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         25.13 1/1/2024 12/31/2299 N
72040 X-RAY EXAM NECK SPINE 2-3 VW MAXFEE DEF TC       16.33 1/1/2024 12/31/2299 N
72040 X-RAY EXAM NECK SPINE 2-3 VW MAXFEE DEF 26       8.80 1/1/2024 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         36.91 1/1/2024 12/31/2299 N
72050 X-RAY EXAM NECK SPINE 4/5VWS MAXFEE DEF TC       23.99 1/1/2024 12/31/2299 N
72050 X-RAY EXAM NECK SPINE 4/5VWS MAXFEE DEF 26       12.92 1/1/2024 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         45.18 1/1/2024 12/31/2299 N
72052 X-RAY EXAM NECK SPINE 6/>VWS MAXFEE DEF TC       29.37 1/1/2024 12/31/2299 N
72052 X-RAY EXAM NECK SPINE 6/>VWS MAXFEE DEF 26       15.81 1/1/2024 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         26.44 1/1/2024 12/31/2299 N
72070 X-RAY EXAM THORAC SPINE 2VWS MAXFEE DEF TC       17.19 1/1/2024 12/31/2299 N
72070 X-RAY EXAM THORAC SPINE 2VWS MAXFEE DEF 26       9.25 1/1/2024 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         33.85 1/1/2024 12/31/2299 N
72074 X-RAY EXAM THORAC SPINE4/>VW MAXFEE DEF TC       23.70 1/1/2024 12/31/2299 N
72074 X-RAY EXAM THORAC SPINE4/>VW MAXFEE DEF 26       10.16 1/1/2024 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         26.95 1/1/2024 12/31/2299 N
72080 X-RAY EXAM THORACOLMB 2/> VW MAXFEE DEF TC       17.52 1/1/2024 12/31/2299 N
72080 X-RAY EXAM THORACOLMB 2/> VW MAXFEE DEF 26       9.43 1/1/2024 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         26.95 1/1/2024 12/31/2299 N
72100 X-RAY EXAM L-S SPINE 2/3 VWS MAXFEE DEF TC       17.52 1/1/2024 12/31/2299 N
72100 X-RAY EXAM L-S SPINE 2/3 VWS MAXFEE DEF 26       9.43 1/1/2024 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         37.41 1/1/2024 12/31/2299 N
72110 X-RAY EXAM L-2 SPINE 4/>VWS MAXFEE DEF TC       24.32 1/1/2024 12/31/2299 N
72110 X-RAY EXAM L-2 SPINE 4/>VWS MAXFEE DEF 26       13.09 1/1/2024 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         46.63 1/1/2024 12/31/2299 N
72114 X-RAY EXAM L-S SPINE BENDING MAXFEE DEF TC       34.97 1/1/2024 12/31/2299 N
72114 X-RAY EXAM L-S SPINE BENDING MAXFEE DEF 26       11.66 1/1/2024 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         26.25 1/1/2024 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         18.38 1/1/2024 12/31/2299 S
97813 ACUPUNCT W/STIMUL 15 MIN PRXOVR DEF         NA NA NA S
97813 ACUPUNCT W/STIMUL 15 MIN MAXFEE DEF         32.71 1/1/2024 12/31/2299 S
97814 ACUPUNCT W/STIMUL ADDL 15M PRXOVR DEF         NA NA NA S
97814 ACUPUNCT W/STIMUL ADDL 15M MAXFEE DEF         24.83 1/1/2024 12/31/2299 S
98940 CHIROPRACT MANJ 1-2 REGIONS PRXOVR DEF         NA NA NA S
98940 CHIROPRACT MANJ 1-2 REGIONS MAXFEE FAC         11.37 1/1/2024 12/31/2299 S
98940 CHIROPRACT MANJ 1-2 REGIONS MAXFEE NFF         16.76 1/1/2024 12/31/2299 S
98941 CHIROPRACT MANJ 3-4 REGIONS PRXOVR DEF         NA NA NA S
98941 CHIROPRACT MANJ 3-4 REGIONS MAXFEE FAC         16.84 1/1/2024 12/31/2299 S
98941 CHIROPRACT MANJ 3-4 REGIONS MAXFEE NFF         22.25 1/1/2024 12/31/2299 S
98942 CHIROPRACTIC MANJ 5 REGIONS PRXOVR DEF         NA NA NA S
98942 CHIROPRACTIC MANJ 5 REGIONS MAXFEE FAC         23.88 1/1/2024 12/31/2299 S
98942 CHIROPRACTIC MANJ 5 REGIONS MAXFEE NFF         29.37 1/1/2024 12/31/2299 S
99202 OFFICE O/P NEW SF 15 MIN PRXOVR DEF         NA NA NA N
99202 OFFICE O/P NEW SF 15 MIN MAXFEE FAC         24.75 1/1/2024 12/31/2299 N
99202 OFFICE O/P NEW SF 15 MIN MAXFEE NFF         41.27 1/1/2024 12/31/2299 N
99203 OFFICE O/P NEW LOW 30 MIN PRXOVR DEF         NA NA NA N
99203 OFFICE O/P NEW LOW 30 MIN MAXFEE FAC         42.22 1/1/2024 12/31/2299 N
99203 OFFICE O/P NEW LOW 30 MIN MAXFEE NFF         61.22 1/1/2024 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         5.88 1/1/2024 12/31/2299 N
99211 OFF/OP EST MAY X REQ PHY/QHP MAXFEE NFF         15.37 1/1/2024 12/31/2299 N
99212 OFFICE O/P EST SF 10 MIN PRXOVR DEF         NA NA NA N
99212 OFFICE O/P EST SF 10 MIN MAXFEE FAC         18.34 1/1/2024 12/31/2299 N
99212 OFFICE O/P EST SF 10 MIN MAXFEE NFF         28.73 1/1/2024 12/31/2299 N
99213 OFFICE O/P EST LOW 20 MIN PRXOVR DEF         NA NA NA N
99213 OFFICE O/P EST LOW 20 MIN MAXFEE FAC         33.74 1/1/2024 12/31/2299 N
99213 OFFICE O/P EST LOW 20 MIN MAXFEE NFF         46.23 1/1/2024 12/31/2299 N
T1015 CLINIC SERVICE PRXOVR DEF         NA NA NA N
T1015 CLINIC SERVICE UCCENC UC8         NA NA NA N