Reimbursement Policy UB-04 Policy Number 2020F7013C Proprietary information of UnitedHealthcare Community Plan. Copyright 2020 United HealthCare Services, Inc. 2020F7013C Add-on Codes Policy, Facility IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT ® *), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts, the enrollee’s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. *CPT Copyright American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. Application This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products. This reimbursement policy applies to services reported using the UB-04 Health Insurance Claim Form or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network facilities and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract facilities. Policy Overview Add-on codes are reimbursable services when reported in addition to the appropriate primary service by the Same Facility reporting the same Federal Tax Identification Number unless otherwise specified within the policy. Add-on codes reported as Stand-alone codes are not reimbursable services in accordance with Current Procedural Terminology (CPT®) and the Centers for Medicare and Medicaid Services (CMS) guidelines. For the purpose of this policy, the Same Facility is the same facility rendering health care services reporting the same Federal Tax Identification number. Reimbursement Guidelines The basis for Add-on codes is to enable providers to separately identify a service that is performed in certain situations as an additional service or a commonly performed supplemental service complementary to the primary service/procedure. UnitedHealthcare Community Plan follows the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) with respect to the reporting of “Add-on” CPT and HCPCS codes. Per CPT, Add-on codes
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Reimbursement Policy
UB-04 Policy Number 2020F7013C
Proprietary information of UnitedHealthcare Community Plan. Copyright 2020 United HealthCare Services, Inc. 2020F7013C
Add-on Codes Policy, Facility
IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts,
the enrollee’s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. *CPT Copyright American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
Application
This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products. This reimbursement policy applies to services reported using the UB-04 Health Insurance Claim Form or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network facilities and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract facilities.
Policy
Overview
Add-on codes are reimbursable services when reported in addition to the appropriate primary service by the Same Facility reporting the same Federal Tax Identification Number unless otherwise specified within the policy. Add-on codes reported as Stand-alone codes are not reimbursable services in accordance with Current Procedural Terminology (CPT®) and the Centers for Medicare and Medicaid Services (CMS) guidelines. For the purpose of this policy, the Same Facility is the same facility rendering health care services reporting the same Federal Tax Identification number.
Reimbursement Guidelines
The basis for Add-on codes is to enable providers to separately identify a service that is performed in certain situations as an additional service or a commonly performed supplemental service complementary to the primary service/procedure.
UnitedHealthcare Community Plan follows the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) with respect to the reporting of “Add-on” CPT and HCPCS codes. Per CPT, Add-on codes
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Reimbursement Policy
UB-04 Policy Number 2020F7013C
Proprietary information of UnitedHealthcare Community Plan. Copyright 2020 United HealthCare Services, Inc. 2020F7013C
describe additional intra-service work associated with a primary procedure/service, are always reported in addition to the primary service/procedure, and must be performed by the Same Facility reporting the primary service/procedure. Many Add-on codes are designated by the AMA with a “+” symbol and are also listed in Appendix D of the CPT book.
In some instances, a Definitive Source specifies the primary procedure/service codes that must be reported in conjunction with a given Add-on code. In other situations, a primary/add-on code relationship may exist but the guidance from CPT or CMS is not as well-defined. Specifically, the code description does not directly identify the Add-on code or identify any specific primary codes that correspond with that code. In those instances an interpretation is necessary utilizing CPT, CMS and/or specialty society guidelines. UnitedHealthcare Community Plan will interpret these sources to identify additional primary/add-on relationships. For these code pairs, UnitedHealthcare Community Plan also requires that the Add-on code must be reported with a given primary procedure/service code. Please see the Definitions section below for further explanations of Definitive and Interpretive Sources.
Key phrases to identify Add-on codes when not specified in the code description, include, but are not limited to, the following:
list separately in addition to; and each additional; and done at time of other major procedure.
Unless otherwise specified within this policy, add-on procedures must be reported with the primary procedure for the same date of service.
Mohs Micrographic Surgery The Mohs micrographic surgery codes (CPT codes 17311, +17312, 17313, +17314, +17315), describe procedures that involve surgery and pathology services performed together by the same provider. In some instances, the Mohs surgical procedure may extend beyond the initial date of service, thus there are 3 Add-on codes (+17312, +17314 and +17315) that might be performed on a different date of service than their primary procedure. The Add-on code should be reported on same claim as the primary Mohs procedure even though the dates of service may differ.
Infusion Services Hospitals should report only one initial drug administration service, including infusion services, per encounter for each distinct vascular access site, with other services through the same vascular access site being reported via the sequential, concurrent or additional hour codes. Therefore, for Infusion services, the add-on code is not required to be billed for the same date of service as the initial drug service. However, both the initial drug service and the corresponding add-on code must be reported on the same claim.
Note: All services described in this policy may be subject to other UnitedHealthcare Community Plan reimbursement policies.
State Exceptions
Florida
C&S Medicaid facility claims are paid under Ambulatory Patient Groups, or APG payment methodology, and are excluded from this policy.
Nebraska C&S Medicaid facility claims are paid under Ambulatory Patient Groups, or APG payment methodology, and are excluded from this policy.
New York
C&S Medicaid facility claims are paid under Ambulatory Patient Groups, or APG payment methodology, and are excluded from this policy.
Ohio C&S Medicaid facility claims are paid under Ambulatory Patient Groups, or APG payment methodology, and are excluded from this policy.
Virginia
C&S Medicaid facility claims are paid under Ambulatory Patient Groups, or APG payment methodology, and are excluded from this policy.
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Reimbursement Policy
UB-04 Policy Number 2020F7013C
Proprietary information of UnitedHealthcare Community Plan. Copyright 2020 United HealthCare Services, Inc. 2020F7013C
Washington
C&S Medicaid facility claims are paid under Ambulatory Patient Groups, or APG payment methodology, and are excluded from this policy.
Wisconsin
C&S Medicaid facility claims are paid under Ambulatory Patient Groups, or APG payment methodology, and are excluded from this policy.
Definitions
Add-on code Add-on codes describe additional intra-service work associated with the primary service/procedure.
Same Facility The same Facility rendering health care services reporting the same Federal Tax Identification number.
Stand-alone code A code reported without another primary service/procedure code by the Same Individual Physician or Other Health Care Professional.
Definitive Source Definitive Sources contain the exact codes, modifiers or very specific instructions from the given source.
Interpretive Source An edit source that includes guidelines; however, no exact or specific code or modifier information is listed. Therefore, an interpretation must be made as to what codes correlate to the guidelines. Additionally, an interpretation may be applied to surrounding or similar codes based on related definitively sourced edits.
Questions and Answers
1
Q: How has UnitedHealthcare Community Plan determined which codes are “Add-on” codes that must be reported with a primary service?
A: The policy follows CPT guidelines for those codes designated with a “+” symbol. These codes are considered to be Add-on codes by UnitedHealthcare Community Plan.
2
Q: Does UnitedHealthcare Community Plan require the Add-on code be submitted on the same claim as the primary code?
A: No. The Add-on code may be reported on a separate claim submission from the primary code; however it is recommended the Add-on and primary procedure codes be reported on the same claim form.
Attachments
UnitedHealthcare Community Plan Add On to Primary Code Relationship
List
This table includes Add-on codes which will only be reimbursed when reported with the appropriate primary code.
