Description - DE Medical Assistance Program

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D9930 TREATMENT OF COMPLICATIONS 80 D9940 DENTAL OCCLUSAL GUARD 80 D9999 ADJUNCTIVE PROCEDURE 80
Procedure Code Description RVU RVU Coeff Value 00100 ANESTH, SALIVARY GLAND 5 16.05 00102 ANESTH, REPAIR OF CLEFT LIP 6 16.05 00103 ANESTH, BLEPHAROPLASTY 5 16.05 00104 ANESTH, ELECTROSHOCK 4 16.05 00120 ANESTH, EAR SURGERY 4 16.05 00124 ANESTH, EAR EXAM 4 16.05 00126 ANESTH, TYMPANOTOMY 4 16.05 00140 ANESTH, PROCEDURES ON EYE 5 16.05 00142 ANESTH, LENS SURGERY 6 16.05 00144 ANESTH, CORNEAL TRANSPLANT 6 16.05 00145 ANESTH, VITREORETINAL SURG 6 16.05 00147 ANESTH, IRIDECTOMY 4 16.05 00148 ANESTH, EYE EXAM 4 16.05 00160 ANESTH, NOSE/SINUS SURGERY 5 16.05 00162 ANESTH, NOSE/SINUS SURGERY 7 16.05 00164 ANESTH, BIOPSY OF NOSE 4 16.05 00170 ANESTH, PROCEDURE ON MOUTH 5 16.05 00172 ANESTH, CLEFT PALATE REPAIR 6 16.05 00174 ANESTH, PHARYNGEAL SURGERY 6 16.05 00176 ANESTH, PHARYNGEAL SURGERY 7 16.05 00190 ANESTH, FACE/SKULL BONE SURG 5 16.05 00192 ANESTH, FACIAL BONE SURGERY 7 16.05 00210 ANESTH, CRANIAL SURG NOS 11 16.05 00211 ANESTH, CRAN SURG, HEMOTOMA 10 16.05 00212 ANESTH, SKULL DRAINAGE 5 16.05 00214 ANESTH, SKULL DRAINAGE 9 16.05 00215 ANESTH, SKULL REPAIR/FRACT 9 16.05 00216 ANESTH, HEAD VESSEL SURGERY 15 16.05 00218 ANESTH, SPECIAL HEAD SURGERY 13 16.05 00220 ANESTH, INTRCRN NERVE 10 16.05 00222 ANESTH, HEAD NERVE SURGERY 6 16.05 00300 ANESTH, HEAD/NECK/PTRUNK 5 16.05 00320 ANESTH, NECK ORGAN, 1 & OVER 6 16.05 00322 ANESTH, BIOPSY OF THYROID 3 16.05
Page 1 and 2:
Procedure Pricing Action Maximum Co
Page 3 and 4:
00402 ANESTH, SURGERY OF BREAST A $
Page 5 and 6:
00794 ANESTH, PANCREAS REMOVAL A $0
Page 7 and 8:
0111T RBC MEMBRANES FATTY ACIDS 9 $
Page 9 and 10:
01634 ANESTH, SHOULDER JOINT AMPUT
Page 11 and 12:
0195T ARTHROD PRESAC INTERBODY 9 $0
Page 13 and 14:
10141 INCISION AND DRAINAGE OF HEMA
Page 15 and 16:
11422 EXC H-F-NK-SP B9+MARG 1.1-2 3
Page 17 and 18:
12021 CLOSURE OF SPLIT WOUND 3 $144
Page 19 and 20:
15343 CULTURE SKN GRAFT ADDL 25 CM
Page 21 and 22:
15876 SUCTION ASSISTED LIPECTOMY 5
Page 23 and 24:
17313 MOHS, 1 STAGE, T/A/L 3 $575.2
Page 25 and 26:
20251 OPEN BONE BIOPSY 3 $381.57 20
Page 27 and 28:
21015 RESECT FACE TUM < 2 CM 3 $589
Page 29 and 30:
21260 REVISE EYE SOCKETS 3 $1,189.5
