Schedule J Plan Design with Procedure Codes.xlsx
XLSX spreadsheet 28 KB Posted
- Attached to
- MPSERS Dental Benefit Plan Administration
- Solicitation number
- RFP-171-200000001290-3
- Issued by
- Grand Traverse County, Lansing City, Michigan
About this file
This is a dental plan design document from the State of Michigan (RFP No. 200000001290) Schedule J that outlines comprehensive coverage details and procedure codes. The plan provides different coverage levels for in-network and out-of-network services, with diagnostic and preventative services covered at 95% in-network and 90% out-of-network, basic services ranging from 75-80% coverage, and major services at 50% coverage. Orthodontic services for patients up to age 19 are covered at 50% both in and out of network.
The plan features a $0 deductible for in-network services and a $50 per person deductible for out-of-network services, with the deductible waived for diagnostic and preventive services. There is a $1,100 per person annual maximum for diagnostic, preventive, basic, and major services, and a $1,200 lifetime maximum for orthodontics. The plan considers the deepest discount network as "in-network" and all other networks as "out-of-network," with specific provisions for how out-of-network providers can bill members for differences between in-network fee schedules and their charges.
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Text version
Plan Design
STATE OF MICHIGAN
| RFP No. 200000001290 |
| SCHEDULE J |
Plan Design with Procedure Codes
| Plan Pays | ||
| Benefits | In Network | Out of network |
| Diagnostic and Preventative | ||
| Diagnostic and Preventative Services | 95% | 90% |
| Emergency Palliative Treatment | 95% | 90% |
| Radiographs | 95% | 75% |
| Basic Services | ||
| Minor Restorative | 80% | 75% |
| Major Restorative | 75% | 75% |
| Reriodontic Servcies | 75% | 75% |
| Endodontic Services | 75% | 75% |
| Oral Surgery Services | 75% | 75% |
| Relines and Repairs | 75% | 75% |
| Major Services | ||
| Prosthodontics | 50% | 50% |
| Orthodontics | ||
| Orthodontic Services (to age 19) | 50% | 50% |
| Deductible | ||
| Waived for Diagnostic and Preventive Services from any provider and for all services provided in-network*. | $0 | $50/ person |
| Plan Maximums | ||
| $1,100 per person total per calendar year for Diagnostic & Preventive, Basic Servcies, and Major Services. | ||
| $1,200 lifetime maximum per Eligible Person for Orthodontics. | ||
| *NOTE: Plan Sponsor considers the deepest discount network "in-network" and all other networks "out-of-network". The Plan Sponsor's liability for out of network providers is calculated based on cost share applied to their deepest discounted (a.k.a. in-network) network. Out of network providers that participate with Bidder via another fee schedule can charge Members the difference between theirs and the in-network fee schedule but not balance bill up to their charge, and non-participating providers can charge members the difference between the in-network fee schedule and their charge. |
