment gastric band","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S2112",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Knee arthroscp harv","By Report","By Report",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2]
["S2207",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Minimally invasive direct co","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S2266",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Induced abortion 29-31 wks","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S2402",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Fetal surg cong cyst malf","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S3630",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Eosinophil blood count","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S3708",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Gastrointestinal fat absorpt","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S3844",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dna analysis deafness","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S3902",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ballistocardiogram","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S4021",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ivf canc p aspir case rate","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S4031",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Sperm procure subs visit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S4990",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nicotine patch legend","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S5101",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Adult day care per half day","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S5126",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Attendant care service /diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S5145",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Child fostercare th per diem","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S5180",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hh respiratory thrpy in eval","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S5518",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit cath repair kit","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S5522",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hit picc insert no supp","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S8040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Topographic brain mapping","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,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,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Infect control supplies nos","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,28]
["S8415",null,{"$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,2,20]
["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,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Intra-vag motion sens biofk","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2]
["S9007",null,{"$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",43.43,43.43,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,28]
["S9123",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nursing care in home rn",87.29,87.29,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,28]
["S9124",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Nursing care, in the home; b",63.06,63.06,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-ONC",2,28]
["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,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Pt education noc individ",46.69,46.69,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2]
["S9446",null,{"$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,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med record copy admin",30.23,30.23,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2]
["S9982",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Med record copy per page",0.6,0.6,0,0,0,0,9,9,9,9,9,9,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,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Clinic service","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,null,2,26]
["T1016",null,{"$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",50.65,50.65,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2]
["U0002",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Covid-19 lab test non-cdc",72.349999999999994,72.349999999999994,0,0,0,0,9,9,9,9,9,9,null,"L",null,"Y-CM",2]
["V0028",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Travel, vocational services, claimant","State Rate","State Rate",0,0,0,0,9,9,9,9,9,9,null,"S",null,null,2,18]
["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,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing screening",94.02,94.02,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,4]
["V5010",null,{"$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,2,4]
["V5011",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid fitting/checking","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,4]
["V5014",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid repair/modifying",62.69,62.69,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,4]
["V5020",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Conformity evaluation","Bundled","Bundled",0,0,0,0,9,9,9,9,9,9,null,"B",null,null,2,4]
["V5030",null,{"$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",2,4]
["V5040",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Body-worn hearing aid bone","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5050",null,{"$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",2,4]
["V5060",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Behind ear hearing aid","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5070",null,{"$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",2,4]
["V5080",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glasses bone conduction","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5090",null,{"$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,2,4]
["V5095",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Implant mid ear hearing pros","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5100",null,{"$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",2,4]
["V5110",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid dispensing fee","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5120",null,{"$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",2,4]
["V5130",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"In ear binaural hearing aid","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5140",null,{"$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",2,4]
["V5150",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Glasses binaural hearing aid","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5160",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dispensing fee binaural",1780.27,1780.27,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,4]
["V5171",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural ite","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5172",null,{"$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",2,4]
["V5181",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid monaural bte","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5190",null,{"$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",2,4]
["V5200",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disp fee contralateral monau",1067.05,1067.05,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,4]
["V5211",null,{"$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",2,4]
["V5212",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural ite/itc","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5213",null,{"$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",2,4]
["V5214",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural itc/itc","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5215",null,{"$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",2,4]
["V5221",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid binaural bte/bte","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5230",null,{"$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",2,4]
["V5240",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Disp fee contralateral binau",1067.05,1067.05,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,4]
["V5241",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Dispensing fee, monaural",890.13,890.13,0,0,0,0,9,9,9,9,9,9,null,"F",null,"Y-CM",2,4]