Page 31 and 32:
21742 REPAIR STERN/NUSS W/O SCOPE 5
Page 33 and 34:
22842 INSERT SPINE FIXATION DEVICE
Page 35 and 36:
23515 TREAT CLAVICLE FRACTURE 3 $65
Page 37 and 38:
24358 REPAIR ELBOW W/DEB, OPEN 3 $4
Page 39 and 40:
25107 REMOVE WRIST JOINT CARTILAGE
Page 41 and 42:
25570 TREATMENT OF OPEN RADIAL AND
Page 43 and 44:
26262 RESECT DISTAL FINGER TUMOR 3
Page 45 and 46:
26610 TREATMENT OF OPEN METACARPAL
Page 47 and 48:
27093 INJECTION FOR HIP X-RAY 3 $17
Page 49 and 50:
27307 INCISION OF THIGH TENDONS 3 $
Page 51 and 52:
27506 TREATMENT OF THIGH FRACTURE 3
Page 53 and 54:
27704 REMOVAL OF ANKLE IMPLANT 3 $5
Page 55 and 56:
28050 BIOPSY OF FOOT JOINT LINING 3
Page 57 and 58:
28406 TREATMENT OF HEEL FRACTURE 3
Page 59 and 60:
29280 STRAPPING OF HAND OR FINGER 3
Page 61 and 62:
29901 MCP JOINT ARTHROSCOPY, SURG 3
Page 63 and 64:
30901 CONTROL OF NOSEBLEED 3 $96.29
Page 65 and 66:
31368 PARTIAL REMOVAL OF LARYNX 3 $
Page 67 and 68:
31725 CLEARANCE OF AIRWAYS 3 $91.78
Page 69 and 70:
32655 THORACOSCOPY, SURGICAL 3 $923
Page 71 and 72:
33214 UPGRADE OF PACEMAKER SYSTEM 3
Page 73 and 74:
33471 VALVOTOMY, PULMONARY VALVE 3
Page 75 and 76:
3374F AJCC BRST CNCR STAGE 1+DOCD 9
Page 77 and 78:
34101 REMOVAL OF ARTERY CLOT 3 $613
Page 79 and 80:
35226 REPAIR BLOOD VESSEL LESION 3
Page 81 and 82:
35570 ARTERY BYPASS GRAFT 3 $1,495.
Page 83 and 84:
36261 REVISION OF INFUSION PUMP 3 $
Page 85 and 86:
36821 AV FUSION DIRECT ANY SITE 3 $
Page 87 and 88:
38240 BONE MARROW/STEM TRANSPLANT 3
Page 89 and 90:
40527 RECONSTRUCT LIP WITH FLAP 3 $
Page 91 and 92:
4149F HEP B VAC INJXN ADMIN/RECVD 9
Page 93 and 94:
42326 CREATE SALIVARY CYST DRAIN O
Page 95 and 96:
43100 EXCISION OF ESOPHAGUS LESION
Page 97 and 98:
43360 GASTROINTESTINAL REPAIR 3 $2,
Page 99 and 100:
44110 EXCISE INTESTINE LESION(S) 3
Page 101 and 102:
44615 INTESTINAL STRICTUROPLASTY 3
Page 103 and 104:
45505 REPAIR OF RECTUM 3 $522.20 45
Page 105 and 106:
46947 HEMORRHOIDOPEXY BY STAPLING 3
Page 107 and 108:
48140 PARTIAL REMOVAL OF PANCREAS 3
Page 109 and 110:
49507 PRP I/HERN INIT BLOCK >5 YR 3
Page 111 and 112:
50392 INSERT KIDNEY DRAIN 3 $183.67
Page 113 and 114:
5100F RSK FX REF W/N 24 HRS X-RAY 9
Page 115 and 116:
52305 CYSTOSCOPY AND TREATMENT 3 $2
Page 117 and 118:
53661 DILATION OF URETHRA 3 $72.79