Procedure Codes
| Procedure Code | In network | Out of Network |
| D0120 | 95 | 90 |
| D0140 | 95 | 90 |
| D0145 | 95 | 90 |
| D0150 | 95 | 90 |
| D0160 | 95 | 90 |
| D0170 | Not Covered | Not Covered |
| D0171 | Not Covered | Not Covered |
| D0180 | 95 | 90 |
| D0190 | 95 | 90 |
| D0191 | Not Covered | Not Covered |
| D0210 | 95 | 75 |
| D0220 | 95 | 75 |
| D0230 | 95 | 75 |
| D0240 | 95 | 75 |
| D0250 | 95 | 75 |
| D0251 | Not Covered | Not Covered |
| D0270 | 95 | 75 |
| D0272 | 95 | 75 |
| D0273 | 95 | 75 |
| D0274 | 95 | 75 |
| D0277 | 95 | 75 |
| D0310 | Not Covered | Not Covered |
| D0320 | Not Covered | Not Covered |
| D0321 | Not Covered | Not Covered |
| D0322 | Not Covered | Not Covered |
| D0330 | 95 | 75 |
| D0340 | 95 | 75 |
| D0350 | 75 | 75 |
| D0351 | Not Covered | Not Covered |
| D0364 | Not Covered | Not Covered |
| D0365 | Not Covered | Not Covered |
| D0366 | Not Covered | Not Covered |
| D0367 | Not Covered | Not Covered |
| D0368 | Not Covered | Not Covered |
| D0369 | Not Covered | Not Covered |
| D0370 | Not Covered | Not Covered |
| D0371 | Not Covered | Not Covered |
| D0380 | Not Covered | Not Covered |
| D0381 | Not Covered | Not Covered |
| D0382 | Not Covered | Not Covered |
| D0383 | Not Covered | Not Covered |
| D0384 | Not Covered | Not Covered |
| D0385 | Not Covered | Not Covered |
| D0386 | Not Covered | Not Covered |
| D0391 | Not Covered | Not Covered |
| D0393 | Not Covered | Not Covered |
| D0394 | Not Covered | Not Covered |
| D0395 | Not Covered | Not Covered |
| D0411 | Not Covered | Not Covered |
| D0412 | Not Covered | Not Covered |
| D0414 | Not Covered | Not Covered |
| D0415 | Not Covered | Not Covered |
| D0416 | Not Covered | Not Covered |
| D0417 | Not Covered | Not Covered |
| D0418 | Not Covered | Not Covered |
| D0419 | 75 | 75 |
| D0422 | Not Covered | Not Covered |
| D0423 | Not Covered | Not Covered |
| D0425 | Not Covered | Not Covered |
| D0431 | Not Covered | Not Covered |
| D0460 | 75 | 75 |
| D0470 | 75 | 75 |
| D0472 | Not Covered | Not Covered |
| D0473 | Not Covered | Not Covered |
| D0474 | Not Covered | Not Covered |
| D0475 | Not Covered | Not Covered |
| D0476 | Not Covered | Not Covered |
| D0477 | Not Covered | Not Covered |
| D0478 | Not Covered | Not Covered |
| D0479 | Not Covered | Not Covered |
| D0480 | Not Covered | Not Covered |
| D0481 | Not Covered | Not Covered |
| D0482 | Not Covered | Not Covered |
| D0483 | Not Covered | Not Covered |
| D0484 | Not Covered | Not Covered |
| D0485 | Not Covered | Not Covered |
| D0486 | Not Covered | Not Covered |
| D0502 | Not Covered | Not Covered |
| D0600 | Not Covered | Not Covered |
| D0601 | 75 | 75 |
| D0602 | 75 | 75 |
| D0603 | 75 | 75 |
| D0999 | 95 | 75 |
| D1110 | 95 | 90 |
| D1120 | 95 | 90 |
| D1206 | 95 | 90 |
| D1208 | 95 | 90 |
| D1310 | Not Covered | Not Covered |
| D1320 | Not Covered | Not Covered |
| D1330 | Not Covered | Not Covered |
