| Procedure Code | Procedure Description | Pricing Indicator | Rate Type | Mod1 | Mod2 | Mod3 | Mod4 | Max Fee | Max Fee Eff. Date | Max Fee End Date | PA |
| 97810 | ACUPUNCT W/O STIMUL 15 MIN | PRXOVR | DEF | NA | NA | NA | S | ||||
| 97810 | ACUPUNCT W/O STIMUL 15 MIN | MAXFEE | DEF | 25 | 1/1/2017 | 12/31/2299 | S | ||||
| 97811 | ACUPUNCT W/O STIMUL ADDL 15M | PRXOVR | DEF | NA | NA | NA | S | ||||
| 97811 | ACUPUNCT W/O STIMUL ADDL 15M | MAXFEE | DEF | 17.50 | 1/1/2017 | 12/31/2299 | S | ||||
| 97813 | ACUPUNCT W/STIMUL 15 MIN | PRXOVR | DEF | NA | NA | NA | S | ||||
| 97813 | ACUPUNCT W/STIMUL 15 MIN | MAXFEE | DEF | 31.15 | 1/1/2018 | 12/31/2299 | S | ||||
| 97814 | ACUPUNCT W/STIMUL ADDL 15M | PRXOVR | DEF | NA | NA | NA | S | ||||
| 97814 | ACUPUNCT W/STIMUL ADDL 15M | MAXFEE | DEF | 23.65 | 1/1/2018 | 12/31/2299 | S |