Procedure Code	Procedure Description	Pricing Indicator	Rate Type	Mod1	Mod2	Mod3	Mod4	Max Fee	Max Fee Eff. Date	Max Fee End Date	PA
36415	ROUTINE VENIPUNCTURE	PRXOVR	DEF					NA	NA	NA	N
36415	ROUTINE VENIPUNCTURE	MAXFEE	DEF					2.25	1/1/2018	12/31/2299	N
57170	FITTING OF DIAPHRAGM/CAP	PRXOVR	DEF					NA	NA	NA	N
57170	FITTING OF DIAPHRAGM/CAP	MAXFEE	FAC					27.54	1/1/2014	12/31/2299	N
57170	FITTING OF DIAPHRAGM/CAP	MAXFEE	NFF					38.34	1/1/2014	12/31/2299	N
59020	FETAL CONTRACT STRESS TEST	PRXOVR	DEF					NA	NA	NA	N
59020	FETAL CONTRACT STRESS TEST	MAXFEE	DEF					46.77	3/22/2006	12/31/2299	N
59020	FETAL CONTRACT STRESS TEST	MAXFEE	DEF	TC				18.71	3/22/2006	12/31/2299	N
59020	FETAL CONTRACT STRESS TEST	MAXFEE	DEF	26				28.06	3/22/2006	12/31/2299	N
59025	FETAL NON-STRESS TEST	PRXOVR	DEF					NA	NA	NA	N
59025	FETAL NON-STRESS TEST	MAXFEE	DEF					30.98	7/26/2007	12/31/2299	N
59025	FETAL NON-STRESS TEST	MAXFEE	DEF	TC				9.29	7/26/2007	12/31/2299	N
59025	FETAL NON-STRESS TEST	MAXFEE	DEF	26				21.69	7/26/2007	12/31/2299	N
59400	OBSTETRICAL CARE	PRXOVR	DEF					NA	NA	NA	N
59400	OBSTETRICAL CARE	MAXFEE	DEF					1175.28	1/1/2012	12/31/2299	N
59409	OBSTETRICAL CARE	PRXOVR	DEF					NA	NA	NA	N
59409	OBSTETRICAL CARE	MAXFEE	DEF					637.72	7/1/2008	12/31/2299	N
59410	OBSTETRICAL CARE	PRXOVR	DEF					NA	NA	NA	N
59410	OBSTETRICAL CARE	MAXFEE	DEF					731.10	7/1/2008	12/31/2299	N
59425	ANTEPARTUM CARE ONLY	PRXOVR	DEF					NA	NA	NA	N
59425	ANTEPARTUM CARE ONLY	MAXFEE	FAC					134.37	1/1/2014	12/31/2299	N
59425	ANTEPARTUM CARE ONLY	MAXFEE	NFF					201.90	1/1/2014	12/31/2299	N
59426	ANTEPARTUM CARE ONLY	PRXOVR	DEF					NA	NA	NA	N
59426	ANTEPARTUM CARE ONLY	MAXFEE	FAC					236.68	1/1/2014	12/31/2299	N
59426	ANTEPARTUM CARE ONLY	MAXFEE	NFF					363.42	1/1/2014	12/31/2299	N
59430	CARE AFTER DELIVERY	PRXOVR	DEF					NA	NA	NA	N
59430	CARE AFTER DELIVERY	MAXFEE	FAC					51.01	1/1/2014	12/31/2299	N
59430	CARE AFTER DELIVERY	MAXFEE	NFF					79.85	1/1/2014	12/31/2299	N
76801	OB US < 14 WKS SINGLE FETUS	PRXOVR	DEF					NA	NA	NA	N
76801	OB US < 14 WKS SINGLE FETUS	MAXFEE	DEF					71.57	1/1/2018	12/31/2299	N
76801	OB US < 14 WKS SINGLE FETUS	MAXFEE	DEF	26				28.63	1/1/2018	12/31/2299	N
