| 1 | Medical Care Start: 09/20/2009 |
| 2 | Surgical Start: 09/20/2009 |
| 3 | Consultation Start: 09/20/2009 |
| 4 | Diagnostic X-Ray Start: 09/20/2009 |
| 5 | Diagnostic Lab Start: 09/20/2009 |
| 6 | Radiation Therapy Start: 09/20/2009 |
| 7 | Anesthesia Start: 09/20/2009 |
| 8 | Surgical Assistance Start: 09/20/2009 |
| 10 | Blood Start: 09/20/2009 |
| 11 | Durable Medical Equipment Used Start: 09/20/2009 |
| 12 | Durable Medical Equipment Purchased Start: 09/20/2009 |
| 14 | Renal Supplies Start: 09/20/2009 |
| 17 | Pre-Admission Testing Start: 09/20/2009 |
| 18 | Durable Medical Equipment Rental Start: 09/20/2009 |
| 19 | Pneumonia Vaccine Start: 09/20/2009 |
| 20 | Second Surgical Opinion Start: 09/20/2009 |
| 21 | Third Surgical Opinion Start: 09/20/2009 |
| 22 | Social Work Start: 09/20/2009 |
| 23 | Diagnostic Dental Start: 09/20/2009 |
| 24 | Periodontics Start: 09/20/2009 |
| 25 | Restorative Start: 09/20/2009 |
| 26 | Endodontics Start: 09/20/2009 |
| 27 | Maxillofacial Prosthetics Start: 09/20/2009 |
| 28 | Adjunctive Dental Services Start: 09/20/2009 |
| 30 | Health Benefit Plan Coverage Start: 09/20/2009 |
| 32 | Plan Waiting Period Start: 09/20/2009 |
| 33 | Chiropractic Start: 09/20/2009 |
| 34 | Chiropractic Modality Start: 09/20/2009 |
| 35 | Dental Care Start: 09/20/2009 |
| 36 | Dental Crowns Start: 09/20/2009 |
| 37 | Dental Accident Start: 09/20/2009 |
| 38 | Orthodontics Start: 09/20/2009 |
| 39 | Prosthodontics Start: 09/20/2009 |
| 40 | Oral Surgery Start: 09/20/2009 |
| 41 | Preventive Dental Start: 09/20/2009 | Last Modified: 01/24/2010 |
| 42 | Home Health Care Start: 09/20/2009 |
| 43 | Home Health Prescriptions Start: 09/20/2009 |
| 45 | Hospice Start: 09/20/2009 |
| 46 | Respite Care Start: 09/20/2009 |
| 47 | Hospitalization Start: 09/20/2009 |
| 49 | Hospital - Room and Board Start: 09/20/2009 |
| 54 | Long Term Care Start: 09/20/2009 |
| 55 | Major Medical Start: 09/20/2009 |
| 56 | Medically Related Transportation Start: 09/20/2009 |
| 60 | General Benefits Start: 09/20/2009 |
| 61 | In-vitro Fertilization Start: 09/20/2009 |
| 62 | MRI Scan Start: 09/20/2009 |
| 63 | Donor Procedures Start: 09/20/2009 |
| 64 | Acupuncture Start: 09/20/2009 |
| 65 | Newborn Care Start: 09/20/2009 |
| 66 | Pathology Start: 09/20/2009 |
| 67 | Smoking Cessation Start: 09/20/2009 |
| 68 | Well Baby Care Start: 09/20/2009 |
| 69 | Maternity Start: 09/20/2009 |
| 70 | Transplants Start: 09/20/2009 |
| 71 | Audiology Start: 09/20/2009 |
| 72 | Inhalation Therapy Start: 09/20/2009 |
| 73 | Diagnostic Medical Start: 09/20/2009 |
| 74 | Private Duty Nursing Start: 09/20/2009 |
| 75 | Prosthetic Device Start: 09/20/2009 |
| 76 | Dialysis Start: 09/20/2009 |
| 77 | Otology Start: 09/20/2009 |
| 78 | Chemotherapy Start: 09/20/2009 |
| 79 | Allergy Testing Start: 09/20/2009 |
| 80 | Immunizations Start: 09/20/2009 |
| 81 | Routine Physical Start: 09/20/2009 |
| 82 | Family Planning Start: 09/20/2009 |
| 83 | Infertility Start: 09/20/2009 |
| 84 | Abortion Start: 09/20/2009 |