| D1351 | Not Covered | Not Covered |
| D1352 | Not Covered | Not Covered |
| D1353 | Not Covered | Not Covered |
| D1354 | Not Covered | Not Covered |
| D1510 | 95 | 90 |
| D1516 | 95 | 90 |
| D1517 | 95 | 90 |
| D1520 | 95 | 90 |
| D1526 | 95 | 90 |
| D1527 | 95 | 90 |
| D1551 | 95 | 90 |
| D1552 | 95 | 90 |
| D1553 | 95 | 90 |
| D1556 | 95 | 90 |
| D1557 | 95 | 90 |
| D1558 | 95 | 90 |
| D1575 | 95 | 90 |
| D1999 | 95 | 90 |
| D2140 | 80 | 75 |
| D2150 | 80 | 75 |
| D2160 | 80 | 75 |
| D2161 | 80 | 75 |
| D2330 | 80 | 75 |
| D2331 | 80 | 75 |
| D2332 | 80 | 75 |
| D2335 | 80 | 75 |
| D2390 | 80 | 75 |
| D2391 | Optional | Optional |
| D2392 | Optional | Optional |
| D2393 | Optional | Optional |
| D2394 | Optional | Optional |
| D2410 | Optional | Optional |
| D2420 | Optional | Optional |
| D2430 | Optional | Optional |
| D2510 | Optional | Optional |
| D2520 | Optional | Optional |
| D2530 | Optional | Optional |
| D2542 | 75 | 75 |
| D2543 | 75 | 75 |
| D2544 | 75 | 75 |
| D2610 | Optional | Optional |
| D2620 | Optional | Optional |
| D2630 | Optional | Optional |
| D2642 | 75 | 75 |
| D2643 | 75 | 75 |
| D2644 | 75 | 75 |
| D2650 | Optional | Optional |
| D2651 | Optional | Optional |
| D2652 | Optional | Optional |
| D2662 | 75 | 75 |
| D2663 | 75 | 75 |
| D2664 | 75 | 75 |
| D2710 | 75 | 75 |
| D2712 | 75 | 75 |
| D2720 | 75 | 75 |
| D2721 | 75 | 75 |
| D2722 | 75 | 75 |
| D2740 | 75 | 75 |
| D2750 | 75 | 75 |
| D2751 | 75 | 75 |
| D2752 | 75 | 75 |
| D2753 | 75 | 75 |
| D2780 | 75 | 75 |
| D2781 | 75 | 75 |
| D2782 | 75 | 75 |
| D2783 | 75 | 75 |
| D2790 | 75 | 75 |
| D2791 | 75 | 75 |
| D2792 | 75 | 75 |
| D2794 | 75 | 75 |
| D2799 | Not Covered | Not Covered |
| D2910 | 80 | 75 |
| D2915 | 80 | 75 |
| D2920 | 80 | 75 |
| D2921 | 80 | 75 |
| D2929 | 75 | 75 |
| D2930 | 75 | 75 |
| D2931 | 75 | 75 |
| D2932 | 75 | 75 |
| D2933 | 75 | 75 |
| D2934 | 75 | 75 |
| D2940 | 80 | 75 |
| D2941 | 80 | 75 |
| D2949 | Not Covered | Not Covered |
| D2950 | 75 | 75 |
| D2951 | 80 | 75 |
| D2952 | 75 | 75 |
| D2953 | Not Covered | Not Covered |
| D2954 | 75 | 75 |
| D2955 | 75 | 75 |
| D2957 | Not Covered | Not Covered |
| D2960 | 80 | 75 |
| D2961 | 80 | 75 |
| D2962 | 80 | 75 |
| D2971 | 75 | 75 |
| D2975 | Not Covered | Not Covered |
| D2980 | 80 | 75 |
| D2981 | 80 | 75 |
| D2982 | 80 | 75 |
| D2983 | 80 | 75 |
| D2990 | Not Covered | Not Covered |
| D2999 | 80 | 75 |
| D3110 | Not Covered | Not Covered |
| D3120 | Not Covered | Not Covered |
| D3220 | 75 | 75 |
| D3221 | 75 | 75 |
| D3222 | 75 | 75 |
| D3230 | 75 | 75 |
| D3240 | 75 | 75 |
| D3310 | 75 | 75 |
| D3320 | 75 | 75 |
| D3330 | 75 | 75 |
| D3331 | Not Covered | Not Covered |
| D3332 | 75 | 75 |
| D3333 | 75 | 75 |
| D3346 | 75 | 75 |
| D3347 | 75 | 75 |
| D3348 | 75 | 75 |
| D3351 | 75 | 75 |
| D3352 | 75 | 75 |
| D3353 | 75 | 75 |
| D3355 | Not Covered | Not Covered |
| D3356 | Not Covered | Not Covered |
| D3357 | Not Covered | Not Covered |
| D3410 | 75 | 75 |
| D3421 | 75 | 75 |
| D3425 | 75 | 75 |