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Add-on Code Primary Code
0054T 22840
0054T 22842
0054T 22843
0054T 22844
0054T 27120
0054T 27122
0054T 27125
0054T 27130
0054T 27132
0054T 27134
0054T 27137
0054T 27138
0054T 27140
0054T 27146
0054T 27147
0054T 27151
0054T 27156
0054T 27158
0054T 27161
0054T 27165
0054T 27170
0054T 27175
0054T 27176
0054T 27177
0054T 27178
0054T 27179
0054T 27181
0054T 27185
0054T 27187
0054T 27200
0054T 27202
0054T 27215
0054T 27216
0054T 27217
0054T 27218
0054T 27220
0054T 27222
0054T 27226
0054T 27227
0054T 27228
0054T 27230
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
Page 1 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0054T 27232
0054T 27235
0054T 27236
0054T 27238
0054T 27240
0054T 27244
0054T 27245
0054T 27246
0054T 27248
0054T 27250
0054T 27252
0054T 27253
0054T 27254
0054T 27256
0054T 27257
0054T 27258
0054T 27259
0054T 27265
0054T 27266
0054T 27267
0054T 27268
0054T 27269
0054T 27405
0054T 27407
0054T 27409
0054T 27437
0054T 27438
0054T 27440
0054T 27441
0054T 27442
0054T 27443
0054T 27445
0054T 27446
0054T 27447
0054T 27448
0054T 27450
0054T 27454
0054T 27455
0054T 27457
0054T 27465
0054T 27466
Page 2 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0054T 27468
0054T 27470
0054T 27472
0054T 27475
0054T 27477
0054T 27479
0054T 27485
0054T 27486
0054T 27487
0054T 27500
0054T 27501
0054T 27502
0054T 27503
0054T 27506
0054T 27507
0054T 27508
0054T 27509
0054T 27510
0054T 27511
0054T 27513
0054T 27514
0054T 27516
0054T 27517
0054T 27519
0054T 27520
0054T 27524
0054T 27530
0054T 27532
0054T 27535
0054T 27536
0054T 27538
0054T 27540
0054T 27550
0054T 27552
0054T 27556
0054T 27557
0054T 27558
0054T 27560
0054T 27562
0054T 27566
0054T 27705
Page 3 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0054T 27707
0054T 27709
0054T 27712
0054T 27715
0054T 27720
0054T 27722
0054T 27724
0054T 27725
0054T 29850
0054T 29851
0054T 29855
0054T 29856
0054T 29888
0054T 29889
0055T 22840
0055T 22842
0055T 22843
0055T 22844
0055T 27120
0055T 27122
0055T 27125
0055T 27130
0055T 27132
0055T 27134
0055T 27137
0055T 27138
0055T 27140
0055T 27146
0055T 27147
0055T 27151
0055T 27156
0055T 27158
0055T 27161
0055T 27165
0055T 27170
0055T 27175
0055T 27176
0055T 27177
0055T 27178
0055T 27179
0055T 27181
Page 4 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0055T 27185
0055T 27187
0055T 27200
0055T 27202
0055T 27215
0055T 27216
0055T 27217
0055T 27218
0055T 27220
0055T 27222
0055T 27226
0055T 27227
0055T 27228
0055T 27230
0055T 27232
0055T 27235
0055T 27236
0055T 27238
0055T 27240
0055T 27244
0055T 27245
0055T 27246
0055T 27248
0055T 27250
0055T 27252
0055T 27253
0055T 27254
0055T 27256
0055T 27257
0055T 27258
0055T 27259
0055T 27265
0055T 27266
0055T 27267
0055T 27268
0055T 27269
0055T 27405
0055T 27407
0055T 27409
0055T 27437
0055T 27438
Page 5 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0055T 27440
0055T 27441
0055T 27442
0055T 27443
0055T 27445
0055T 27446
0055T 27447
0055T 27448
0055T 27450
0055T 27454
0055T 27455
0055T 27457
0055T 27465
0055T 27466
0055T 27468
0055T 27470
0055T 27472
0055T 27475
0055T 27477
0055T 27479
0055T 27485
0055T 27486
0055T 27487
0055T 27500
0055T 27501
0055T 27502
0055T 27503
0055T 27506
0055T 27507
0055T 27508
0055T 27509
0055T 27510
0055T 27511
0055T 27513
0055T 27514
0055T 27516
0055T 27517
0055T 27519
0055T 27520
0055T 27524
0055T 27530
Page 6 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0055T 27532
0055T 27535
0055T 27536
0055T 27538
0055T 27540
0055T 27550
0055T 27552
0055T 27556
0055T 27557
0055T 27558
0055T 27560
0055T 27562
0055T 27566
0055T 27705
0055T 27707
0055T 27709
0055T 27712
0055T 27715
0055T 27720
0055T 27722
0055T 27724
0055T 27725
0055T 29850
0055T 29851
0055T 29855
0055T 29856
0055T 29888
0055T 29889
0071U 0070U
0072U 0070U
0073U 0070U
0074U 0070U
0075U 0070U
0076T 0075T
0076U 0070U
0095T 22864
0098T 22861
0130U 81435
0130U 0101U
0131U 81162
0131U 81432
Page 7 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0131U 0102U
0132U 81162
0132U 81432
0132U 0103U
0133U 81162
0134U 81162
0134U 81432
0134U 81435
0135U 81162
0136U 81408
0137U 81307
0138U 81162
0157U 81201
0158U 81292
0159U 81295
0160U 81298
0161U 81317
0162U 81292
0162U 81295
0162U 81298
0162U 81317
0162U 81435
0163T 22857
0164T 22865
0165T 22862
0174T 71045
0174T 71046
0174T 71047
0174T 71048
01953 01952
0205T 92920
0205T 92924
0205T 92928
0205T 92933
0205T 92937
0205T 92941
0205T 92943
0205T 92975
0205T 93454
0205T 93455
0205T 93456
Page 8 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0205T 93457
0205T 93458
0205T 93459
0205T 93460
0205T 93461
0205T 93563
0205T 93564
0214T 0213T
0215T 0213T
0215T 0214T
0217T 0216T
0218T 0216T
0218T 0217T
0222T 0219T
0222T 0220T
0222T 0221T
0229T 0228T
0231T 0230T
0290T 65710
0290T 65730
0290T 65750
0290T 65755
0376T 0191T
0396T 27445
0396T 27446
0396T 27447
0396T 27486
0396T 27487
0396T 27488
0397T 43260
0397T 43261
0397T 43262
0397T 43263
0397T 43264
0397T 43265
0397T 43274
0397T 43275
0397T 43276
0397T 43277
0397T 43278
0399T 93303
Page 9 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0399T 93304
0399T 93306
0399T 93307
0399T 93308
0399T 93312
0399T 93314
0399T 93315
0399T 93317
0399T 93350
0399T 93351
0399T 93355
0437T 15734
0437T 19364
0437T 19367
0437T 19368
0437T 19369
0437T 38100
0437T 38101
0437T 38115
0437T 38120
0437T 38382
0437T 38562
0437T 38564
0437T 38570
0437T 38571
0437T 38572
0437T 38770
0437T 38780
0437T 39503
0437T 39540
0437T 39541
0437T 39545
0437T 39561
0437T 43101
0437T 43107
0437T 43108
0437T 43112
0437T 43113
0437T 43116
0437T 43117
0437T 43118
Page 10 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0437T 43122
0437T 43123
0437T 43124
0437T 43279
0437T 43280
0437T 43320
0437T 43325
0437T 43327
0437T 43330
0437T 43340
0437T 43360
0437T 43361
0437T 43415
0437T 43425
0437T 43496
0437T 43500
0437T 43501
0437T 43502
0437T 43510
0437T 43520
0437T 43605
0437T 43610
0437T 43611
0437T 43620
0437T 43621
0437T 43622
0437T 43631
0437T 43632
0437T 43633
0437T 43634
0437T 43640
0437T 43641
0437T 43644
0437T 43645
0437T 43653
0437T 43770
0437T 43771
0437T 43772
0437T 43773
0437T 43774
0437T 43775
Page 11 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0437T 43800
0437T 43810
0437T 43820
0437T 43825
0437T 43830
0437T 43831
0437T 43832
0437T 43840
0437T 43842
0437T 43843
0437T 43845
0437T 43846
0437T 43847
0437T 43848
0437T 43850
0437T 43855
0437T 43860
0437T 43865
0437T 43870
0437T 43880
0437T 43886
0437T 43887
0437T 43888
0437T 44005
0437T 44010
0437T 44020
0437T 44021
0437T 44025
0437T 44050
0437T 44055
0437T 44110
0437T 44111
0437T 44120
0437T 44125
0437T 44126
0437T 44127
0437T 44130
0437T 44133
0437T 44135
0437T 44136
0437T 44137
Page 12 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0437T 44140
0437T 44141
0437T 44143
0437T 44144
0437T 44145
0437T 44146
0437T 44147
0437T 44150
0437T 44151
0437T 44155
0437T 44156
0437T 44157
0437T 44158
0437T 44160
0437T 44180
0437T 44186
0437T 44187
0437T 44188
0437T 44202
0437T 44204
0437T 44205
0437T 44206
0437T 44207
0437T 44208
0437T 44210
0437T 44211
0437T 44212
0437T 44227
0437T 44300
0437T 44310
0437T 44312
0437T 44314
0437T 44316
