Procedure Code	Procedure Description	Pricing Indicator	Rate Type	Mod1	Mod2	Mod3	Mod4	Max Fee	Max Fee Eff. Date	Max Fee End Date	PA
77046	MRI BREAST C- UNILATERAL	PRXOVR	DEF					NA	NA	NA	N
77046	MRI BREAST C- UNILATERAL	MAXFEE	DEF	26				58.14	1/1/2019	12/31/2299	N
77046	MRI BREAST C- UNILATERAL	MAXFEE	DEF	TC				131.15	1/1/2019	12/31/2299	N
77046	MRI BREAST C- UNILATERAL	MAXFEE	DEF					189.29	1/1/2019	12/31/2299	N
77047	MRI BREAST C- BILATERAL	PRXOVR	DEF					NA	NA	NA	N
77047	MRI BREAST C- BILATERAL	MAXFEE	DEF	26				64.34	1/1/2019	12/31/2299	N
77047	MRI BREAST C- BILATERAL	MAXFEE	DEF	TC				130.36	1/1/2019	12/31/2299	N
77047	MRI BREAST C- BILATERAL	MAXFEE	DEF					194.70	1/1/2019	12/31/2299	N
77048	MRI BREAST C-+ W/CAD UNI	PRXOVR	DEF					NA	NA	NA	N
77048	MRI BREAST C-+ W/CAD UNI	MAXFEE	DEF	26				84.12	1/1/2019	12/31/2299	N
77048	MRI BREAST C-+ W/CAD UNI	MAXFEE	DEF	TC				216.05	1/1/2019	12/31/2299	N
77048	MRI BREAST C-+ W/CAD UNI	MAXFEE	DEF					300.17	1/1/2019	12/31/2299	N
77049	MRI BREAST C-+ W/CAD BI	PRXOVR	DEF					NA	NA	NA	N
77049	MRI BREAST C-+ W/CAD BI	MAXFEE	DEF	26				92.03	1/1/2019	12/31/2299	N
77049	MRI BREAST C-+ W/CAD BI	MAXFEE	DEF	TC				214.99	1/1/2019	12/31/2299	N
77049	MRI BREAST C-+ W/CAD BI	MAXFEE	DEF					307.02	1/1/2019	12/31/2299	N
77051	COMPUTER DX MAMMOGRAM ADD-ON	PRXOVR	DEF					NA	NA	NA	N
77051	COMPUTER DX MAMMOGRAM ADD-ON	MAXFEE	DEF					NA			N
77052	COMP SCREEN MAMMOGRAM ADD-ON	PRXOVR	DEF					NA	NA	NA	N
77052	COMP SCREEN MAMMOGRAM ADD-ON	MAXFEE	DEF					NA			N
77055	MAMMOGRAM ONE BREAST	PRXOVR	DEF					NA	NA	NA	N
77055	MAMMOGRAM ONE BREAST	MAXFEE	DEF					NA			N
77056	MAMMOGRAM BOTH BREASTS	PRXOVR	DEF					NA	NA	NA	N
77056	MAMMOGRAM BOTH BREASTS	MAXFEE	DEF					NA			N
77057	MAMMOGRAM SCREENING	PRXOVR	DEF					NA	NA	NA	N
77057	MAMMOGRAM SCREENING	MAXFEE	DEF					NA			N
77063	BREAST TOMOSYNTHESIS BI	PRXOVR	DEF					NA	NA	NA	N
77063	BREAST TOMOSYNTHESIS BI	MAXFEE	DEF					40.91	1/1/2018	12/31/2299	N
77063	BREAST TOMOSYNTHESIS BI	MAXFEE	DEF	26				24.55	1/1/2018	12/31/2299	N
77063	BREAST TOMOSYNTHESIS BI	MAXFEE	DEF	TC				16.36	1/1/2018	12/31/2299	N
77065	DX MAMMO INCL CAD UNI	PRXOVR	DEF					NA	NA	NA	N
77065	DX MAMMO INCL CAD UNI	MAXFEE	DEF					48.17	1/1/2018	12/31/2299	N
77065	DX MAMMO INCL CAD UNI	MAXFEE	DEF	26				9.63	1/1/2018	12/31/2299	N
77065	DX MAMMO INCL CAD UNI	MAXFEE	DEF	TC				38.54	1/1/2018	12/31/2299	N
77066	DX MAMMO INCL CAD BI	PRXOVR	DEF					NA	NA	NA	N
77066	DX MAMMO INCL CAD BI	MAXFEE	DEF					71.97	1/1/2018	12/31/2299	N
77066	DX MAMMO INCL CAD BI	MAXFEE	DEF	26				28.79	1/1/2018	12/31/2299	N
77066	DX MAMMO INCL CAD BI	MAXFEE	DEF	TC				43.18	1/1/2018	12/31/2299	N
77067	SCR MAMMO BI INCL CAD	PRXOVR	DEF					NA	NA	NA	N
77067	SCR MAMMO BI INCL CAD	MAXFEE	DEF					52.74	1/1/2018	12/31/2299	N
77067	SCR MAMMO BI INCL CAD	MAXFEE	DEF	26				21.10	1/1/2018	12/31/2299	N
77067	SCR MAMMO BI INCL CAD	MAXFEE	DEF	TC				31.64	1/1/2018	12/31/2299	N
G0202	SCR MAMMO BI INCL CAD	PRXOVR	DEF					NA	NA	NA	N
G0202	SCR MAMMO BI INCL CAD	MAXFEE	DEF					NA			N
G0204	DX MAMMO INCL CAD BI	PRXOVR	DEF					NA	NA	NA	N
G0204	DX MAMMO INCL CAD BI	MAXFEE	DEF					NA			N
G0206	DX MAMMO INCL CAD UNI	PRXOVR	DEF					NA	NA	NA	N
G0206	DX MAMMO INCL CAD UNI	MAXFEE	DEF					NA			N
G0279	TOMOSYNTHESIS; MAMMO	PRXOVR	DEF					NA	NA	NA	N
G0279	TOMOSYNTHESIS; MAMMO	MAXFEE	DEF	26				25.51	1/1/2017	12/31/2299	N
G0279	TOMOSYNTHESIS; MAMMO	MAXFEE	DEF	TC				17.01	1/1/2017	12/31/2299	N
G0279	TOMOSYNTHESIS; MAMMO	MAXFEE	DEF					42.52	1/1/2017	12/31/2299	N