| D3426 | 75 | 75 |
| D3427 | 75 | 75 |
| D3428 | Not Covered | Not Covered |
| D3429 | Not Covered | Not Covered |
| D3430 | 75 | 75 |
| D3431 | Not Covered | Not Covered |
| D3432 | Not Covered | Not Covered |
| D3450 | 75 | 75 |
| D3460 | Not Covered | Not Covered |
| D3470 | Not Covered | Not Covered |
| D3910 | Not Covered | Not Covered |
| D3920 | 75 | 75 |
| D3950 | Not Covered | Not Covered |
| D3999 | 75 | 75 |
| D4210 | 75 | 75 |
| D4211 | 75 | 75 |
| D4212 | Not Covered | Not Covered |
| D4230 | Not Covered | Not Covered |
| D4231 | Not Covered | Not Covered |
| D4240 | 75 | 75 |
| D4241 | 75 | 75 |
| D4245 | 75 | 75 |
| D4249 | 75 | 75 |
| D4260 | 75 | 75 |
| D4261 | 75 | 75 |
| D4263 | 75 | 75 |
| D4264 | 75 | 75 |
| D4265 | 75 | 75 |
| D4266 | 75 | 75 |
| D4267 | 75 | 75 |
| D4268 | 75 | 75 |
| D4270 | 75 | 75 |
| D4273 | 75 | 75 |
| D4274 | 75 | 75 |
| D4275 | 75 | 75 |
| D4276 | 75 | 75 |
| D4277 | 75 | 75 |
| D4278 | 75 | 75 |
| D4283 | 75 | 75 |
| D4285 | 75 | 75 |
| D4320 | Not Covered | Not Covered |
| D4321 | Not Covered | Not Covered |
| D4341 | 75 | 75 |
| D4342 | 75 | 75 |
| D4346 | 75 | 75 |
| D4355 | 75 | 75 |
| D4381 | Not Covered | Not Covered |
| D4910 | 75 | 75 |
| D4920 | Not Covered | Not Covered |
| D4921 | Not Covered | Not Covered |
| D4999 | 75 | 75 |
| D5110 | 50 | 50 |
| D5120 | 50 | 50 |
| D5130 | 50 | 50 |
| D5140 | 50 | 50 |
| D5211 | 50 | 50 |
| D5212 | 50 | 50 |
| D5213 | 50 | 50 |
| D5214 | 50 | 50 |
| D5221 | 50 | 50 |
| D5222 | 50 | 50 |
| D5223 | 50 | 50 |
| D5224 | 50 | 50 |
| D5225 | 50 | 50 |
| D5226 | 50 | 50 |
| D5282 | 50 | 50 |
| D5283 | 50 | 50 |
| D5284 | 50 | 50 |
| D5286 | 50 | 50 |
| D5410 | 75 | 75 |
| D5411 | 75 | 75 |
| D5421 | 75 | 75 |
| D5422 | 75 | 75 |
| D5511 | 75 | 75 |
| D5512 | 75 | 75 |
| D5520 | 75 | 75 |
| D5611 | 75 | 75 |
| D5612 | 75 | 75 |
| D5621 | 75 | 75 |
| D5622 | 75 | 75 |
| D5630 | 75 | 75 |
| D5640 | 75 | 75 |
| D5650 | 75 | 75 |
| D5660 | 75 | 75 |
| D5670 | 75 | 75 |
| D5671 | 75 | 75 |
| D5710 | 75 | 75 |
| D5711 | 75 | 75 |
| D5720 | 75 | 75 |
| D5721 | 75 | 75 |
| D5730 | 75 | 75 |
| D5731 | 75 | 75 |
| D5740 | 75 | 75 |
| D5741 | 75 | 75 |
| D5750 | 75 | 75 |
| D5751 | 75 | 75 |
| D5760 | 75 | 75 |
| D5761 | 75 | 75 |
| D5810 | Not Covered | Not Covered |
| D5811 | Not Covered | Not Covered |
| D5820 | 50 | 50 |
| D5821 | 50 | 50 |
| D5850 | 75 | 75 |
| D5851 | 75 | 75 |
| D5862 | Not Covered | Not Covered |
| D5863 | Optional | Optional |
| D5864 | Optional | Optional |
| D5865 | Optional | Optional |
| D5866 | Optional | Optional |
| D5867 | Not Covered | Not Covered |
| D5875 | 50 | 50 |
| D5876 | Not Covered | Not Covered |
| D5899 | 50 | 50 |
| D5911 | Not Covered | Not Covered |
| D5912 | Not Covered | Not Covered |
| D5913 | Not Covered | Not Covered |
| D5914 | Not Covered | Not Covered |
| D5915 | Not Covered | Not Covered |
| D5916 | Not Covered | Not Covered |
| D5919 | Not Covered | Not Covered |
| D5922 | Not Covered | Not Covered |