0437T 44320
0437T 44322
0437T 44340
0437T 44345
0437T 44346
0437T 44602
0437T 44603
0437T 44604
Page 13 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0437T 44605
0437T 44615
0437T 44620
0437T 44625
0437T 44626
0437T 44640
0437T 44650
0437T 44660
0437T 44661
0437T 44680
0437T 44800
0437T 44820
0437T 44850
0437T 44900
0437T 44950
0437T 44960
0437T 44970
0437T 45110
0437T 45111
0437T 45112
0437T 45113
0437T 45114
0437T 45119
0437T 45120
0437T 45121
0437T 45126
0437T 45135
0437T 45136
0437T 45395
0437T 45397
0437T 45400
0437T 45402
0437T 45540
0437T 45550
0437T 45562
0437T 45563
0437T 45800
0437T 45805
0437T 45820
0437T 45825
0437T 46712
Page 14 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0437T 46735
0437T 46742
0437T 46746
0437T 46748
0437T 47010
0437T 47015
0437T 47100
0437T 47120
0437T 47122
0437T 47125
0437T 47130
0437T 47135
0437T 47140
0437T 47141
0437T 47142
0437T 47300
0437T 47350
0437T 47360
0437T 47361
0437T 47362
0437T 47370
0437T 47371
0437T 47380
0437T 47381
0437T 47400
0437T 47420
0437T 47425
0437T 47460
0437T 47480
0437T 47562
0437T 47563
0437T 47564
0437T 47570
0437T 47600
0437T 47605
0437T 47610
0437T 47612
0437T 47620
0437T 47700
0437T 47701
0437T 47711
Page 15 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0437T 47712
0437T 47715
0437T 47720
0437T 47721
0437T 47740
0437T 47741
0437T 47760
0437T 47765
0437T 47780
0437T 47785
0437T 47800
0437T 47802
0437T 47900
0437T 48100
0437T 48105
0437T 48120
0437T 48140
0437T 48145
0437T 48146
0437T 48148
0437T 48150
0437T 48152
0437T 48153
0437T 48154
0437T 48155
0437T 48160
0437T 48520
0437T 48540
0437T 48545
0437T 48547
0437T 48548
0437T 48554
0437T 48556
0437T 49000
0437T 49002
0437T 49010
0437T 49203
0437T 49204
0437T 49205
0437T 49215
0437T 49220
Page 16 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
0437T 49250
0437T 49255
0437T 49325
0437T 49402
0437T 49900
0437T 49904
0437T 49906
0437T 50040
0437T 50045
0437T 50060
0437T 50065
0437T 50070
0437T 50075
0437T 50100
0437T 50120
0437T 50125
0437T 50130
0437T 50135
0437T 50205
0437T 50220
0437T 50225
0437T 50230
0437T 50234
0437T 50236
0437T 50240
0437T 50250
0437T 50280
0437T 50290
0437T 50320
0437T 50340
0437T 50360
0437T 50365
0437T 50370
0437T 50380
0437T 50400
0437T 50405
0437T 50500
0437T 50525
0437T 50540
0437T 50541
0437T 50542
Page 17 of 1139
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0437T 50543
0437T 50544
0437T 50545
0437T 50546
0437T 50547
0437T 50548
0437T 50600
0437T 50605
0437T 50610
0437T 50620
0437T 50630
0437T 50650
0437T 50660
0437T 50700
0437T 50715
0437T 50722
0437T 50725
0437T 50727
0437T 50728
0437T 50740
0437T 50750
0437T 50760
0437T 50770
0437T 50780
0437T 50782
0437T 50783
0437T 50785
0437T 50800
0437T 50810
0437T 50815
0437T 50820
0437T 50825
0437T 50830
0437T 50840
0437T 50845
0437T 50860
0437T 50900
0437T 50920
0437T 50930
0437T 50940
0437T 50945
Page 18 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
0437T 50947
0437T 50948
0437T 51040
0437T 51045
0437T 51050
0437T 51060
0437T 51065
0437T 51080
0437T 51500
0437T 51520
0437T 51525
0437T 51530
0437T 51535
0437T 51550
0437T 51555
0437T 51565
0437T 51570
0437T 51575
0437T 51580
0437T 51585
0437T 51590
0437T 51595
0437T 51596
0437T 51597
0437T 51900
0437T 51960
0437T 54535
0437T 54560
0437T 54650
0437T 54692
0437T 55535
0437T 57270
0437T 57280
0437T 57284
0437T 57296
0437T 57305
0437T 57307
0437T 57540
0437T 57545
0437T 58140
0437T 58146
Page 19 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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0437T 58150
0437T 58152
0437T 58180
0437T 58200
0437T 58210
0437T 58240
0437T 58600
0437T 58605
0437T 58805
0437T 58822
0437T 58951
0437T 58952
0437T 58953
0437T 58956
0437T 58957
0437T 58960
0437T 59100
0437T 59120
0437T 59130
0437T 59325
0439T 93306
0439T 93307
0439T 93308
0439T 93350
0439T 93351
0443T 55700
0450T 0449T
0466T 64568
0471T 0470T
0480T 0479T
0482T 78491
0482T 78492
0492T 0491T
0496T 0495T
0513T 0512T
0514T 66982
0514T 66984
0523T 93454
0523T 93455
0523T 93456
0523T 93457
Page 20 of 1139
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0523T 93458
0523T 93459
0523T 93460
0523T 93461
0560T 0559T
0562T 0561T
0570T 0569T
10004 10021
10006 10005
10008 10007
10010 10009
10012 10011
10036 10035
11001 11000
11008 10180
11008 11004
11008 11005
11008 11006
11045 11042
11046 11043
11047 11044
11103 11102
11103 11104
11103 11106
11105 11104
11105 11106
11107 11106
11201 11200
11732 11730
11922 11921
13102 13101
13122 13121
13133 13132
13153 13152
14302 14301
15003 15002
15005 15004
15101 15100
15111 15110
15116 15115
15121 15120
Page 21 of 1139
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Add-on Code Primary Code
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15131 15130
15136 15135
15151 15150
15152 15151
15156 15155
15157 15156
15201 15200
15221 15220
15241 15240
15261 15260
15272 15271
15274 15273
15276 15275
15278 15277
15772 15771
15774 15773
15777 11970
15777 13160
15777 15002
15777 15004
15777 15040
15777 15050
15777 15100
15777 15110
15777 15115
15777 15120
15777 15130
15777 15135
15777 15150
15777 15155
15777 15200
15777 15220
15777 15240
15777 15260
15777 15271
15777 15273
15777 15275
15777 15277
15777 15734
15777 19316
15777 19318
Page 22 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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15777 19324
15777 19325
15777 19328
15777 19330
15777 19340
15777 19342
15777 19350
15777 19355
15777 19357
15777 19361
15777 19364
15777 19366
15777 19367
15777 19368
15777 19369
15777 19370
15777 19371
15777 19380
15777 19396
15777 S2066
15777 S2067
15777 S2068
15787 15786
15847 15830
16036 16035
17003 17000
19001 19000
19082 19081
19084 19083
19086 19085
19126 19125
19282 19281
19284 19283
19286 19285
19288 19287
19294 19301
19294 19302
19297 19301
19297 19302
20700 11010
20700 11011
Page 23 of 1139
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UnitedHealthcare Community Plan
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20700 11012
20700 11043
20700 11044
20700 11046
20700 11047
20700 20240
20700 20245
20700 20250
20700 20251
20700 21010
20700 21025
20700 21026
20700 21501
20700 21502
20700 21510
20700 21627
20700 21630
20700 22010
20700 22015
20700 23030
20700 23031
20700 23035
20700 23040
20700 23044
20700 23170
20700 23172
20700 23174
20700 23180
20700 23182
20700 23184
20700 23334
20700 23335
20700 23930
20700 23931
20700 23935
20700 24000
20700 24134
20700 24136
20700 24138
20700 24140
20700 24147
Page 24 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
20700 24160
20700 25031
20700 25035
20700 25040
20700 25145
20700 25150
20700 25151
20700 26070
20700 26230
20700 26235
20700 26236
20700 26990
20700 26991
20700 26992
20700 27030
20700 27070
20700 27071
20700 27090
20700 27301
20700 27303
20700 27310
20700 27360
20700 27603
20700 27604
20700 27610
20700 27640
20700 27641
20700 28001
20700 28002
20700 28003
20700 28020
20700 28120
20700 28122
20701 11010
20701 11011
20701 11012
20701 11043
20701 11044
20701 11046
20701 11047
20701 20240
Page 25 of 1139
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20701 20245
20701 20250
20701 20251
20701 21010