Page 119 and 120:
54670 REPAIR TESTIS INJURY 3 $412.0
Page 121 and 122:
56342 LAPAROSCOPIC CHOLECYSTECTOMY
Page 123 and 124:
57295 REVISE VAG GRAFT VIA VAGINA 3
Page 125 and 126:
58548 LAP RADICAL HYST 3 $1,693.35
Page 127 and 128:
59160 D & C AFTER DELIVERY 3 $198.1
Page 129 and 130:
61150 PIERCE SKULL FOR DRAINAGE 3 $
Page 131 and 132:
61606 RESECT/EXCISE CRANIAL LESION
Page 133 and 134:
62225 REPLACE/IRRIGATE CATHETER 3 $
Page 135 and 136:
63198 INCISE SPINAL COLUMN & CORD 3
Page 137 and 138:
64475 INJ PARAVERTEBRAL L/S O $0.00
Page 139 and 140:
64823 REMOVE SYMPATHETIC NERVES 3 $
Page 141 and 142:
65782 OCULAR RECONST, TRANSPLANT 3
Page 143 and 144:
67120 REMOVE EYE IMPLANT MATERIAL 3
Page 145 and 146:
68020 INCISE/DRAIN EYELID LINING 3
Page 147 and 148:
69620 REPAIR OF EARDRUM 3 $646.90 6
Page 149 and 150:
70482 CT ORBIT/EAR/FOSSA W/O&W/DYE
Page 151 and 152:
72195 MRI PELVIS W/O DYE 3 $430.97
Page 153 and 154:
74181 MRI ABDOMEN W/O DYE 3 $430.73
Page 155 and 156:
75564 HT MRI W/FLO/VEL/STRS & DYE O
Page 157 and 158:
75804 LYMPHANGIOGRAPHY, EXTREMITY O
Page 159 and 160:
76013 PERCUT VERTEBROPLASTY, CT O $
Page 161 and 162:
76831 ECHO EXAM, UTERUS 3 $118.55 7
Page 163 and 164:
77371 SRS, MULTISOURCE 3 $1,188.49
Page 165 and 166:
78191 PLATELET SURVIVAL 3 $177.47 7
Page 167 and 168:
78591 VENT IMAGE, 1 BREATH, 1 PROJ
Page 169 and 170:
80049 METABOLIC PANEL, BASIC 9 $0.0
Page 171 and 172:
80439 TRH STIMULATION PANEL 3 $94.3
Page 173 and 174:
82210 BARBITURATES QUANTITATIVE AND
Page 175 and 176:
82536 CORTISOL AFTER ADRENOCORTICOT
Page 177 and 178:
82784 ASSAY, IGA/IGD/IGG/IGM EACH 3
Page 179 and 180:
83486 HYDROXYBUTYRIC DEHYDROGENASE,
Page 181 and 182:
83785 ASSAY OF MANGANESE 3 $15.28 8
Page 183 and 184:
84061 PHOSPHATASE, FORENSIC EXAM 3
Page 185 and 186:
84377 SUGARS, MULTIPLE, QUAL 3 $7.7
Page 187 and 188:
85012 BLOOD COUNT EOSINOPHIL COUNT,
Page 189 and 190:
85420 FIBRINOLYTIC PLASMINOGEN 3 $9
Page 191 and 192:
86085 BLOOD TYPING ANTIGEN SCREENIN
Page 193 and 194:
86360 T CELL, ABSOLUTE COUNT/RATIO
Page 195 and 196:
86704 HEP B CORE ANTIBODY, TOTAL 3
Page 197 and 198:
87040 BLOOD CULTURE FOR BACTERIA 3
Page 199 and 200:
87301 ADENOVIRUS AG, EIA 3 $15.45 8
Page 201 and 202:
87652 STREP A, DNA, QUANT 3 $39.83
Page 203 and 204:
88261 CHROMOSOME ANALYSIS, 5 3 $248
Page 205 and 206:
89259 CRYOPRESERVATION, SPERM 9 $0.
Page 207 and 208:
90460 REST HOME (EG, BOARDING HOME)
Page 209 and 210:
90723 DTAP-HEP B-IPV VACCINE, IM 5
Page 211 and 212:
90857 INTAC GROUP PSYTX 3 $35.20 90
Page 213 and 214:
92014 EYE EXAM & TREATMENT 3 $108.6
Page 215 and 216:
92562 LOUDNESS BALANCE TEST 3 $25.3
Page 217 and 218:
93024 CARDIAC DRUG STRESS TEST 3 $1
Page 219 and 220:
93547 COMBINED LEFT HEART CATHETERI
Page 221 and 222:
93971 EXTREMITY STUDY 3 $122.45 939
Page 223 and 224:
95031 INTRACUTANEOUS (INTRADERMAL)
Page 225 and 226:
95904 SENSE NERVE CONDUCTION TEST 3
Page 227 and 228:
96413 CHEMO, IV INFUSION, 1 HR 3 $1
Page 229 and 230:
97605 NEG PRESS WOUND TX, < 50 CM 3
Page 231 and 232:
99183 HYPERBARIC OXYGEN THERAPY 3 $
Page 233 and 234:
99336 DOMICIL/R-HOME VISIT EST PAT
Page 235 and 236:
99499 UNLISTED E&M SERVICE 5 $0.00
Page 237 and 238:
A0396 ALS ESOPHAGEAL INTUB SUPPLS 9
Page 239 and 240:
A4321 CATH THERAPEUTIC IRRIG AGENT
Page 241 and 242:
A4427 OST PCH DRAIN/BARR LK FLNG/F
Page 243 and 244:
A4635 UNDERARM CRUTCH PAD 3 $4.16 A
Page 245 and 246:
A5062 DRNBLE OSTOMY POUCH W/O BARR
Page 247 and 248:
A6246 HYDROGEL DRG >16 48 SQ IN W/B
Page 249 and 250:
A7008 DISPOSABLE NEBULIZER PREFILL
Page 251 and 252:
A9518 I-131 SODIUM IODIDE SOLUTION
Page 253 and 254:
B4150 EF COMPLET W/INTACT NUTRIENT
Page 255 and 256:
C1068 PULSAR DDD PMKR 9 $0.00 C1069
Page 257 and 258:
C1178 BUSULFAN IV, 6 MG O $0.00 C11
Page 259 and 260:
C1721 AICD, DUAL CHAMBER 9 $0.00 C1
Page 261 and 262:
C1869 GORE THYROPLASTY DEVICE 9 $0.
Page 263 and 264:
C2607 SPINECATH INTRADISCAL CATH 9
Page 265 and 266:
C4602 TENDRIL SDX, 1488K PMKR LEAD
Page 267 and 268:
C6036 BARD EPTFE: 50/75SQCM-1,2MM 9
Page 269 and 270:
C8830 GIANTURCO-ROUBIN COR SNT 9 $0
Page 271 and 272:
C9224 INJECTION, GALSULFASE O $0.00
Page 273 and 274:
C9700 WATER INDUCED THERMO 9 $0.00
Page 275 and 276:
D1320 TOBACCO COUNSELING 1 $0.00 D1
Page 277 and 278:
D2975 COPING 9 $0.00 D2980 CROWN RE
Page 279 and 280:
D5640 REPLACE PART DENTURE TEETH 1
Page 281 and 282:
D6067 IMPLANT SUPPORTED MTL CROWN 9
Page 283 and 284:
D7140 EXTRACTION ERUPTED TOOTH/EXR
Page 285 and 286:
D7877 TMJ ARTHROSCOPY DEBRIDEMENT 9
Page 287 and 288:
D9941 FABRICATION ATHLETIC GUARD 9
Page 289 and 290:
E0232 WARMING CARD FOR NWT 5 $0.00
Page 291 and 292:
E0480 PERCUSSOR ELECT/PNEUM HOME M
Page 293 and 294:
E0754 PULSEGENERATOR PT PROGRAMMER
Page 295 and 296:
E1001 WHEELCHAIR WHEEL O $0.00 E100
Page 297 and 298:
E1298 WHEELCHAIR SPEC SEAT DEPTH/W