| D5923 | Not Covered | Not Covered |
| D5924 | Not Covered | Not Covered |
| D5925 | Not Covered | Not Covered |
| D5926 | Not Covered | Not Covered |
| D5927 | Not Covered | Not Covered |
| D5928 | Not Covered | Not Covered |
| D5929 | Not Covered | Not Covered |
| D5931 | 50 | 50 |
| D5932 | Not Covered | Not Covered |
| D5933 | Not Covered | Not Covered |
| D5934 | Not Covered | Not Covered |
| D5935 | Not Covered | Not Covered |
| D5936 | Not Covered | Not Covered |
| D5937 | Not Covered | Not Covered |
| D5951 | Not Covered | Not Covered |
| D5952 | Not Covered | Not Covered |
| D5953 | Not Covered | Not Covered |
| D5954 | Not Covered | Not Covered |
| D5955 | Not Covered | Not Covered |
| D5958 | Not Covered | Not Covered |
| D5959 | Not Covered | Not Covered |
| D5960 | Not Covered | Not Covered |
| D5982 | Not Covered | Not Covered |
| D5983 | Not Covered | Not Covered |
| D5984 | Not Covered | Not Covered |
| D5985 | Not Covered | Not Covered |
| D5986 | Not Covered | Not Covered |
| D5987 | Not Covered | Not Covered |
| D5988 | Not Covered | Not Covered |
| D5991 | Not Covered | Not Covered |
| D5992 | Not Covered | Not Covered |
| D5993 | Not Covered | Not Covered |
| D5994 | Not Covered | Not Covered |
| D5999 | 50 | 50 |
| D6010 | 50 | 50 |
| D6011 | Not Covered | Not Covered |
| D6012 | Not Covered | Not Covered |
| D6013 | 50 | 50 |
| D6040 | Not Covered | Not Covered |
| D6050 | Not Covered | Not Covered |
| D6051 | Not Covered | Not Covered |
| D6052 | Not Covered | Not Covered |
| D6055 | Not Covered | Not Covered |
| D6056 | 50 | 50 |
| D6057 | 50 | 50 |
| D6058 | 50 | 50 |
| D6059 | 50 | 50 |
| D6060 | 50 | 50 |
| D6061 | 50 | 50 |
| D6062 | 50 | 50 |
| D6063 | 50 | 50 |
| D6064 | 50 | 50 |
| D6065 | 50 | 50 |
| D6066 | 50 | 50 |
| D6067 | 50 | 50 |
| D6068 | 50 | 50 |
| D6069 | 50 | 50 |
| D6070 | 50 | 50 |
| D6071 | 50 | 50 |
| D6072 | 50 | 50 |
| D6073 | 50 | 50 |
| D6074 | 50 | 50 |
| D6075 | 50 | 50 |
| D6076 | 50 | 50 |
| D6077 | 50 | 50 |
| D6080 | 75 | 75 |
| D6081 | 75 | 75 |
| D6082 | 50 | 50 |
| D6083 | 50 | 50 |
| D6084 | 50 | 50 |
| D6085 | Not Covered | Not Covered |
| D6086 | 50 | 50 |
| D6087 | 50 | 50 |
| D6088 | 50 | 50 |
| D6090 | 75 | 75 |
| D6091 | Not Covered | Not Covered |
| D6092 | 75 | 75 |
| D6093 | 75 | 75 |
| D6094 | 50 | 50 |
| D6095 | 75 | 75 |
| D6096 | 75 | 75 |
| D6097 | 50 | 50 |
| D6098 | 50 | 50 |
| D6099 | 50 | 50 |
| D6100 | 75 | 75 |
| D6101 | 50 | 50 |
| D6102 | 50 | 50 |
| D6103 | Not Covered | Not Covered |
| D6104 | Not Covered | Not Covered |
| D6110 | Optional | Optional |
| D6111 | Optional | Optional |
| D6112 | Optional | Optional |
| D6113 | Optional | Optional |
| D6114 | Optional | Optional |
| D6115 | Optional | Optional |
| D6116 | Optional | Optional |
| D6117 | Optional | Optional |
| D6118 | Not Covered | Not Covered |
| D6119 | Not Covered | Not Covered |
| D6120 | 50 | 50 |
| D6121 | 50 | 50 |
| D6122 | 50 | 50 |
| D6123 | 50 | 50 |
| D6190 | Not Covered | Not Covered |
