Procedure Code Procedure Description Pricing Indicator Rate Type Mod1 Mod2 Mod3 Mod4 Max Fee Max Fee Eff. Date Max Fee End Date PA
72010 X-RAY EXAM SPINE AP&LAT PRXOVR DEF         NA NA NA N
72010 X-RAY EXAM SPINE AP&LAT MAXFEE DEF         NA     N
72040 X-RAY EXAM NECK SPINE 2-3 VW PRXOVR DEF         NA NA NA N
72040 X-RAY EXAM NECK SPINE 2-3 VW MAXFEE DEF         23.93 1/1/2018 12/31/2299 N
72040 X-RAY EXAM NECK SPINE 2-3 VW MAXFEE DEF 26       8.38 1/1/2018 12/31/2299 N
72040 X-RAY EXAM NECK SPINE 2-3 VW MAXFEE DEF TC       15.55 1/1/2018 12/31/2299 N
72050 X-RAY EXAM NECK SPINE 4/5VWS PRXOVR DEF         NA NA NA N
72050 X-RAY EXAM NECK SPINE 4/5VWS MAXFEE DEF         35.15 1/1/2018 12/31/2299 N
72050 X-RAY EXAM NECK SPINE 4/5VWS MAXFEE DEF 26       12.30 1/1/2018 12/31/2299 N
72050 X-RAY EXAM NECK SPINE 4/5VWS MAXFEE DEF TC       22.85 1/1/2018 12/31/2299 N
72052 X-RAY EXAM NECK SPINE 6/>VWS PRXOVR DEF         NA NA NA N
72052 X-RAY EXAM NECK SPINE 6/>VWS MAXFEE DEF         43.03 1/1/2018 12/31/2299 N
72052 X-RAY EXAM NECK SPINE 6/>VWS MAXFEE DEF 26       15.06 1/1/2018 12/31/2299 N
72052 X-RAY EXAM NECK SPINE 6/>VWS MAXFEE DEF TC       27.97 1/1/2018 12/31/2299 N
72070 X-RAY EXAM THORAC SPINE 2VWS PRXOVR DEF         NA NA NA N
72070 X-RAY EXAM THORAC SPINE 2VWS MAXFEE DEF         25.18 1/1/2018 12/31/2299 N
72070 X-RAY EXAM THORAC SPINE 2VWS MAXFEE DEF 26       8.81 1/1/2018 12/31/2299 N
72070 X-RAY EXAM THORAC SPINE 2VWS MAXFEE DEF TC       16.37 1/1/2018 12/31/2299 N
72074 X-RAY EXAM THORAC SPINE4/>VW PRXOVR DEF         NA NA NA N
72074 X-RAY EXAM THORAC SPINE4/>VW MAXFEE DEF         32.23 1/1/2018 12/31/2299 N
72074 X-RAY EXAM THORAC SPINE4/>VW MAXFEE DEF 26       9.67 1/1/2018 12/31/2299 N
72074 X-RAY EXAM THORAC SPINE4/>VW MAXFEE DEF TC       22.56 1/1/2018 12/31/2299 N
72080 X-RAY EXAM THORACOLMB 2/> VW PRXOVR DEF         NA NA NA N
72080 X-RAY EXAM THORACOLMB 2/> VW MAXFEE DEF         25.67 1/1/2018 12/31/2299 N
72080 X-RAY EXAM THORACOLMB 2/> VW MAXFEE DEF 26       8.98 1/1/2018 12/31/2299 N
72080 X-RAY EXAM THORACOLMB 2/> VW MAXFEE DEF TC       16.69 1/1/2018 12/31/2299 N
72100 X-RAY EXAM L-S SPINE 2/3 VWS PRXOVR DEF         NA NA NA N
72100 X-RAY EXAM L-S SPINE 2/3 VWS MAXFEE DEF         25.67 1/1/2018 12/31/2299 N
72100 X-RAY EXAM L-S SPINE 2/3 VWS MAXFEE DEF 26       8.98 1/1/2018 12/31/2299 N
72100 X-RAY EXAM L-S SPINE 2/3 VWS MAXFEE DEF TC       16.69 1/1/2018 12/31/2299 N
72110 X-RAY EXAM L-2 SPINE 4/>VWS PRXOVR DEF         NA NA NA N