76801	OB US < 14 WKS SINGLE FETUS	MAXFEE	DEF	TC				42.94	1/1/2018	12/31/2299	N
76802	OB US < 14 WKS ADDL FETUS	PRXOVR	DEF					NA	NA	NA	N
76802	OB US < 14 WKS ADDL FETUS	MAXFEE	DEF					50.22	1/1/2018	12/31/2299	N
76802	OB US < 14 WKS ADDL FETUS	MAXFEE	DEF	26				25.11	1/1/2018	12/31/2299	N
76802	OB US < 14 WKS ADDL FETUS	MAXFEE	DEF	TC				25.11	1/1/2018	12/31/2299	N
76805	OB US >= 14 WKS SNGL FETUS	PRXOVR	DEF					NA	NA	NA	N
76805	OB US >= 14 WKS SNGL FETUS	MAXFEE	DEF					94.88	1/1/2018	12/31/2299	N
76805	OB US >= 14 WKS SNGL FETUS	MAXFEE	DEF	26				37.95	1/1/2018	12/31/2299	N
76805	OB US >= 14 WKS SNGL FETUS	MAXFEE	DEF	TC				56.93	1/1/2018	12/31/2299	N
76815	OB US LIMITED FETUS(S)	PRXOVR	DEF					NA	NA	NA	N
76815	OB US LIMITED FETUS(S)	MAXFEE	DEF					63.63	1/1/2018	12/31/2299	N
76815	OB US LIMITED FETUS(S)	MAXFEE	DEF	26				25.45	1/1/2018	12/31/2299	N
76815	OB US LIMITED FETUS(S)	MAXFEE	DEF	TC				38.18	1/1/2018	12/31/2299	N
76816	OB US FOLLOW-UP PER FETUS	PRXOVR	DEF					NA	NA	NA	N
76816	OB US FOLLOW-UP PER FETUS	MAXFEE	DEF					68.79	1/1/2018	12/31/2299	N
76816	OB US FOLLOW-UP PER FETUS	MAXFEE	DEF	26				34.40	1/1/2018	12/31/2299	N
76816	OB US FOLLOW-UP PER FETUS	MAXFEE	DEF	TC				34.39	1/1/2018	12/31/2299	N
76817	TRANSVAGINAL US OBSTETRIC	PRXOVR	DEF					NA	NA	NA	N
76817	TRANSVAGINAL US OBSTETRIC	MAXFEE	DEF					65.72	1/1/2018	12/31/2299	N
76817	TRANSVAGINAL US OBSTETRIC	MAXFEE	DEF	26				26.29	1/1/2018	12/31/2299	N
76817	TRANSVAGINAL US OBSTETRIC	MAXFEE	DEF	TC				39.43	1/1/2018	12/31/2299	N
76818	FETAL BIOPHYS PROFILE W/NST	PRXOVR	DEF					NA	NA	NA	N
76818	FETAL BIOPHYS PROFILE W/NST	MAXFEE	DEF					73.59	1/1/2018	12/31/2299	N
76818	FETAL BIOPHYS PROFILE W/NST	MAXFEE	DEF	26				29.44	1/1/2018	12/31/2299	N
76818	FETAL BIOPHYS PROFILE W/NST	MAXFEE	DEF	TC				44.15	1/1/2018	12/31/2299	N
84703	CHORIONIC GONADOTROPIN ASSAY	PRXOVR	DEF					NA	NA	NA	N
84703	CHORIONIC GONADOTROPIN ASSAY	MAXFEE	DEF					5.64	1/1/2021	12/31/2299	N
85013	SPUN MICROHEMATOCRIT	PRXOVR	DEF					NA	NA	NA	N
85013	SPUN MICROHEMATOCRIT	MAXFEE	DEF					5.25	4/1/2019	12/31/2299	N
85014	HEMATOCRIT	PRXOVR	DEF					NA	NA	NA	N
85014	HEMATOCRIT	MAXFEE	DEF					1.78	1/1/2021	12/31/2299	N
90371	HEP B IG IM	PRXOVR	DEF					NA	NA	NA	N