| D6194 | 50 | 50 |
| D6195 | 50 | 50 |
| D6199 | 75 | 75 |
| D6205 | Optional | Optional |
| D6210 | 50 | 50 |
| D6211 | 50 | 50 |
| D6212 | 50 | 50 |
| D6214 | 50 | 50 |
| D6240 | 50 | 50 |
| D6241 | 50 | 50 |
| D6242 | 50 | 50 |
| D6243 | 50 | 50 |
| D6245 | Optional | Optional |
| D6250 | 50 | 50 |
| D6251 | 50 | 50 |
| D6252 | 50 | 50 |
| D6253 | Not Covered | Not Covered |
| D6545 | 50 | 50 |
| D6548 | Optional | Optional |
| D6549 | Optional | Optional |
| D6600 | Optional | Optional |
| D6601 | Optional | Optional |
| D6602 | 50 | 50 |
| D6603 | 50 | 50 |
| D6604 | 50 | 50 |
| D6605 | 50 | 50 |
| D6606 | 50 | 50 |
| D6607 | 50 | 50 |
| D6608 | Optional | Optional |
| D6609 | Optional | Optional |
| D6610 | 50 | 50 |
| D6611 | 50 | 50 |
| D6612 | 50 | 50 |
| D6613 | 50 | 50 |
| D6614 | 50 | 50 |
| D6615 | 50 | 50 |
| D6624 | 50 | 50 |
| D6634 | 50 | 50 |
| D6710 | Optional | Optional |
| D6720 | 50 | 50 |
| D6721 | 50 | 50 |
| D6722 | 50 | 50 |
| D6740 | Optional | Optional |
| D6750 | 50 | 50 |
| D6751 | 50 | 50 |
| D6752 | 50 | 50 |
| D6753 | 50 | 50 |
| D6780 | 50 | 50 |
| D6781 | 50 | 50 |
| D6782 | 50 | 50 |
| D6783 | Optional | Optional |
| D6784 | 50 | 50 |
| D6790 | 50 | 50 |
| D6791 | 50 | 50 |
| D6792 | 50 | 50 |
| D6793 | Not Covered | Not Covered |
| D6794 | 50 | 50 |
| D6920 | Not Covered | Not Covered |
| D6930 | 75 | 75 |
| D6940 | Not Covered | Not Covered |
| D6950 | Not Covered | Not Covered |
| D6980 | 75 | 75 |
| D6985 | Not Covered | Not Covered |
| D6999 | 50 | 50 |
| D7111 | 75 | 75 |
| D7140 | 75 | 75 |
| D7210 | 75 | 75 |
| D7220 | 75 | 75 |
| D7230 | 75 | 75 |
| D7240 | 75 | 75 |
| D7241 | 75 | 75 |
| D7250 | 75 | 75 |
| D7251 | 75 | 75 |
| D7260 | Not Covered | Not Covered |
| D7261 | Not Covered | Not Covered |
| D7270 | 75 | 75 |
| D7272 | Not Covered | Not Covered |
| D7280 | 75 | 75 |
| D7282 | 75 | 75 |
| D7283 | 75 | 75 |
| D7285 | Not Covered | Not Covered |
| D7286 | 75 | 75 |
| D7287 | Not Covered | Not Covered |
| D7288 | 0 | 0 |
| D7290 | 75 | 75 |
| D7291 | 75 | 75 |
| D7292 | Not Covered | Not Covered |
| D7293 | Not Covered | Not Covered |
| D7294 | Not Covered | Not Covered |
| D7295 | Not Covered | Not Covered |
| D7296 | Not Covered | Not Covered |
| D7297 | Not Covered | Not Covered |
| D7310 | 75 | 75 |
| D7311 | 75 | 75 |
| D7320 | 75 | 75 |
| D7321 | 75 | 75 |
| D7340 | Not Covered | Not Covered |
| D7350 | Not Covered | Not Covered |
| D7410 | Not Covered | Not Covered |
| D7411 | Not Covered | Not Covered |
| D7412 | Not Covered | Not Covered |
| D7413 | Not Covered | Not Covered |
| D7414 | Not Covered | Not Covered |
| D7415 | Not Covered | Not Covered |
| D7440 | Not Covered | Not Covered |
| D7441 | Not Covered | Not Covered |
| D7450 | Not Covered | Not Covered |
| D7451 | Not Covered | Not Covered |
| D7460 | Not Covered | Not Covered |
| D7461 | Not Covered | Not Covered |
| D7465 | Not Covered | Not Covered |
| D7471 | Not Covered | Not Covered |
| D7472 | Not Covered | Not Covered |