Page 299 and 300:
E2206 COMPLETE WHEEL LOCK ASSEMBLY
Page 301 and 302:
E2599 SGD ACCESSORY NOC 6 $0.00 E26
Page 303 and 304:
G0073 INDIVIDUAL PSYCHOTHERAPY, INS
Page 305 and 306:
G0194 SENSORYTESTINGENDOSCOPICSTUD
Page 307 and 308:
G0304 PRE-OP SERVICE LVRS 1-9 DOS 9
Page 309 and 310:
G0415 OPEN TX POST PELVIC FXCTURE 9
Page 311 and 312:
G8153 PT NOT DOC FOR AB 1 HR PRIOR
Page 313 and 314:
G8268 PT NOT DOC REC CARE URIN INC
Page 315 and 316:
G8366 PT DOC TO HAVE EMPIRIC AB 9 $
Page 317 and 318:
G8473 ACE/ARB THXPY RX'D 9 $0.00 G8
Page 319 and 320:
G8573 STK/CVA CABG 9 $0.00 G8574 NO
Page 321 and 322:
G9052 ONC SURVEILLANCE FOR DISEASE
Page 323 and 324:
H0007 ALCOHOL AND/OR DRUG SERVICES
Page 325 and 326:
H5200 NURSING CARE, OTHER 9 $0.00 H
Page 327 and 328:
J0390 CHLOROQUINE INJECTION 5 $0.00
Page 329 and 330:
J1070 TESTOSTERONE CYPIONAT 100 MG
Page 331 and 332:
J1675 HISTRELIN ACETATE 6 $0.00 J16
Page 333 and 334:
J2469 PALONOSETRON HCL 3 $17.51 J24
Page 335 and 336:
J3265 INJECTION TORSEMIDE 10 MG/ML
Page 337 and 338:
J7321 HYALGAN/SUPARTZ INJ PER DOSE
Page 339 and 340:
J7672 METAPROTERENOL SULFATE .6% O
Page 341 and 342:
J9240 MEDROXYPROGESTERONE ACETATE,
Page 343 and 344:
K0064 ZERO PRESSURE TUBE FLAT FREE
Page 345 and 346:
K0169 DISPOSABLE NEBULIZER SMALL 9
Page 347 and 348:
K0276 OSTOMY FACEPLATE; CONVEX; CUS
Page 349 and 350:
K0531 HEATED HUMIDIFIER USED W PAP
Page 351 and 352:
K0663 POSITION BACK CUSH WDTH GREAT
Page 353 and 354:
L0180 CER POST COL OCC/MAN SUP ADJ
Page 355 and 356:
L0974 TLSO FULL CORSET 3 $128.76 L0
Page 357 and 358:
L1971 AFO W/ANKLE JOINT, PREFAB 6 $
Page 359 and 360:
L2750 PLATING CHROME/NICKEL PR BAR
Page 361 and 362:
L3560 O SHOE ADD HORSESHOE TOE TAP
Page 363 and 364:
L3960 SEWHO AIRPLAN DESIG ABDU POS
Page 365 and 366:
L5580 PREP AK ISCHIAL THERMO MOLD 3
Page 367 and 368:
L5781 LOWER LIMB PROS VACUUM PUMP 5
Page 369 and 370:
L6611 ADDITIONAL SWITCH, EXT POWER
Page 371 and 372:
L6873 HAND MECH INF STEEPER OR EQU
Page 373 and 374:
L8120 COMPRESSION STOCKING BK40-50
Page 375 and 376: M0023 ROUTINE NEWBORN CARE, INHOSPI
Page 377 and 378: P9052 PLATELETS, HLA-M, L/R, UNIT 9
Page 379 and 380: Q0185 METABOLIC ACTIVE D/E TISSUE 9
Page 381 and 382: Q4011 CAST SUP SHT ARM PED PLASTER
Page 383 and 384: Q9924 EPOETIN WITH HCT = 24 O $0.00
Page 385 and 386: S0128 INJ FOLLITROPIN BETA 75 IU 9
Page 387 and 388: S0518 SUNGLASS FRAMES 9 $0.00 S0580
Page 389 and 390: S2340 CHEMODENERVATION OF ABDUCTOR
Page 391 and 392: S4028 MICROSURG EPI SPERM ASP 9 $0.