90371	HEP B IG IM	MAXFEE	DEF					137.58	10/1/2023	12/31/2299	N
90707	MMR VACCINE SC	PRXOVR	DEF					NA	NA	NA	N
90707	MMR VACCINE SC	MAXFEE	DEF					93.75	10/1/2022	12/31/2299	N
92950	HEART/LUNG RESUSCITATION CPR	PRXOVR	DEF					NA	NA	NA	N
92950	HEART/LUNG RESUSCITATION CPR	MAXFEE	FAC					77	1/1/2014	12/31/2299	N
92950	HEART/LUNG RESUSCITATION CPR	MAXFEE	NFF					156.12	1/1/2014	12/31/2299	N
96360	HYDRATION IV INFUSION INIT	PRXOVR	DEF					NA	NA	NA	N
96360	HYDRATION IV INFUSION INIT	MAXFEE	DEF					45.65	1/1/2009	12/31/2299	N
96361	HYDRATE IV INFUSION ADD-ON	PRXOVR	DEF					NA	NA	NA	N
96361	HYDRATE IV INFUSION ADD-ON	MAXFEE	DEF					12.78	12/31/2014	12/31/2299	N
96365	THER/PROPH/DIAG IV INF INIT	PRXOVR	DEF					NA	NA	NA	N
96365	THER/PROPH/DIAG IV INF INIT	MAXFEE	DEF					55.80	1/1/2009	12/31/2299	N
96366	THER/PROPH/DIAG IV INF ADDON	PRXOVR	DEF					NA	NA	NA	N
96366	THER/PROPH/DIAG IV INF ADDON	MAXFEE	DEF					15.98	12/31/2014	12/31/2299	N
96372	THER/PROPH/DIAG INJ SC/IM	PRXOVR	DEF					NA	NA	NA	N
96372	THER/PROPH/DIAG INJ SC/IM	MAXFEE	DEF					14.57	1/1/2009	12/31/2299	N
99202	OFFICE O/P NEW SF 15 MIN	PRXOVR	DEF					NA	NA	NA	N
99202	OFFICE O/P NEW SF 15 MIN	MAXFEE	FAC					20.84	1/1/2016	12/31/2299	N
99202	OFFICE O/P NEW SF 15 MIN	MAXFEE	NFF					38.93	1/1/2016	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					32.94	1/1/2016	12/31/2299	N
99203	OFFICE O/P NEW LOW 30 MIN	MAXFEE	NFF					57.76	1/1/2016	12/31/2299	N
99204	OFFICE O/P NEW MOD 45 MIN	PRXOVR	DEF					NA	NA	NA	N
99204	OFFICE O/P NEW MOD 45 MIN	MAXFEE	FAC					56.15	1/1/2016	12/31/2299	N
99204	OFFICE O/P NEW MOD 45 MIN	MAXFEE	NFF					88.07	1/1/2016	12/31/2299	N
99205	OFFICE O/P NEW HI 60 MIN	PRXOVR	DEF					NA	NA	NA	N
99205	OFFICE O/P NEW HI 60 MIN	MAXFEE	FAC					72.01	1/1/2016	12/31/2299	N
99205	OFFICE O/P NEW HI 60 MIN	MAXFEE	NFF					110.67	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 MIN	PRXOVR	DEF					NA	NA	NA	N
99212	OFFICE O/P EST SF 10 MIN	MAXFEE	FAC					12.81	1/1/2016	12/31/2299	N
99212	OFFICE O/P EST SF 10 MIN	MAXFEE	NFF					26.73	1/1/2016	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					24.85	1/1/2016	12/31/2299	N
99213	OFFICE O/P EST LOW 20 MIN	MAXFEE	NFF					43.61	1/1/2016	12/31/2299	N
99214	OFFICE O/P EST MOD 30 MIN	PRXOVR	DEF					NA	NA	NA	N