| D7473 | Not Covered | Not Covered |
| D7485 | Not Covered | Not Covered |
| D7490 | Not Covered | Not Covered |
| D7510 | 75 | 75 |
| D7511 | 75 | 75 |
| D7520 | Not Covered | Not Covered |
| D7521 | Not Covered | Not Covered |
| D7530 | Not Covered | Not Covered |
| D7540 | Not Covered | Not Covered |
| D7550 | Not Covered | Not Covered |
| D7560 | Not Covered | Not Covered |
| D7610 | Not Covered | Not Covered |
| D7620 | Not Covered | Not Covered |
| D7630 | Not Covered | Not Covered |
| D7640 | Not Covered | Not Covered |
| D7650 | Not Covered | Not Covered |
| D7660 | Not Covered | Not Covered |
| D7670 | Not Covered | Not Covered |
| D7671 | Not Covered | Not Covered |
| D7680 | Not Covered | Not Covered |
| D7710 | Not Covered | Not Covered |
| D7720 | Not Covered | Not Covered |
| D7730 | Not Covered | Not Covered |
| D7740 | Not Covered | Not Covered |
| D7750 | Not Covered | Not Covered |
| D7760 | Not Covered | Not Covered |
| D7770 | Not Covered | Not Covered |
| D7771 | Not Covered | Not Covered |
| D7780 | Not Covered | Not Covered |
| D7810 | Not Covered | Not Covered |
| D7820 | Not Covered | Not Covered |
| D7830 | Not Covered | Not Covered |
| D7840 | Not Covered | Not Covered |
| D7850 | Not Covered | Not Covered |
| D7852 | Not Covered | Not Covered |
| D7854 | Not Covered | Not Covered |
| D7856 | Not Covered | Not Covered |
| D7858 | Not Covered | Not Covered |
| D7860 | Not Covered | Not Covered |
| D7865 | Not Covered | Not Covered |
| D7870 | Not Covered | Not Covered |
| D7871 | Not Covered | Not Covered |
| D7872 | Not Covered | Not Covered |
| D7873 | Not Covered | Not Covered |
| D7874 | Not Covered | Not Covered |
| D7875 | Not Covered | Not Covered |
| D7876 | Not Covered | Not Covered |
| D7877 | Not Covered | Not Covered |
| D7880 | Not Covered | Not Covered |
| D7881 | Not Covered | Not Covered |
| D7899 | Not Covered | Not Covered |
| D7910 | 75 | 75 |
| D7911 | Not Covered | Not Covered |
| D7912 | Not Covered | Not Covered |
| D7920 | Not Covered | Not Covered |
| D7921 | Not Covered | Not Covered |
| D7922 | Not Covered | Not Covered |
| D7940 | Not Covered | Not Covered |
| D7941 | Not Covered | Not Covered |
| D7943 | Not Covered | Not Covered |
| D7944 | Not Covered | Not Covered |
| D7945 | Not Covered | Not Covered |
| D7946 | Not Covered | Not Covered |
| D7947 | Not Covered | Not Covered |
| D7948 | Not Covered | Not Covered |
| D7949 | Not Covered | Not Covered |
| D7950 | Not Covered | Not Covered |
| D7951 | Not Covered | Not Covered |
| D7952 | Not Covered | Not Covered |
| D7953 | Not Covered | Not Covered |
| D7955 | Not Covered | Not Covered |
| D7960 | Not Covered | Not Covered |
| D7963 | Not Covered | Not Covered |
| D7970 | 75 | 75 |
| D7971 | 75 | 75 |
| D7972 | Not Covered | Not Covered |
| D7979 | Not Covered | Not Covered |
| D7980 | Not Covered | Not Covered |
| D7981 | Not Covered | Not Covered |
| D7982 | Not Covered | Not Covered |
| D7983 | Not Covered | Not Covered |