20701 21025
20701 21026
20701 21501
20701 21502
20701 21510
20701 21627
20701 21630
20701 22010
20701 22015
20701 23030
20701 23031
20701 23035
20701 23040
20701 23044
20701 23170
20701 23172
20701 23174
20701 23180
20701 23182
20701 23184
20701 23334
20701 23335
20701 23930
20701 23931
20701 23935
20701 24000
20701 24134
20701 24136
20701 24138
20701 24140
20701 24147
20701 24160
20701 25031
20701 25035
20701 25040
20701 25145
20701 25150
Page 26 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
20701 25151
20701 26070
20701 26230
20701 26235
20701 26236
20701 26990
20701 26991
20701 26992
20701 27030
20701 27070
20701 27071
20701 27090
20701 27301
20701 27303
20701 27310
20701 27360
20701 27603
20701 27604
20701 27610
20701 27640
20701 27641
20701 28001
20701 28002
20701 28003
20701 28020
20701 28120
20701 28122
20702 20680
20702 20690
20702 20692
20702 20694
20702 20802
20702 20805
20702 20838
20702 21510
20702 23035
20702 23170
20702 23180
20702 23184
20702 23515
20702 23615
Page 27 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
20702 23935
20702 24134
20702 24138
20702 24140
20702 24147
20702 24430
20702 24516
20702 25035
20702 25145
20702 25150
20702 25151
20702 25400
20702 25515
20702 25525
20702 25526
20702 25545
20702 25574
20702 25575
20702 27245
20702 27259
20702 27360
20702 27470
20702 27506
20702 27640
20702 27720
20703 20690
20703 20692
20703 20694
20703 20802
20703 20805
20703 20838
20703 21510
20703 23035
20703 23170
20703 23180
20703 23184
20703 23515
20703 23615
20703 23935
20703 24134
20703 24138
Page 28 of 1139
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UnitedHealthcare Community Plan
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Relationship List
20703 24140
20703 24147
20703 24430
20703 24516
20703 25035
20703 25145
20703 25150
20703 25151
20703 25400
20703 25515
20703 25525
20703 25526
20703 25545
20703 25574
20703 25575
20703 27245
20703 27259
20703 27360
20703 27470
20703 27506
20703 27640
20703 27720
20704 22864
20704 22865
20704 23040
20704 23044
20704 23334
20704 24000
20704 24160
20704 25040
20704 25250
20704 25251
20704 26070
20704 26075
20704 26080
20704 26990
20704 27030
20704 27090
20704 27301
20704 27310
20704 27603
Page 29 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
20704 27610
20704 28020
20705 22864
20705 22865
20705 23040
20705 23044
20705 23334
20705 24000
20705 24160
20705 25040
20705 25250
20705 25251
20705 26070
20705 26075
20705 26080
20705 26990
20705 27030
20705 27090
20705 27301
20705 27310
20705 27603
20705 27610
20705 28020
20930 22319
20930 22532
20930 22533
20930 22548
20930 22551
20930 22552
20930 22554
20930 22556
20930 22558
20930 22590
20930 22595
20930 22600
20930 22610
20930 22612
20930 22630
20930 22633
20930 22634
20930 22800
Page 30 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
20930 22802
20930 22804
20930 22808
20930 22810
20930 22812
20931 22319
20931 22532
20931 22533
20931 22548
20931 22551
20931 22552
20931 22554
20931 22556
20931 22558
20931 22590
20931 22595
20931 22600
20931 22610
20931 22612
20931 22630
20931 22633
20931 22634
20931 22800
20931 22802
20931 22804
20931 22808
20931 22810
20931 22812
20932 23210
20932 23220
20932 24150
20932 25170
20932 27075
20932 27076
20932 27077
20932 27365
20932 27645
20932 27704
20933 23210
20933 23220
20933 24150
Page 31 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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20933 25170
20933 27075
20933 27076
20933 27077
20933 27365
20933 27645
20933 27704
20934 23210
20934 23220
20934 24150
20934 25170
20934 27075
20934 27076
20934 27077
20934 27365
20934 27645
20934 27704
20936 22319
20936 22532
20936 22533
20936 22548
20936 22551
20936 22552
20936 22554
20936 22556
20936 22558
20936 22590
20936 22595
20936 22600
20936 22610
20936 22612
20936 22630
20936 22633
20936 22634
20936 22800
20936 22802
20936 22804
20936 22808
20936 22810
20936 22812
20937 22319
Page 32 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
20937 22532
20937 22533
20937 22548
20937 22551
20937 22552
20937 22554
20937 22556
20937 22558
20937 22590
20937 22595
20937 22600
20937 22610
20937 22612
20937 22630
20937 22633
20937 22634
20937 22800
20937 22802
20937 22804
20937 22808
20937 22810
20937 22812
20937 0219T
20937 0220T
20937 0221T
20938 22319
20938 22532
20938 22533
20938 22548
20938 22551
20938 22552
20938 22554
20938 22556
20938 22558
20938 22590
20938 22595
20938 22600
20938 22610
20938 22612
20938 22630
20938 22633
Page 33 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
20938 22634
20938 22800
20938 22802
20938 22804
20938 22808
20938 22810
20938 22812
20938 0219T
20938 0220T
20938 0221T
20939 22319
20939 22532
20939 22533
20939 22534
20939 22548
20939 22551
20939 22552
20939 22554
20939 22556
20939 22558
20939 22590
20939 22595
20939 22600
20939 22610
20939 22612
20939 22630
20939 22633
20939 22634
20939 22800
20939 22802
20939 22804
20939 22808
20939 22810
20939 22812
20985 22840
20985 22842
20985 22843
20985 22844
20985 27120
20985 27122
20985 27125
Page 34 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
20985 27130
20985 27132
20985 27134
20985 27137
20985 27138
20985 27140
20985 27146
20985 27147
20985 27151
20985 27156
20985 27158
20985 27161
20985 27165
20985 27170
20985 27175
20985 27176
20985 27177
20985 27178
20985 27179
20985 27181
20985 27185
20985 27187
20985 27200
20985 27202
20985 27215
20985 27216
20985 27217
20985 27218
20985 27220
20985 27222
20985 27226
20985 27227
20985 27228
20985 27230
20985 27232
20985 27235
20985 27236
20985 27238
20985 27240
20985 27244
20985 27245
Page 35 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
20985 27246
20985 27248
20985 27250
20985 27252
20985 27253
20985 27254
20985 27256
20985 27257
20985 27258
20985 27259
20985 27265
20985 27266
20985 27405
20985 27407
20985 27409
20985 27437
20985 27438
20985 27440
20985 27441
20985 27442
20985 27443
20985 27445
20985 27446
20985 27447
20985 27448
20985 27450
20985 27454
20985 27455
20985 27457
20985 27465
20985 27466
20985 27468
20985 27470
20985 27472
20985 27475
20985 27477
20985 27479
20985 27485
20985 27486
20985 27487
20985 27500
Page 36 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
20985 27501
20985 27502
20985 27503
20985 27506
20985 27507
20985 27508
20985 27509
20985 27510
20985 27511
20985 27513
20985 27514
20985 27516
20985 27517
20985 27519
20985 27520
20985 27524
20985 27530
20985 27532
20985 27535
20985 27536
20985 27538
20985 27540
20985 27550
20985 27552
20985 27556
20985 27557
20985 27558
20985 27560
20985 27562
20985 27566
20985 27705
20985 27707
20985 27709
20985 27712
20985 27715
20985 27720
20985 27722
20985 27724
20985 27725
20985 29850
20985 29851
Page 37 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
20985 29855
20985 29856
20985 29888
20985 29889
22103 22100
22103 22101
22103 22102
22116 22110
22116 22112
22116 22114
22208 22206
22208 22207
22216 22210
22216 22212
22216 22214
22226 22220
22226 22222
22226 22224
22328 22325
22328 22326
22328 22327
22512 22510
22512 22511
22515 22513
22515 22514
22527 22526
22534 22532
22534 22533
22552 22551
22585 22554
22585 22556
22585 22558