99214	OFFICE O/P EST MOD 30 MIN	MAXFEE	FAC					39.90	1/1/2016	12/31/2299	N
99214	OFFICE O/P EST MOD 30 MIN	MAXFEE	NFF					66.14	1/1/2016	12/31/2299	N
99215	OFFICE O/P EST HI 40 MIN	PRXOVR	DEF					NA	NA	NA	N
99215	OFFICE O/P EST HI 40 MIN	MAXFEE	FAC					57.36	1/1/2016	12/31/2299	N
99215	OFFICE O/P EST HI 40 MIN	MAXFEE	NFF					89.63	1/1/2016	12/31/2299	N
99354	PROLNG SVC O/P 1ST HOUR	PRXOVR	DEF					NA	NA	NA	N
99354	PROLNG SVC O/P 1ST HOUR	MAXFEE	DEF					NA			N
99355	PROLNG SVC O/P EA ADDL 30	PRXOVR	DEF					NA	NA	NA	N
99355	PROLNG SVC O/P EA ADDL 30	MAXFEE	DEF					NA			N
99406	BEHAV CHNG SMOKING 3-10 MIN	PRXOVR	DEF					NA	NA	NA	N
99406	BEHAV CHNG SMOKING 3-10 MIN	MAXFEE	FAC					7.28	1/1/2014	12/31/2299	N
99406	BEHAV CHNG SMOKING 3-10 MIN	MAXFEE	NFF					9.43	1/1/2014	12/31/2299	N
99407	BEHAV CHNG SMOKING > 10 MIN	PRXOVR	DEF					NA	NA	NA	N
99407	BEHAV CHNG SMOKING > 10 MIN	MAXFEE	FAC					15.98	1/1/2014	12/31/2299	N
99407	BEHAV CHNG SMOKING > 10 MIN	MAXFEE	NFF					19	1/1/2014	12/31/2299	N
99415	PROLNG CLIN STAFF SVC 1ST HR	PRXOVR	DEF					NA	NA	NA	N
99415	PROLNG CLIN STAFF SVC 1ST HR	MAXFEE	DEF					7.38	7/1/2021	12/31/2299	N
99416	PROLNG CLIN STAFF SVC EA ADD	PRXOVR	DEF					NA	NA	NA	N
99416	PROLNG CLIN STAFF SVC EA ADD	MAXFEE	DEF					3.79	7/1/2021	12/31/2299	N
99417	PROLNG OP E/M EACH 15 MIN	PRXOVR	DEF					NA	NA	NA	N
99417	PROLNG OP E/M EACH 15 MIN	MAXFEE	FAC					21.58	1/1/2021	12/31/2299	N
99417	PROLNG OP E/M EACH 15 MIN	MAXFEE	NFF					22.48	1/1/2021	12/31/2299	N
99460	INIT NB EM PER DAY HOSP	PRXOVR	DEF					NA	NA	NA	N
99460	INIT NB EM PER DAY HOSP	MAXFEE	DEF					74.73	1/1/2018	12/31/2299	N
99461	INIT NB EM PER DAY NON-FAC	PRXOVR	DEF					NA	NA	NA	N
99461	INIT NB EM PER DAY NON-FAC	MAXFEE	FAC					47.18	1/1/2018	12/31/2299	N
99461	INIT NB EM PER DAY NON-FAC	MAXFEE	NFF					67.94	1/1/2018	12/31/2299	N
99463	SAME DAY NB DISCHARGE	PRXOVR	DEF					NA	NA	NA	N
99463	SAME DAY NB DISCHARGE	MAXFEE	DEF					88.52	1/1/2018	12/31/2299	N
99465	NB RESUSCITATION	PRXOVR	DEF					NA	NA	NA	N
99465	NB RESUSCITATION	MAXFEE	DEF					132.30	1/1/2016	12/31/2299	N
A4261	CERVICAL CAP CONTRACEPTIVE	PRXOVR	DEF					NA	NA	NA	N
A4261	CERVICAL CAP CONTRACEPTIVE	MAXFEE	DEF					17.65	1/1/1999	12/31/2299	N