Page 393 and 394: S8042 MRI LOW FIELD 5 $0.00 S8048 I
Page 395 and 396: S9129 OCCUPATIONAL THERAPY, IN THE
Page 397 and 398: S9476 VESTIBULAR REHAB PER DIEM 9 $
Page 399 and 400: T2004 N-ET; COMMERC CARRIER PASS 9
Page 401 and 402: V2105 SPHEROCYLINDER 4.00D/4.25-6D
Page 403 and 404: V2710 GLASS/PLASTIC SLAB OFF PRISM
Page 405 and 406: V5298 HEARING AID NOC 5 $0.00 V5299
Page 407 and 408: WW524 VISION PROGRAM UNDER EPSDT-UN
Page 409 and 410: WW851 OXYGEN CONTENT, GASEOUS, PER
Page 411 and 412: YY409 DPH TUBERCULOSIS CLINIC VISIT
Page 413 and 414: YY645 HOME & COMMUNITY-BASED WAIVER
Page 415 and 416: ZR002 MCO SPECIFIC CODE: HOME INFUS
Page 417 and 418: Procedure Code Description Pricing
Page 419 and 420: D2791 CROWN FULL CAST BASE METAL 80
Page 421 and 422: D4276 CON TISSUE W DBLE PED GRAFT 8
Page 423 and 424: D5937 TRISMUS APPLIANCE 80 D5951 FE
Page 425: D7970 EXCISION HYPERPLASTIC TISSUE
Page 429 and 430: 00567 ANESTH, CABG W/PUMP 18 16.05
Page 431 and 432: 00936 ANESTH, PENIS, NODES REMOVAL
Page 433 and 434: 01652 ANESTH, SHOULDER VESSEL SURG
Page 435 and 436: 33031 PARTIAL REMOVAL OF HEART SAC
Page 437 and 438: 33414 REPAIR OF AORTIC VALVE 62.02
Page 439 and 440: 33676 CLOSE MULT VSD W/RESECTION 53
Page 441 and 442: 33916 SURGERY OF GREAT VESSEL 46.93
Page 443 and 444: 35102 REPAIR DEFECT OF ARTERY 55.37
Page 445 and 446: 35481 ATHERECTOMY, OPEN 11.67 1.00
Page 447 and 448: 35651 ARTERY BYPASS GRAFT 40.71 1.0
Page 449 and 450: 36425 VEIN ACCESS CUTDOWN > 1 YR 1.
Page 451 and 452: 36831 OPEN THROMBECT AV FISTULA 12.
Page 453 and 454: 38221 BONE MARROW BIOPSY 2.07 1.00
Page 455 and 456: 56800 REPAIR OF VAGINA 6.56 1.00 56
Page 457 and 458: 57455 BIOPSY OF CERVIX W/SCOPE 3.01
Page 459 and 460: 58559 HYSTEROSCOPY, LYSIS 9.37 1.00
Page 461 and 462: 61314 OPEN SKULL FOR DRAINAGE 47.7
Page 463 and 464: 61584 ORBITOCRANIAL APPROACH/SKULL
Page 465 and 466: 61880 REVISE/REMOVE NEUROELECTRODE
Page 467 and 468: 63001 REMOVAL OF SPINAL LAMINA 32.2
Page 469 and 470: 63281 BIOPSY/EXCISE SPINAL TUMOR 54
Page 471 and 472: 64492 INJ PARAVERT F JNT C/T 3 LEV
Page 473 and 474: 64774 REMOVE SKIN NERVE LESION 10.7
Page 475 and 476: 65155 REINSERT OCULAR IMPLANT 21.52
Page 477 and 478:
66600 REMOVE IRIS AND LESION 19.97
Page 479 and 480:
67316 REVISE TWO EYE MUSCLES 20.51
Page 481 and 482:
67973 RECONSTRUCTION OF EYELID 24.2
Page 483 and 484:
70332 X-RAY EXAM OF JAW JOINT 2.23
Page 485 and 486:
72074 X-RAY EXAM OF THORACIC SPINE
Page 487 and 488:
73220 MRI UPPR EXTREMITY W/O&W/DYE
Page 489 and 490:
74320 CONTRAST X-RAY OF BILE DUCTS
Page 491 and 492:
75952 ENDOVASC REPAIR ABDOM AORTA 6
Page 493 and 494:
77402 RADIATION TREATMENT DELIVERY
Page 495 and 496:
78230 SALIVARY GLAND IMAGING 4.2 1.
Page 497 and 498:
78730 URINARY BLADDER RETENTION 1.9
Page 499 and 500:
93270 ECG RECORDING 0.46 1.00 93271
Page 501 and 502:
93722 PLETHYSMOGRAPHY REPORT 0.23 1
Page 503 and 504:
E0189 RR 3 3.63 E0155 RR 3 3.68 E04
Page 505 and 506:
94010 26 3 8.16 73000 26 3 8.18 760
Page 507 and 508:
E0276 UE 3 10.07 K0053 RR 3 10.14 E
Page 509 and 510:
73520 26 3 13.1 71021 26 3 13.22 71
Page 511 and 512:
74455 26 3 16.85 92542 26 3 16.85 7
Page 513 and 514:
73070 TC 3 19.1 92543 TC 3 19.1 E09
Page 515 and 516:
78201 26 3 21.99 93979 26 3 21.99 7
Page 517 and 518:
94260 TC 3 24.65 74410 26 3 24.66 7
Page 519 and 520:
76080 26 3 27.18 77332 26 3 27.18 K
Page 521 and 522:
76100 26 3 29.83 77003 TC 3 29.83 9
Page 523 and 524:
88332 26 3 33.09 95867 TC 3 33.15 7
Page 525 and 526:
E1298 RR 3 36.55 72275 26 3 36.76 7
Page 527 and 528:
E0480 RR 3 42.04 75801 26 3 42.06 9
Page 529 and 530:
95922 26 3 47 88360 TC 3 47.05 E097
Page 531 and 532:
88365 26 3 52.43 93615 26 3 52.62 7
Page 533 and 534:
75889 26 3 57.49 75891 26 3 57.49 7
Page 535 and 536:
76998 26 3 62.24 95864 TC 3 62.38 7
Page 537 and 538:
93616 26 3 67.38 70540 26 3 67.44 7
Page 539 and 540:
K0069 UE 3 74.56 75984 TC 3 74.58 E
Page 541 and 542:
73222 26 3 81.04 70015 TC 3 81.23 E
Page 543 and 544:
72159 26 3 89.58 70549 26 3 89.69 7
Page 545 and 546:
E1100 RR 3 99.32 93890 TC 3 99.49 9
Page 547 and 548:
93318 26 3 112.63 72197 26 3 112.91
Page 549 and 550:
78466 TC 3 137.32 51725 TC 3 138.56
Page 551 and 552:
75893 TC 3 166.3 75961 TC 3 166.3 7
Page 553 and 554:
95816 TC 3 190.21 73200 TC 3 190.71
Page 555 and 556:
95813 TC 3 232.61 93508 26 3 232.99
Page 557 and 558:
93609 26 3 282.25 78807 TC 3 282.3
Page 559 and 560:
77295 TC 3 370.93 E0550 UE 3 373.5
Page 561 and 562:
E1070 UE 3 544.05 70543 TC 3 548.34
Page 563:
E0781 UE 3 1335.9 K0005 UE 3 1379.6
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Description - DE Medical Assistance Program

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