72110 X-RAY EXAM L-2 SPINE 4/>VWS MAXFEE DEF         35.63 1/1/2018 12/31/2299 N
72110 X-RAY EXAM L-2 SPINE 4/>VWS MAXFEE DEF 26       12.47 1/1/2018 12/31/2299 N
72110 X-RAY EXAM L-2 SPINE 4/>VWS MAXFEE DEF TC       23.16 1/1/2018 12/31/2299 N
72114 X-RAY EXAM L-S SPINE BENDING PRXOVR DEF         NA NA NA N
72114 X-RAY EXAM L-S SPINE BENDING MAXFEE DEF         44.41 1/1/2018 12/31/2299 N
72114 X-RAY EXAM L-S SPINE BENDING MAXFEE DEF 26       11.10 1/1/2018 12/31/2299 N
72114 X-RAY EXAM L-S SPINE BENDING MAXFEE DEF TC       33.31 1/1/2018 12/31/2299 N
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
98940 CHIROPRACT MANJ 1-2 REGIONS PRXOVR DEF         NA NA NA S
98940 CHIROPRACT MANJ 1-2 REGIONS MAXFEE FAC         10.83 1/1/2014 12/31/2299 S
98940 CHIROPRACT MANJ 1-2 REGIONS MAXFEE NFF         15.96 1/1/2014 12/31/2299 S
98941 CHIROPRACT MANJ 3-4 REGIONS PRXOVR DEF         NA NA NA S
98941 CHIROPRACT MANJ 3-4 REGIONS MAXFEE FAC         16.04 1/1/2014 12/31/2299 S
98941 CHIROPRACT MANJ 3-4 REGIONS MAXFEE NFF         21.19 1/1/2014 12/31/2299 S
98942 CHIROPRACTIC MANJ 5 REGIONS PRXOVR DEF         NA NA NA S
98942 CHIROPRACTIC MANJ 5 REGIONS MAXFEE FAC         22.74 1/1/2014 12/31/2299 S
98942 CHIROPRACTIC MANJ 5 REGIONS MAXFEE NFF         27.97 1/1/2014 12/31/2299 S
99202 OFFICE O/P NEW SF 15-29 MIN PRXOVR DEF         NA NA NA N
99202 OFFICE O/P NEW SF 15-29 MIN MAXFEE FAC         20.84 1/1/2016 12/31/2299 N
99202 OFFICE O/P NEW SF 15-29 MIN MAXFEE NFF         38.93 1/1/2016 12/31/2299 N
99203 OFFICE O/P NEW LOW 30-44 MIN PRXOVR DEF         NA NA NA N
99203 OFFICE O/P NEW LOW 30-44 MIN MAXFEE FAC         32.94 1/1/2016 12/31/2299 N
99203 OFFICE O/P NEW LOW 30-44 MIN MAXFEE NFF         57.76 1/1/2016 12/31/2299 N
99211 OFF/OP EST MAY X REQ PHY/QHP PRXOVR DEF         NA NA NA N
99211 OFF/OP EST MAY X REQ PHY/QHP MAXFEE FAC         5.55 1/1/2016 12/31/2299 N
99211 OFF/OP EST MAY X REQ PHY/QHP MAXFEE NFF         14.50 1/1/2016 12/31/2299 N
99212 OFFICE O/P EST SF 10-19 MIN PRXOVR DEF         NA NA NA N
99212 OFFICE O/P EST SF 10-19 MIN MAXFEE FAC         12.81 1/1/2016 12/31/2299 N
99212 OFFICE O/P EST SF 10-19 MIN MAXFEE NFF         26.73 1/1/2016 12/31/2299 N
99213 OFFICE O/P EST LOW 20-29 MIN PRXOVR DEF         NA NA NA N
99213 OFFICE O/P EST LOW 20-29 MIN MAXFEE FAC         24.85 1/1/2016 12/31/2299 N
99213 OFFICE O/P EST LOW 20-29 MIN MAXFEE NFF         43.61 1/1/2016 12/31/2299 N
T1015 CLINIC SERVICE PRXOVR DEF         NA NA NA N
T1015 CLINIC SERVICE UCCENC UC8         NA NA NA N