| 85 | HIV - AIDS Treatment Start: 09/20/2009 |
| 86 | Emergency Services Start: 09/20/2009 |
| 87 | Cancer Treatment Start: 09/20/2009 |
| 88 | Pharmacy Start: 09/20/2009 |
| 89 | Free Standing Prescription Drug Start: 09/20/2009 |
| 90 | Mail Order Prescription Drug Start: 09/20/2009 |
| 91 | Brand Name Prescription Drug Start: 09/20/2009 |
| 92 | Generic Prescription Drug Start: 09/20/2009 |
| 93 | Podiatry Start: 09/20/2009 |
| A4 | Psychiatric Start: 09/20/2009 |
| A6 | Psychotherapy Start: 09/20/2009 |
| A7 | Psychiatric - Inpatient Start: 09/20/2009 |
| A8 | Psychiatric - Outpatient Start: 09/20/2009 |
| A9 | Rehabilitation Start: 09/20/2009 |
| AB | Rehabilitation - Inpatient Start: 09/20/2009 |
| AC | Rehabilitation - Outpatient Start: 09/20/2009 |
| AD | Occupational Therapy Start: 09/20/2009 |
| AE | Physical Medicine Start: 09/20/2009 |
| AF | Speech Therapy Start: 09/20/2009 |
| AG | Skilled Nursing Care Start: 09/20/2009 |
| AI | Substance Abuse Start: 09/20/2009 |
| AJ | Alcoholism Treatment Start: 09/20/2009 |
| AK | Drug Addiction Start: 09/20/2009 |
| AL | Optometry Start: 09/20/2009 |
| AM | Frames Start: 09/20/2009 |
| AO | Lenses Start: 09/20/2009 |
| AP | Routine Eye Exam Start: 09/20/2009 |
| AQ | Nonmedically Necessary Physical (These physicals are required by other entities e.g., insurance application, pilot license, employment or school) Start: 09/20/2009 |
| AR | Experimental Drug Therapy Start: 09/20/2009 |
| B1 | Burn Care Start: 09/20/2009 |
| B2 | Brand Name Prescription Drug - Formulary Start: 09/20/2009 |
| B3 | Brand Name Prescription Drug - Non-Formulary Start: 09/20/2009 |
| BA | Independent Medical Evaluation Start: 09/20/2009 |
| BB | Psychiatric Treatment Partial Hospitalization Start: 09/20/2009 |
| BC | Day Care (Psychiatric) Start: 09/20/2009 |
| BD | Cognitive Therapy Start: 09/20/2009 |
| BE | Massage Therapy Start: 09/20/2009 |
| BF | Pulmonary Rehabilitation Start: 09/20/2009 |
| BG | Cardiac Rehabilitation Start: 09/20/2009 |
| BH | Pediatric Start: 09/20/2009 |
| BI | Nursery Room and Board Start: 09/20/2009 |
| BK | Orthopedic Start: 09/20/2009 |
| BL | Cardiac Start: 09/20/2009 |
| BM | Lymphatic Start: 09/20/2009 |
| BN | Gastrointestinal Start: 09/20/2009 |
| BP | Endocrine Start: 09/20/2009 |
| BQ | Neurology Start: 09/20/2009 |
| BT | Gynecological Start: 09/20/2009 |
| BU | Obstetrical Start: 09/20/2009 |
| BV | Obstetrical/Gynecological Start: 09/20/2009 |
| BW | Mail Order Prescription Drug: Brand Name Start: 09/20/2009 |
| BX | Mail Order Prescription Drug: Generic Start: 09/20/2009 |
| BY | Physician Visit - Sick Start: 09/20/2009 |
| BZ | Physician Visit - Well Start: 09/20/2009 |
| C1 | Coronary Care Start: 09/20/2009 |
| CK | Screening X-ray Start: 09/20/2009 |
| CL | Screening laboratory Start: 09/20/2009 |
| CM | Mammogram, High Risk Patient Start: 09/20/2009 |
| CN | Mammogram, Low Risk Patient Start: 09/20/2009 |
| CO | Flu Vaccination Start: 09/20/2009 |
| CP | Eyewear Accessories Start: 09/20/2009 |