22614 22600
22614 22610
22614 22612
22614 22630
22614 22632
22614 22633
22632 22612
22632 22614
22632 22630
Page 38 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
22632 22633
22632 22634
22634 22612
22634 22614
22634 22630
22634 22632
22634 22633
22840 22100
22840 22101
22840 22102
22840 22110
22840 22112
22840 22114
22840 22206
22840 22207
22840 22210
22840 22212
22840 22214
22840 22220
22840 22222
22840 22224
22840 22310
22840 22315
22840 22318
22840 22319
22840 22325
22840 22326
22840 22327
22840 22532
22840 22533
22840 22548
22840 22551
22840 22552
22840 22554
22840 22556
22840 22558
22840 22590
22840 22595
22840 22600
22840 22610
22840 22612
Page 39 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
22840 22630
22840 22633
22840 22634
22840 22800
22840 22802
22840 22804
22840 22808
22840 22810
22840 22812
22840 63001
22840 63003
22840 63005
22840 63011
22840 63012
22840 63015
22840 63016
22840 63017
22840 63020
22840 63030
22840 63040
22840 63042
22840 63045
22840 63046
22840 63047
22840 63050
22840 63051
22840 63055
22840 63056
22840 63064
22840 63075
22840 63077
22840 63081
22840 63085
22840 63087
22840 63090
22840 63101
22840 63102
22840 63170
22840 63172
22840 63173
22840 63180
Page 40 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
22840 63182
22840 63185
22840 63190
22840 63191
22840 63194
22840 63195
22840 63196
22840 63197
22840 63198
22840 63199
22840 63200
22840 63250
22840 63251
22840 63252
22840 63265
22840 63266
22840 63267
22840 63268
22840 63270
22840 63271
22840 63272
22840 63273
22840 63275
22840 63276
22840 63277
22840 63278
22840 63280
22840 63281
22840 63282
22840 63283
22840 63285
22840 63286
22840 63287
22840 63290
22840 63300
22840 63301
22840 63302
22840 63303
22840 63304
22840 63305
22840 63306
Page 41 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22840 63307
22841 22100
22841 22101
22841 22102
22841 22110
22841 22112
22841 22114
22841 22206
22841 22207
22841 22210
22841 22212
22841 22214
22841 22220
22841 22222
22841 22224
22841 22310
22841 22315
22841 22318
22841 22319
22841 22325
22841 22326
22841 22327
22841 22532
22841 22533
22841 22548
22841 22551
22841 22552
22841 22554
22841 22556
22841 22558
22841 22590
22841 22595
22841 22600
22841 22610
22841 22612
22841 22630
22841 22633
22841 22634
22841 22800
22841 22802
22841 22804
Page 42 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
22841 22808
22841 22810
22841 22812
22841 63001
22841 63003
22841 63005
22841 63011
22841 63012
22841 63015
22841 63016
22841 63017
22841 63020
22841 63030
22841 63040
22841 63042
22841 63045
22841 63046
22841 63047
22841 63050
22841 63051
22841 63055
22841 63056
22841 63064
22841 63075
22841 63077
22841 63081
22841 63085
22841 63087
22841 63090
22841 63101
22841 63102
22841 63170
22841 63172
22841 63173
22841 63180
22841 63182
22841 63185
22841 63190
22841 63191
22841 63194
22841 63195
Page 43 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22841 63196
22841 63197
22841 63198
22841 63199
22841 63200
22841 63250
22841 63251
22841 63252
22841 63265
22841 63266
22841 63267
22841 63268
22841 63270
22841 63271
22841 63272
22841 63273
22841 63275
22841 63276
22841 63277
22841 63278
22841 63280
22841 63281
22841 63282
22841 63283
22841 63285
22841 63286
22841 63287
22841 63290
22841 63300
22841 63301
22841 63302
22841 63303
22841 63304
22841 63305
22841 63306
22841 63307
22842 22100
22842 22101
22842 22102
22842 22110
22842 22112
Page 44 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22842 22114
22842 22206
22842 22207
22842 22210
22842 22212
22842 22214
22842 22220
22842 22222
22842 22224
22842 22310
22842 22315
22842 22318
22842 22319
22842 22325
22842 22326
22842 22327
22842 22532
22842 22533
22842 22548
22842 22551
22842 22552
22842 22554
22842 22556
22842 22558
22842 22590
22842 22595
22842 22600
22842 22610
22842 22612
22842 22630
22842 22633
22842 22634
22842 22800
22842 22802
22842 22804
22842 22808
22842 22810
22842 22812
22842 63001
22842 63003
22842 63005
Page 45 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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22842 63011
22842 63012
22842 63015
22842 63016
22842 63017
22842 63020
22842 63030
22842 63040
22842 63042
22842 63045
22842 63046
22842 63047
22842 63050
22842 63051
22842 63055
22842 63056
22842 63064
22842 63075
22842 63077
22842 63081
22842 63085
22842 63087
22842 63090
22842 63101
22842 63102
22842 63170
22842 63172
22842 63173
22842 63180
22842 63182
22842 63185
22842 63190
22842 63191
22842 63194
22842 63195
22842 63196
22842 63197
22842 63198
22842 63199
22842 63200
22842 63250
Page 46 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22842 63251
22842 63252
22842 63265
22842 63266
22842 63267
22842 63268
22842 63270
22842 63271
22842 63272
22842 63273
22842 63275
22842 63276
22842 63277
22842 63278
22842 63280
22842 63281
22842 63282
22842 63283
22842 63285
22842 63286
22842 63287
22842 63290
22842 63300
22842 63301
22842 63302
22842 63303
22842 63304
22842 63305
22842 63306
22842 63307
22843 22100
22843 22101
22843 22102
22843 22110
22843 22112
22843 22114
22843 22206
22843 22207
22843 22210
22843 22212
22843 22214
Page 47 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22843 22220
22843 22222
22843 22224
22843 22310
22843 22315
22843 22318
22843 22319
22843 22325
22843 22326
22843 22327
22843 22532
22843 22533
22843 22548
22843 22551
22843 22552
22843 22554
22843 22556
22843 22558
22843 22590
22843 22595
22843 22600
22843 22610
22843 22612
22843 22630
22843 22633
22843 22634
22843 22800
22843 22802
22843 22804
22843 22808
22843 22810
22843 22812
22843 63001
22843 63003
22843 63005
22843 63011
22843 63012
22843 63015
22843 63016
22843 63017
22843 63020
Page 48 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22843 63030
22843 63040
22843 63042
22843 63045
22843 63046
22843 63047
22843 63050
22843 63051
22843 63055
22843 63056
22843 63064
22843 63075
22843 63077
22843 63081
22843 63085
22843 63087
22843 63090
22843 63101
22843 63102
22843 63170
22843 63172
22843 63173
22843 63180
22843 63182
22843 63185
22843 63190
22843 63191
22843 63194
22843 63195
22843 63196
22843 63197
22843 63198
22843 63199
22843 63200
22843 63250
22843 63251
22843 63252
22843 63265
22843 63266
22843 63267
22843 63268
Page 49 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22843 63270
22843 63271
22843 63272
22843 63273
22843 63275
22843 63276
22843 63277
22843 63278
22843 63280
22843 63281
22843 63282
22843 63283
22843 63285
22843 63286
22843 63287
22843 63290
22843 63300
22843 63301
22843 63302
22843 63303
22843 63304
22843 63305
22843 63306
22843 63307
22844 22100
22844 22101
22844 22102
22844 22110
22844 22112
22844 22114
22844 22206
22844 22207
22844 22210
22844 22212
22844 22214
22844 22220
22844 22222
22844 22224
22844 22310
22844 22315
22844 22318
Page 50 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22844 22319
22844 22325
22844 22326
22844 22327
22844 22532
22844 22533
22844 22548
22844 22551
22844 22552
22844 22554
22844 22556
22844 22558
22844 22590
22844 22595
22844 22600
22844 22610
22844 22612
22844 22630
22844 22633
22844 22634
22844 22800
22844 22802
22844 22804
22844 22808