| D7990 | Not Covered | Not Covered |
| D7991 | Not Covered | Not Covered |
| D7995 | Not Covered | Not Covered |
| D7996 | Not Covered | Not Covered |
| D7997 | Not Covered | Not Covered |
| D7998 | Not Covered | Not Covered |
| D7999 | 75 | 75 |
| D8010 | 50 | 50 |
| D8020 | 50 | 50 |
| D8030 | 50 | 50 |
| D8040 | 50 | 50 |
| D8050 | 50 | 50 |
| D8060 | 50 | 50 |
| D8070 | 50 | 50 |
| D8080 | 50 | 50 |
| D8090 | 50 | 50 |
| D8210 | 50 | 50 |
| D8220 | 50 | 50 |
| D8660 | 50 | 50 |
| D8670 | 50 | 50 |
| D8680 | 50 | 50 |
| D8681 | Not Covered | Not Covered |
| D8690 | 50 | 50 |
| D8695 | Not Covered | Not Covered |
| D8696 | Not Covered | Not Covered |
| D8697 | Not Covered | Not Covered |
| D8698 | Not Covered | Not Covered |
| D8699 | Not Covered | Not Covered |
| D8701 | Not Covered | Not Covered |
| D8702 | Not Covered | Not Covered |
| D8703 | Not Covered | Not Covered |
| D8704 | Not Covered | Not Covered |
| D8999 | 50 | 50 |
| D9110 | 95 | 90 |
| D9120 | 75 | 75 |
| D9130 | Not Covered | Not Covered |
| D9210 | Not Covered | Not Covered |
| D9211 | Not Covered | Not Covered |
| D9212 | Not Covered | Not Covered |
| D9215 | Not Covered | Not Covered |
| D9219 | Not Covered | Not Covered |
| D9222 | 75 | 75 |
| D9223 | 75 | 75 |
| D9230 | Not Covered | Not Covered |
| D9239 | 75 | 75 |
| D9243 | 75 | 75 |
| D9248 | 75 | 75 |
| D9310 | 75 | 75 |
| D9311 | Not Covered | Not Covered |
| D9410 | 75 | 75 |
| D9420 | 75 | 75 |
| D9430 | Not Covered | Not Covered |
| D9440 | 95 | 90 |
| D9450 | Not Covered | Not Covered |
| D9610 | Not Covered | Not Covered |
| D9612 | Not Covered | Not Covered |
| D9613 | Not Covered | Not Covered |
| D9630 | Not Covered | Not Covered |
| D9910 | Not Covered | Not Covered |
| D9911 | Not Covered | Not Covered |
| D9920 | 75 | 75 |
| D9930 | 75 | 75 |
| D9932 | Not Covered | Not Covered |
| D9933 | Not Covered | Not Covered |
| D9934 | Not Covered | Not Covered |
| D9935 | Not Covered | Not Covered |
| D9941 | Not Covered | Not Covered |
| D9942 | Not Covered | Not Covered |
| D9943 | Not Covered | Not Covered |
| D9944 | 75 | 75 |
| D9945 | Not Covered | Not Covered |
| D9946 | 75 | 75 |
| D9950 | Not Covered | Not Covered |
| D9951 | 75 | 75 |
| D9952 | 75 | 75 |
| D9961 | Not Covered | Not Covered |
| D9970 | Not Covered | Not Covered |
| D9971 | Not Covered | Not Covered |
| D9972 | Not Covered | Not Covered |
| D9973 | Not Covered | Not Covered |
| D9974 | Not Covered | Not Covered |
| D9975 | Not Covered | Not Covered |
| D9985 | Not Covered | Not Covered |
| D9986 | Not Covered | Not Covered |
| D9987 | Not Covered | Not Covered |
| D9990 | Not Covered | Not Covered |
| D9991 | Not Covered | Not Covered |
| D9992 | Not Covered | Not Covered |
| D9993 | Not Covered | Not Covered |
| D9994 | Not Covered | Not Covered |
| D9995 | Not Covered | Not Covered |
| D9996 | Not Covered | Not Covered |
| D9997 | Not Covered | Not Covered |
| D9999 | 75 | 75 |
File details come from the government source that posted it. Updated .