| CQ | Case Management Start: 09/20/2009 |
| DG | Dermatology Start: 09/20/2009 |
| DM | Durable Medical Equipment Start: 09/20/2009 |
| DS | Diabetic Supplies Start: 09/20/2009 |
| E0 | Allied Behavioral Analysis Therapy Start: 09/20/2009 |
| E1 | Non-Medical Equipment (non DME) Start: 09/20/2009 |
| E2 | Psychiatric Emergency Start: 09/20/2009 |
| E3 | Step Down Unit Start: 09/20/2009 |
| E4 | Skilled Nursing Facility Head Level of Care Start: 09/20/2009 |
| E5 | Skilled Nursing Facility Ventilator Level of Care Start: 09/20/2009 |
| E6 | Level of Care 1 Start: 09/20/2009 |
| E7 | Level of Care 2 Start: 09/20/2009 |
| E8 | Level of Care 3 Start: 09/20/2009 |
| E9 | Level of Care 4 Start: 09/20/2009 |
| E10 | Radiographs Start: 01/24/2010 |
| E11 | Diagnostic Imaging Start: 01/24/2010 |
| E12 | Basic Restorative - Dental Start: 01/24/2010 |
| E13 | Major Restorative - Dental Start: 01/24/2010 |
| E14 | Fixed Prosthodontics Start: 01/24/2010 |
| E15 | Removable Prosthodontics Start: 01/24/2010 |
| E16 | Intraoral Images - Complete Series Start: 01/24/2010 |
| E17 | Oral Evaluation Start: 01/24/2010 |
| E18 | Dental Prophylaxis Start: 01/24/2010 |
| E19 | Panoramic Images Start: 01/24/2010 |
| E20 | Sealants Start: 01/24/2010 |
| E21 | Flouride Treatments Start: 01/24/2010 |
| E22 | Dental Implants Start: 01/24/2010 |
| E23 | Temporomandibular Joint Dysfunction Start: 01/24/2010 |
| E24 | Retail Pharmacy Prescription Drug Start: 06/06/2010 |
| E25 | Long Term Care Pharmacy Start: 06/06/2010 |
| E26 | Comprehensive Medication Therapy Management Review Start: 06/05/2011 |
| E27 | Targeted Medication Therapy Management Review Start: 06/05/2011 |
| E28 | Dietary/Nutritional Services Start: 01/29/2012 |
| E29 | Technical Cardiac Rehabilitation Services Component Start: 09/30/2012 |
| E30 | Professional Cardiac Rehabilitation Services Component Start: 09/30/2012 |
| E31 | Professional Intensive Cardiac Rehabilitation Services Component Start: 09/30/2012 |
| EA | Preventive Services Start: 09/20/2009 |
| EB | Specialty Pharmacy Start: 09/20/2009 |
| EC | Durable Medical Equipment New Start: 09/20/2009 |
| ED | CAT Scan Start: 09/20/2009 |
| EE | Ophthalmology Start: 09/20/2009 |
| EF | Contact Lenses Start: 09/20/2009 |
| GF | Generic Prescription Drug - Formulary Start: 09/20/2009 |
| GN | Generic Prescription Drug - Non-Formulary Start: 09/20/2009 |
| GY | Allergy Start: 09/20/2009 |
| IC | Intensive Care Start: 09/20/2009 |
| MH | Mental Health Start: 09/20/2009 |
| NI | Neonatal Intensive Care Start: 09/20/2009 |
| ON | Oncology Start: 09/20/2009 |
| PE | Positron Emission Tomography (PET) Scan Start: 09/20/2009 |
| PT | Physical Therapy Start: 09/20/2009 |
| PU | Pulmonary Start: 09/20/2009 |
| RN | Renal Start: 09/20/2009 |
| RT | Residential Psychiatric Treatment Start: 09/20/2009 |
| SMH | Serious Mental Health Start: 01/30/2011 |
| TC | Transitional Care Start: 09/20/2009 |
| TN | Transitional Nursery Care Start: 09/20/2009 |
| UC | Urgent Care Start: 09/20/2009 |