22844 22810
22844 22812
22844 63001
22844 63003
22844 63005
22844 63011
22844 63012
22844 63015
22844 63016
22844 63017
22844 63020
22844 63030
22844 63040
22844 63042
22844 63045
22844 63046
22844 63047
Page 51 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22844 63050
22844 63051
22844 63055
22844 63056
22844 63064
22844 63075
22844 63077
22844 63081
22844 63085
22844 63087
22844 63090
22844 63101
22844 63102
22844 63170
22844 63172
22844 63173
22844 63180
22844 63182
22844 63185
22844 63190
22844 63191
22844 63194
22844 63195
22844 63196
22844 63197
22844 63198
22844 63199
22844 63200
22844 63250
22844 63251
22844 63252
22844 63265
22844 63266
22844 63267
22844 63268
22844 63270
22844 63271
22844 63272
22844 63273
22844 63275
22844 63276
Page 52 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22844 63277
22844 63278
22844 63280
22844 63281
22844 63282
22844 63283
22844 63285
22844 63286
22844 63287
22844 63290
22844 63300
22844 63301
22844 63302
22844 63303
22844 63304
22844 63305
22844 63306
22844 63307
22845 22100
22845 22101
22845 22102
22845 22110
22845 22112
22845 22114
22845 22206
22845 22207
22845 22210
22845 22212
22845 22214
22845 22220
22845 22222
22845 22224
22845 22310
22845 22315
22845 22318
22845 22319
22845 22325
22845 22326
22845 22327
22845 22532
22845 22533
Page 53 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22845 22548
22845 22551
22845 22552
22845 22554
22845 22556
22845 22558
22845 22590
22845 22595
22845 22600
22845 22610
22845 22612
22845 22630
22845 22633
22845 22634
22845 22800
22845 22802
22845 22804
22845 22808
22845 22810
22845 22812
22845 63001
22845 63003
22845 63005
22845 63011
22845 63012
22845 63015
22845 63016
22845 63017
22845 63020
22845 63030
22845 63040
22845 63042
22845 63045
22845 63046
22845 63047
22845 63050
22845 63051
22845 63055
22845 63056
22845 63064
22845 63075
Page 54 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22845 63077
22845 63081
22845 63085
22845 63087
22845 63090
22845 63101
22845 63102
22845 63170
22845 63172
22845 63173
22845 63180
22845 63182
22845 63185
22845 63190
22845 63191
22845 63194
22845 63195
22845 63196
22845 63197
22845 63198
22845 63199
22845 63200
22845 63250
22845 63251
22845 63252
22845 63265
22845 63266
22845 63267
22845 63268
22845 63270
22845 63271
22845 63272
22845 63273
22845 63275
22845 63276
22845 63277
22845 63278
22845 63280
22845 63281
22845 63282
22845 63283
Page 55 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22845 63285
22845 63286
22845 63287
22845 63290
22845 63300
22845 63301
22845 63302
22845 63303
22845 63304
22845 63305
22845 63306
22845 63307
22846 22100
22846 22101
22846 22102
22846 22110
22846 22112
22846 22114
22846 22206
22846 22207
22846 22210
22846 22212
22846 22214
22846 22220
22846 22222
22846 22224
22846 22310
22846 22315
22846 22318
22846 22319
22846 22325
22846 22326
22846 22327
22846 22532
22846 22533
22846 22548
22846 22551
22846 22552
22846 22554
22846 22556
22846 22558
Page 56 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22846 22590
22846 22595
22846 22600
22846 22610
22846 22612
22846 22630
22846 22633
22846 22634
22846 22800
22846 22802
22846 22804
22846 22808
22846 22810
22846 22812
22846 63001
22846 63003
22846 63005
22846 63011
22846 63012
22846 63015
22846 63016
22846 63017
22846 63020
22846 63030
22846 63040
22846 63042
22846 63045
22846 63046
22846 63047
22846 63050
22846 63051
22846 63055
22846 63056
22846 63064
22846 63075
22846 63077
22846 63081
22846 63085
22846 63087
22846 63090
22846 63101
Page 57 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22846 63102
22846 63170
22846 63172
22846 63173
22846 63180
22846 63182
22846 63185
22846 63190
22846 63191
22846 63194
22846 63195
22846 63196
22846 63197
22846 63198
22846 63199
22846 63200
22846 63250
22846 63251
22846 63252
22846 63265
22846 63266
22846 63267
22846 63268
22846 63270
22846 63271
22846 63272
22846 63273
22846 63275
22846 63276
22846 63277
22846 63278
22846 63280
22846 63281
22846 63282
22846 63283
22846 63285
22846 63286
22846 63287
22846 63290
22846 63300
22846 63301
Page 58 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22846 63302
22846 63303
22846 63304
22846 63305
22846 63306
22846 63307
22847 22100
22847 22101
22847 22102
22847 22110
22847 22112
22847 22114
22847 22206
22847 22207
22847 22210
22847 22212
22847 22214
22847 22220
22847 22222
22847 22224
22847 22310
22847 22315
22847 22318
22847 22319
22847 22325
22847 22326
22847 22327
22847 22532
22847 22533
22847 22548
22847 22551
22847 22552
22847 22554
22847 22556
22847 22558
22847 22590
22847 22595
22847 22600
22847 22610
22847 22612
22847 22630
Page 59 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22847 22633
22847 22634
22847 22800
22847 22802
22847 22804
22847 22808
22847 22810
22847 22812
22847 63001
22847 63003
22847 63005
22847 63011
22847 63012
22847 63015
22847 63016
22847 63017
22847 63020
22847 63030
22847 63040
22847 63042
22847 63045
22847 63046
22847 63047
22847 63050
22847 63051
22847 63055
22847 63056
22847 63064
22847 63075
22847 63077
22847 63081
22847 63085
22847 63087
22847 63090
22847 63101
22847 63102
22847 63170
22847 63172
22847 63173
22847 63180
22847 63182
Page 60 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22847 63185
22847 63190
22847 63191
22847 63194
22847 63195
22847 63196
22847 63197
22847 63198
22847 63199
22847 63200
22847 63250
22847 63251
22847 63252
22847 63265
22847 63266
22847 63267
22847 63268
22847 63270
22847 63271
22847 63272
22847 63273
22847 63275
22847 63276
22847 63277
22847 63278
22847 63280
22847 63281
22847 63282
22847 63283
22847 63285
22847 63286
22847 63287
22847 63290
22847 63300
22847 63301
22847 63302
22847 63303
22847 63304
22847 63305
22847 63306
22847 63307
Page 61 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22848 22100
22848 22101
22848 22102
22848 22110
22848 22112
22848 22114
22848 22206
22848 22207
22848 22210
22848 22212
22848 22214
22848 22220
22848 22222
22848 22224
22848 22310
22848 22315
22848 22318
22848 22319
22848 22325
22848 22326
22848 22327
22848 22532
22848 22533
22848 22548
22848 22551
22848 22552
22848 22554
22848 22556
22848 22558
22848 22590
22848 22595
22848 22600
22848 22610
22848 22612
22848 22630
22848 22633
22848 22634
22848 22800
22848 22802
22848 22804
22848 22808
Page 62 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22848 22810
22848 22812
22848 63001
22848 63003
22848 63005
22848 63011
22848 63012
22848 63015
22848 63016
22848 63017
22848 63020
22848 63030
22848 63040
22848 63042
22848 63045
22848 63046
22848 63047
22848 63050
22848 63051
22848 63055
22848 63056
22848 63064
22848 63075
22848 63077
22848 63081
22848 63085
22848 63087
22848 63090
22848 63101
22848 63102
22848 63170
22848 63172
22848 63173
22848 63180
22848 63182
22848 63185
22848 63190
22848 63191
22848 63194
22848 63195
22848 63196
Page 63 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22848 63197
22848 63198
22848 63199
22848 63200
22848 63250
22848 63251
22848 63252
22848 63265
22848 63266
22848 63267
22848 63268
22848 63270
22848 63271
22848 63272
22848 63273
22848 63275
22848 63276
22848 63277
22848 63278
22848 63280
22848 63281