["V5242",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, monaural, cic","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5243",null,{"$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",2,4]
["V5244",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, mon, cic","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5245",null,{"$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",2,4]
["V5246",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, mon, ite","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5247",null,{"$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",2,4]
["V5248",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, binaural, cic","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5249",null,{"$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",2,4]
["V5250",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, bin, cic","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5251",null,{"$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",2,4]
["V5252",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, prog, bin, ite","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5253",null,{"$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",2,4]
["V5254",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing id, digit, mon, cic","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5255",null,{"$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",2,4]
["V5256",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, mon, ite","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5257",null,{"$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",2,4]
["V5258",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, bin, cic","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5259",null,{"$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",2,4]
["V5260",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, digit, bin, ite","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-CM",2,4]
["V5261",null,{"$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",2,4]
["V5262",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid, disp, monaural","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5263",null,{"$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,2,4]
["V5264",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ear mold/insert","By Report ","By Report ",0,0,0,0,9,9,9,9,9,9,null,"N",null,"Y-PHL",2,4]
["V5265",null,{"$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,2,4]
["V5266",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Battery for hearing device",1.1000000000000001,1.1000000000000001,0,0,0,0,9,9,9,9,9,9,null,"F",null,null,2,4]
["V5267",null,{"$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",2,4]
["V5268",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald telephone amplifier","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5269",null,{"$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,2,4]
["V5270",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald, tv amplifier, any type","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5271",null,{"$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,2,4]
["V5272",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Tdd","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5273",null,{"$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,2,4]
["V5274",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald unspecified","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5275",null,{"$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,2,4]
["V5281",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm system, monaural","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5282",null,{"$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,2,4]
["V5283",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald neck, loop ind receiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5284",null,{"$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,2,4]
["V5285",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm aud input receiver","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5286",null,{"$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,2,4]
["V5287",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm receiver, nos","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5288",null,{"$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,2,4]
["V5289",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Ald fm/dm adapt/boot couplin","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5290",null,{"$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,2,4]
["V5298",null,{"$f":"IF(Table1[[#This Row],[Modifiers]]<>\"\",\"Y\",\"N\")","v":"N"},"Hearing aid noc","Not Covered","Not Covered",0,0,0,0,9,9,9,9,9,9,null,"X",null,null,2,4]
["V5299",null,{"$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,2,4]
["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",{"$f":"'Lookup Tool'!B5","v":"RR"}]
["TC","No",null,"mod1",""]
[53,null,null,"mod2",{"$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":"RR"}]
["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":35,"n_cols":4,"rows_kept":35,"cut":false,"hidden":true,"merged":[]}
[null,"Chapter number","URL","Friendly Text"]
[null,1,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter1.pdf","Chapter 1: Introduction"]
[null,2,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter2.pdf","Chapter 2: Information for All Providers"]
[null,3,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter3.pdf","Chapter 3: Attending Providers"]
[null,4,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter4.pdf","Chapter 4: Audiology and Hearing"]
[null,5,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter5.pdf","Chapter 5: Care Coordination"]
[null,6,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter6.pdf","Chapter 6: Dental"]
[null,7,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter7.pdf","Chapter 7: Durable Medical Equipment (DME) and Supplies"]
[null,8,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter8.pdf","Chapter 8: Electrodiagnostics and Radiology"]
[null,9,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter9.pdf","Chapter 9: Evaluation and Management (E/M)"]
[null,10,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter10.pdf","Chapter 10: Home and Vehicle Modifications"]
[null,11,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter11.pdf","Chapter 11: Impairment Ratings and Independent Medical Exams (IMEs)"]
[null,12,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter12.pdf","Chapter 12: Injections and Medication Administration"]
[null,13,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter13.pdf","Chapter 13: Laboratory and Pathology Services"]
[null,14,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter14.pdf","Chapter 14: Language Access Services for Spoken Languages"]
[null,15,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter15.pdf","Chapter 15: Lodging, Transportation, and Travel"]
[null,16,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter16.pdf","Chapter 16: Medical Testimony"]
[null,17,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter17.pdf","Chapter 17: Mental Health and Behavioral Health Interventions (BHI)"]
[null,18,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter18.pdf","Chapter 18: Other Services"]
[null,19,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter19.pdf","Chapter 19: Pharmacy"]
[null,20,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter20.pdf","Chapter 20: Physical Medicine"]
[null,21,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter21.pdf","Chapter 21: Reports and Forms"]
[null,22,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter22.pdf","Chapter 22: Resource-based Relative Value Scale (RBRVS)"]
[null,23,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter23.pdf","Chapter 23: Surgery"]
[null,24,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter24.pdf","Chapter 24: Telehealth, Remote, and Mobile Services"]
[null,25,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter25.pdf","Chapter 25: Vocational Services"]
[null,26,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter26.pdf","Chapter 26: Hospitals and Ambulatory Surgical Centers (ASCs)"]
[null,27,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter27.pdf","Chapter 27: Rehabilitation Programs and Facilities"]
[null,28,"https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2025/2025MarfsChapter28.pdf","Chapter 28: Skilled Nursing, Home Health, and Residential Care"]
[]
[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",58.65,58.65,0,0,0,0,0,0,0,0,0,0,null,"F",null,null,2,12]