"VALUE","LO_VERSION","HI_VERSION","DESCRIPTION"
"0","58","85","No payment adjustment"
"1","58","85","Paid standard amount for pass-through drug or biological"
"2","58","85","Payment based on charge adjusted to cost"
"3","58","85","Additional payment for new drug or new biological applies to APC"
"4","58","85","Deductible not applicable (specific list of HCPCS codes)"
"5","58","85","Blood/blood product used in blood deductible calculation"
"6","58","85","Blood processing/storage not subject to blood deductible"
"7","58","85","Item provided without cost to provider"
"8","58","85","Item provided with partial credit to provider"
"9","58","85","Deductible/co-insurance not applicable"
"10","58","85","Co-insurance not applicable"
"11","58","85","Multiple service units reduced to one by OCE processing; payment based on single payment rate"
"12","58","85","Offset for first device pass-through"
"13","58","85","Offset for second device pass-through"
"14","58","85","PAMA Section 218 reduction on CT scan"
"15","58","85","Reserved for future use"
"16","58","85","Terminated procedure with pass-through device"
"17","58","85","Condition for device credit present"
"18","58","85","Offset for first pass-through drug or biological"
"19","58","85","Offset for second pass-through drug or biological"
"20","58","85","Offset for third pass-through drug or biological"
"21","58","85","CAA Section 502(b) reduction on film X-ray"
"22","58","85","CAA Section 502(b) reduction on computed radiography technology"
"23","58","85","Deductible/co-insurance not applicable and CAA Section 502(b) reduction on film x-ray"
"24","58","85","Deductible/co-insurance not applicable and CAA Section 502(b) reduction due to computed radiography technology"
"25","58","85","Reserved for future use"
"91","58","85","Composite APC present, same value for prime and non-prime codes"
"92","58","85","Composite APC present, same value for prime and non-prime codes"
"93","58","85","Composite APC present, same value for prime and non-prime codes"
"94","58","85","Composite APC present, same value for prime and non-prime codes"
"95","58","85","Composite APC present, same value for prime and non-prime codes"
"96","58","85","Composite APC present, same value for prime and non-prime codes"
"97","58","85","Composite APC present, same value for prime and non-prime codes"
"98","58","85","Composite APC present, same value for prime and non-prime codes"
"99","58","85","Composite APC present, same value for prime and non-prime codes"