22848 63282
22848 63283
22848 63285
22848 63286
22848 63287
22848 63290
22848 63300
22848 63301
22848 63302
22848 63303
22848 63304
22848 63305
22848 63306
22848 63307
22853 22100
22853 22101
22853 22102
22853 22110
22853 22112
22853 22114
Page 64 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22853 22206
22853 22207
22853 22210
22853 22212
22853 22214
22853 22220
22853 22222
22853 22224
22853 22310
22853 22315
22853 22318
22853 22319
22853 22325
22853 22326
22853 22327
22853 22532
22853 22533
22853 22548
22853 22551
22853 22552
22853 22554
22853 22556
22853 22558
22853 22590
22853 22595
22853 22600
22853 22610
22853 22612
22853 22630
22853 22633
22853 22634
22853 22800
22853 22802
22853 22804
22853 22808
22853 22810
22853 22812
22853 63001
22853 63003
22853 63005
22853 63011
Page 65 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22853 63012
22853 63015
22853 63016
22853 63017
22853 63020
22853 63030
22853 63040
22853 63042
22853 63045
22853 63046
22853 63047
22853 63050
22853 63051
22853 63055
22853 63056
22853 63064
22853 63075
22853 63077
22853 63081
22853 63085
22853 63087
22853 63090
22853 63101
22853 63102
22853 63170
22853 63172
22853 63173
22853 63180
22853 63182
22853 63185
22853 63190
22853 63191
22853 63194
22853 63195
22853 63196
22853 63197
22853 63198
22853 63199
22853 63200
22853 63250
22853 63251
Page 66 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22853 63252
22853 63265
22853 63266
22853 63267
22853 63268
22853 63270
22853 63271
22853 63272
22853 63273
22853 63275
22853 63276
22853 63277
22853 63278
22853 63280
22853 63281
22853 63282
22853 63283
22853 63285
22853 63286
22853 63287
22853 63290
22853 63300
22853 63301
22853 63302
22853 63303
22853 63304
22853 63305
22853 63306
22853 63307
22854 22100
22854 22101
22854 22102
22854 22110
22854 22112
22854 22114
22854 22206
22854 22207
22854 22210
22854 22212
22854 22214
22854 22220
Page 67 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22854 22222
22854 22224
22854 22310
22854 22315
22854 22318
22854 22319
22854 22325
22854 22326
22854 22327
22854 22532
22854 22533
22854 22548
22854 22551
22854 22552
22854 22554
22854 22556
22854 22558
22854 22590
22854 22595
22854 22600
22854 22610
22854 22612
22854 22630
22854 22633
22854 22634
22854 22800
22854 22802
22854 22804
22854 22808
22854 22810
22854 22812
22854 63001
22854 63003
22854 63005
22854 63011
22854 63012
22854 63015
22854 63016
22854 63017
22854 63020
22854 63030
Page 68 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22854 63040
22854 63042
22854 63045
22854 63046
22854 63047
22854 63050
22854 63051
22854 63055
22854 63056
22854 63064
22854 63075
22854 63077
22854 63081
22854 63085
22854 63087
22854 63090
22854 63101
22854 63102
22854 63170
22854 63172
22854 63173
22854 63180
22854 63182
22854 63185
22854 63190
22854 63191
22854 63194
22854 63195
22854 63196
22854 63197
22854 63198
22854 63199
22854 63200
22854 63250
22854 63251
22854 63252
22854 63265
22854 63266
22854 63267
22854 63268
22854 63270
Page 69 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22854 63271
22854 63272
22854 63273
22854 63275
22854 63276
22854 63277
22854 63278
22854 63280
22854 63281
22854 63282
22854 63283
22854 63285
22854 63286
22854 63287
22854 63290
22854 63300
22854 63301
22854 63302
22854 63303
22854 63304
22854 63305
22854 63306
22854 63307
22858 22856
22859 22100
22859 22101
22859 22102
22859 22110
22859 22112
22859 22114
22859 22206
22859 22207
22859 22210
22859 22212
22859 22214
22859 22220
22859 22222
22859 22224
22859 22310
22859 22315
22859 22318
Page 70 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22859 22319
22859 22325
22859 22326
22859 22327
22859 22532
22859 22533
22859 22548
22859 22551
22859 22552
22859 22554
22859 22556
22859 22558
22859 22590
22859 22595
22859 22600
22859 22610
22859 22612
22859 22630
22859 22633
22859 22634
22859 22800
22859 22802
22859 22804
22859 22808
22859 22810
22859 22812
22859 63001
22859 63003
22859 63005
22859 63011
22859 63012
22859 63015
22859 63016
22859 63017
22859 63020
22859 63030
22859 63040
22859 63042
22859 63045
22859 63046
22859 63047
Page 71 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22859 63050
22859 63051
22859 63055
22859 63056
22859 63064
22859 63075
22859 63077
22859 63081
22859 63085
22859 63087
22859 63090
22859 63101
22859 63102
22859 63170
22859 63172
22859 63173
22859 63180
22859 63182
22859 63185
22859 63190
22859 63191
22859 63194
22859 63195
22859 63196
22859 63197
22859 63198
22859 63199
22859 63200
22859 63250
22859 63251
22859 63252
22859 63265
22859 63266
22859 63267
22859 63268
22859 63270
22859 63271
22859 63272
22859 63273
22859 63275
22859 63276
Page 72 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
22859 63277
22859 63278
22859 63280
22859 63281
22859 63282
22859 63283
22859 63285
22859 63286
22859 63287
22859 63290
22859 63300
22859 63301
22859 63302
22859 63303
22859 63304
22859 63305
22859 63306
22859 63307
22868 22867
22870 22869
26125 26123
26861 26860
26863 26862
27358 27355
27358 27356
27358 27357
27692 27690
27692 27691
29826 29806
29826 29807
29826 29819
29826 29820
29826 29821
29826 29822
29826 29823
29826 29824
29826 29825
29826 29827
29826 29828
31627 31615
31627 31622
Page 73 of 1139
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31627 31623
31627 31624
31627 31625
31627 31626
31627 31628
31627 31629
31627 31630
31627 31631
31627 31635
31627 31636
31627 31638
31627 31640
31627 31641
31627 31643
31632 31628
31633 31629
31637 31636
31649 31648
31651 31647
31654 31622
31654 31623
31654 31624
31654 31625
31654 31626
31654 31628
31654 31629
31654 31640
31654 31643
31654 31645
31654 31646
32501 32480
32501 32482
32501 32484
32506 32505
32507 32440
32507 32442
32507 32445
32507 32480
32507 32482
32507 32484
32507 32486
Page 74 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
32507 32488
32507 32503
32507 32504
32667 32666
32668 32440
32668 32442
32668 32445
32668 32480
32668 32482
32668 32484
32668 32486
32668 32488
32668 32503
32668 32504
32668 32663
32668 32669
32668 32670
32668 32671
32674 19260
32674 21601
32674 31760
32674 31766
32674 31786
32674 32096
32674 32097
32674 32098
32674 32100
32674 32110
32674 32120
32674 32124
32674 32140
32674 32141
32674 32150
32674 32151
32674 32160
32674 32200
32674 32220
32674 32225
32674 32310
32674 32320
32674 32400
Page 75 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
32674 32405
32674 32440
32674 32442
32674 32445
32674 32480
32674 32482
32674 32484
32674 32486
32674 32488
32674 32491
32674 32503
32674 32504
32674 32505
32674 32601
32674 32604
32674 32606
32674 32607
32674 32608
32674 32609
32674 32650
32674 32651
32674 32652
32674 32653
32674 32654
32674 32655
32674 32656
32674 32658
32674 32659
32674 32661
32674 32662
32674 32663
32674 32666
32674 32669
32674 32670
32674 32671
32674 32672
32674 32673
32674 32815
32674 33025
32674 33030
32674 33050
Page 76 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
32674 33120
32674 33130
32674 39200
32674 39220
32674 39560
32674 39561
32674 43101
32674 43112
32674 43117
32674 43118
32674 43122
32674 43123
32674 43287
32674 43288
32674 43351
32674 60270
32674 60505