A4266	DIAPHRAGM	PRXOVR	DEF					NA	NA	NA	N
A4266	DIAPHRAGM	MAXFEE	DEF					25.46	4/1/2003	12/31/2299	N
G2212	PROLONG OUTPT/OFFICE VIS	PRXOVR	DEF					NA	NA	NA	N
G2212	PROLONG OUTPT/OFFICE VIS	MAXFEE	FAC					21.58	1/1/2021	12/31/2299	N
G2212	PROLONG OUTPT/OFFICE VIS	MAXFEE	NFF					22.48	1/1/2021	12/31/2299	N
J0171	ADRENALIN EPINEPHRINE INJECT	PRXOVR	DEF					NA	NA	NA	N
J0171	ADRENALIN EPINEPHRINE INJECT	MAXFEE	DEF					0.78	10/1/2023	12/31/2299	N
J0290	AMPICILLIN 500 MG INJ	PRXOVR	DEF					NA	NA	NA	N
J0290	AMPICILLIN 500 MG INJ	MAXFEE	DEF					0.95	10/1/2023	12/31/2299	N
J1364	ERYTHRO LACTOBIONATE /500 MG	PRXOVR	DEF					NA	NA	NA	N
J1364	ERYTHRO LACTOBIONATE /500 MG	MAXFEE	DEF					83.64	10/1/2023	12/31/2299	N
J2210	METHYLERGONOVIN MALEATE INJ	PRXOVR	DEF					NA	NA	NA	N
J2210	METHYLERGONOVIN MALEATE INJ	MAXFEE	DEF					21.09	10/1/2023	12/31/2299	N
J2540	PENICILLIN G POTASSIUM INJ	PRXOVR	DEF					NA	NA	NA	N
J2540	PENICILLIN G POTASSIUM INJ	MAXFEE	DEF					0.82	10/1/2023	12/31/2299	N
J2590	OXYTOCIN INJECTION	PRXOVR	DEF					NA	NA	NA	N
J2590	OXYTOCIN INJECTION	MAXFEE	DEF					0.53	4/1/2014	12/31/2299	N
J2788	RHO D IMMUNE GLOBULIN 50 MCG	PRXOVR	DEF					NA	NA	NA	N
J2788	RHO D IMMUNE GLOBULIN 50 MCG	MAXFEE	DEF					25.51	10/1/2023	12/31/2299	N
J2790	RHO D IMMUNE GLOBULIN INJ	PRXOVR	DEF					NA	NA	NA	N
J2790	RHO D IMMUNE GLOBULIN INJ	MAXFEE	DEF					77.30	10/1/2023	12/31/2299	N
J3430	VITAMIN K PHYTONADIONE INJ	PRXOVR	DEF					NA	NA	NA	N
J3430	VITAMIN K PHYTONADIONE INJ	MAXFEE	DEF					2.98	10/1/2023	12/31/2299	N
J3475	INJ MAGNESIUM SULFATE	PRXOVR	DEF					NA	NA	NA	N
J3475	INJ MAGNESIUM SULFATE	MAXFEE	DEF					0.76	10/1/2023	12/31/2299	N
J7050	NORMAL SALINE SOLUTION INFUS	PRXOVR	DEF					NA	NA	NA	N
J7050	NORMAL SALINE SOLUTION INFUS	MAXFEE	DEF					0.65	10/1/2023	12/31/2299	N
J7120	RINGERS LACTATE INFUSION	PRXOVR	DEF					NA	NA	NA	N
J7120	RINGERS LACTATE INFUSION	MAXFEE	DEF					2.45	10/1/2023	12/31/2299	N
S3620	NEWBORN METABOLIC SCREENING	PRXOVR	DEF					NA	NA	NA	N
S3620	NEWBORN METABOLIC SCREENING	MAXFEE	DEF					33.75	2/1/2003	12/31/2299	N
S4005	INTERIM LABOR FACILITY GLOBA	PRXOVR	DEF					NA	NA	NA	N
S4005	INTERIM LABOR FACILITY GLOBA	MAXFEE	DEF					223.55	1/1/2012	12/31/2299	N