33141 33390
33141 33391
33141 33404
33141 33405
33141 33406
33141 33410
33141 33411
33141 33412
33141 33413
33141 33414
33141 33415
33141 33416
33141 33417
33141 33418
33141 33419
33141 33420
33141 33422
33141 33425
33141 33426
33141 33427
33141 33430
33141 33440
33141 33460
33141 33463
Page 77 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
33141 33464
33141 33465
33141 33468
33141 33470
33141 33471
33141 33472
33141 33474
33141 33475
33141 33476
33141 33478
33141 33496
33141 33510
33141 33511
33141 33512
33141 33513
33141 33514
33141 33516
33141 33517
33141 33518
33141 33519
33141 33521
33141 33522
33141 33523
33141 33530
33141 33533
33141 33534
33141 33535
33141 33536
33141 33542
33225 33206
33225 33207
33225 33208
33225 33212
33225 33213
33225 33214
33225 33216
33225 33217
33225 33221
33225 33222
33225 33223
33225 33228
Page 78 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
33225 33229
33225 33230
33225 33231
33225 33233
33225 33234
33225 33235
33225 33240
33225 33249
33225 33263
33225 33264
33257 33120
33257 33130
33257 33250
33257 33251
33257 33261
33257 33300
33257 33305
33257 33310
33257 33315
33257 33320
33257 33321
33257 33322
33257 33330
33257 33335
33257 33365
33257 33390
33257 33391
33257 33404
33257 33405
33257 33406
33257 33410
33257 33411
33257 33412
33257 33413
33257 33414
33257 33415
33257 33416
33257 33417
33257 33420
33257 33422
33257 33425
Page 79 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
33257 33426
33257 33427
33257 33430
33257 33440
33257 33460
33257 33463
33257 33464
33257 33465
33257 33468
33257 33470
33257 33471
33257 33474
33257 33475
33257 33476
33257 33478
33257 33496
33257 33500
33257 33501
33257 33502
33257 33503
33257 33504
33257 33505
33257 33506
33257 33507
33257 33510
33257 33511
33257 33512
33257 33513
33257 33514
33257 33516
33257 33533
33257 33534
33257 33535
33257 33536
33257 33542
33257 33545
33257 33548
33257 33600
33257 33602
33257 33606
33257 33608
Page 80 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
33257 33610
33257 33611
33257 33612
33257 33615
33257 33617
33257 33619
33257 33641
33257 33645
33257 33647
33257 33660
33257 33665
33257 33670
33257 33675
33257 33676
33257 33677
33257 33681
33257 33684
33257 33688
33257 33690
33257 33692
33257 33694
33257 33697
33257 33702
33257 33710
33257 33720
33257 33722
33257 33724
33257 33726
33257 33730
33257 33732
33257 33735
33257 33736
33257 33737
33257 33750
33257 33755
33257 33762
33257 33764
33257 33766
33257 33767
33257 33770
33257 33771
Page 81 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
33257 33774
33257 33775
33257 33776
33257 33777
33257 33778
33257 33779
33257 33780
33257 33781
33257 33782
33257 33783
33257 33786
33257 33788
33257 33800
33257 33802
33257 33803
33257 33813
33257 33814
33257 33820
33257 33822
33257 33824
33257 33840
33257 33845
33257 33851
33257 33852
33257 33853
33257 33858
33257 33859
33257 33860
33257 33863
33257 33864
33257 33870
33257 33871
33257 33875
33257 33877
33257 33910
33257 33915
33257 33916
33257 33917
33257 33920
33257 33922
33257 33925
Page 82 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
33257 33926
33257 33975
33257 33976
33257 33977
33257 33978
33257 33979
33257 33980
33257 33981
33257 33982
33257 33983
33258 33130
33258 33250
33258 33300
33258 33310
33258 33320
33258 33321
33258 33330
33258 33365
33258 33391
33258 33414
33258 33415
33258 33416
33258 33417
33258 33420
33258 33470
33258 33471
33258 33501
33258 33502
33258 33503
33258 33510
33258 33511
33258 33512
33258 33513
33258 33514
33258 33516
33258 33533
33258 33534
33258 33535
33258 33536
33258 33690
33258 33735
Page 83 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
33258 33737
33258 33750
33258 33755
33258 33762
33258 33764
33258 33766
33258 33800
33258 33802
33258 33803
33258 33813
33258 33820
33258 33822
33258 33824
33258 33840
33258 33845
33258 33851
33258 33852
33258 33875
33258 33877
33258 33915
33258 33925
33258 33981
33258 33982
33259 33120
33259 33251
33259 33261
33259 33305
33259 33315
33259 33322
33259 33335
33259 33390
33259 33391
33259 33404
33259 33405
33259 33406
33259 33410
33259 33411
33259 33412
33259 33413
33259 33414
33259 33415
Page 84 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
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Relationship List
33259 33416
33259 33417
33259 33422
33259 33425
33259 33426
33259 33427
33259 33430
33259 33440
33259 33460
33259 33463
33259 33464
33259 33465
33259 33468
33259 33474
33259 33475
33259 33476
33259 33478
33259 33496
33259 33500
33259 33504
33259 33505
33259 33506
33259 33507
33259 33510
33259 33511
33259 33512
33259 33513
33259 33514
33259 33516
33259 33533
33259 33534
33259 33535
33259 33536
33259 33542
33259 33545
33259 33548
33259 33600
33259 33602
33259 33606
33259 33608
33259 33610
Page 85 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
33259 33611
33259 33612
33259 33615
33259 33617
33259 33619
33259 33620
33259 33621
33259 33622
33259 33641
33259 33645
33259 33647
33259 33660
33259 33665
33259 33670
33259 33675
33259 33676
33259 33677
33259 33681
33259 33684
33259 33688
33259 33692
33259 33694
33259 33697
33259 33702
33259 33710
33259 33720
33259 33722
33259 33724
33259 33726
33259 33730
33259 33732
33259 33736
33259 33767
33259 33770
33259 33783
33259 33786
33259 33788
33259 33814
33259 33853
33259 33858
33259 33859
Page 86 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
33259 33860
33259 33863
33259 33864
33259 33866
33259 33870
33259 33871
33259 33875
33259 33877
33259 33910
33259 33916
33259 33917
33259 33920
33259 33922
33259 33926
33259 33975
33259 33976
33259 33977
33259 33978
33259 33979
33259 33980
33259 33983
33367 33361
33367 33362
33367 33363
33367 33364
33367 33365
33367 33366
33367 33418
33367 33477
33367 0483T
33367 0484T
33367 0544T
33367 0545T
33367 0569T
33367 0570T
33368 33361
33368 33362
33368 33363
33368 33364
33368 33365
33368 33366
Page 87 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
33368 33418
33368 33477
33368 0483T
33368 0484T
33368 0544T
33368 0545T
33368 0569T
33368 0570T
33369 33361
33369 33362
33369 33363
33369 33364
33369 33365
33369 33366
33369 33418
33369 33477
33369 0483T
33369 0484T
33369 0544T
33369 0545T
33369 0569T
33369 0570T
33419 33418
33508 33510
33508 33511
33508 33512
33508 33513
33508 33514
33508 33516
33508 33517
33508 33518
33508 33519
33508 33521
33508 33522
33508 33523
33517 33533
33517 33534
33517 33535
33517 33536
33518 33533
33518 33534
Page 88 of 1139
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Add-on Code Primary Code
UnitedHealthcare Community Plan
Add On to Primary Code
Relationship List
33518 33535
33518 33536
33519 33533
33519 33534
33519 33535
33519 33536
33521 33533
33521 33534
33521 33535
33521 33536
33522 33533
33522 33534
33522 33535
33522 33536
33523 33533
33523 33534
33523 33535
33523 33536
33530 33390
33530 33391
33530 33404
33530 33405
33530 33406
33530 33410
33530 33411
33530 33412
33530 33413
33530 33414
33530 33415
33530 33416
33530 33417
33530 33418
33530 33419
33530 33420
33530 33422
33530 33425
33530 33426
33530 33427
33530 33430
33530 33440
335
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