Procedure Code Procedure Description Pricing Indicator Rate Type Mod1 Mod2 Mod3 Mod4 Max Fee Max Fee Eff. Date Max Fee End Date PA
90785 PSYTX COMPLEX INTERACTIVE PRXOVR DEF         NA NA NA N
90785 PSYTX COMPLEX INTERACTIVE MAXFEE DEF         12.46 1/1/2024 12/31/2299 N
90791 PSYCH DIAGNOSTIC EVALUATION PRXOVR DEF         NA NA NA S
90791 PSYCH DIAGNOSTIC EVALUATION MAXFEE FAC         77.14 1/1/2024 12/31/2299 S
90791 PSYCH DIAGNOSTIC EVALUATION MAXFEE NFF         117.91 1/1/2024 12/31/2299 S
90792 PSYCH DIAG EVAL W/MED SRVCS PRXOVR DEF         NA NA NA S
90792 PSYCH DIAG EVAL W/MED SRVCS MAXFEE FAC         87.90 1/1/2024 12/31/2299 S
90792 PSYCH DIAG EVAL W/MED SRVCS MAXFEE NFF         130.20 1/1/2024 12/31/2299 S
90801 PSY DX INTERVIEW PRXOVR DEF         NA NA NA S
90801 PSY DX INTERVIEW MAXFEE DEF         NA     S
90802 INTAC PSY DX INTERVIEW PRXOVR DEF         NA NA NA S
90802 INTAC PSY DX INTERVIEW MAXFEE DEF         NA     S
90804 PSYTX OFFICE 20-30 MIN PRXOVR DEF         NA NA NA S
90804 PSYTX OFFICE 20-30 MIN MAXFEE DEF         NA     S
90805 PSYTX OFF 20-30 MIN W/E&M PRXOVR DEF         NA NA NA N
90805 PSYTX OFF 20-30 MIN W/E&M MAXFEE DEF         NA     N
90806 PSYTX OFF 45-50 MIN PRXOVR DEF         NA NA NA S
90806 PSYTX OFF 45-50 MIN MAXFEE DEF         NA     S
90807 PSYTX OFF 45-50 MIN W/E&M PRXOVR DEF         NA NA NA N
90807 PSYTX OFF 45-50 MIN W/E&M MAXFEE DEF         NA     N
90808 PSYTX OFFICE 75-80 MIN PRXOVR DEF         NA NA NA S
90808 PSYTX OFFICE 75-80 MIN MAXFEE DEF         NA     S
90809 PSYTX OFF 75-80 W/E&M PRXOVR DEF         NA NA NA N
90809 PSYTX OFF 75-80 W/E&M MAXFEE DEF         NA     N
90810 INTAC PSYTX OFF 20-30 MIN PRXOVR DEF         NA NA NA S
90810 INTAC PSYTX OFF 20-30 MIN MAXFEE DEF         NA     S
90811 INTAC PSYTX 20-30 W/E&M PRXOVR DEF         NA NA NA N
90811 INTAC PSYTX 20-30 W/E&M MAXFEE DEF         NA     N
90812 INTAC PSYTX OFF 45-50 MIN PRXOVR DEF         NA NA NA S
90812 INTAC PSYTX OFF 45-50 MIN MAXFEE DEF         NA     S
90813 INTAC PSYTX 45-50 MIN W/E&M PRXOVR DEF         NA NA NA N
90813 INTAC PSYTX 45-50 MIN W/E&M MAXFEE DEF         NA     N
90814 INTAC PSYTX OFF 75-80 MIN PRXOVR DEF         NA NA NA S
90814 INTAC PSYTX OFF 75-80 MIN MAXFEE DEF         NA     S
90815 INTAC PSYTX 75-80 W/E&M PRXOVR DEF         NA NA NA N
90815 INTAC PSYTX 75-80 W/E&M MAXFEE DEF         NA     N
90816 PSYTX HOSP 20-30 MIN PRXOVR DEF         NA NA NA N
90816 PSYTX HOSP 20-30 MIN MAXFEE DEF         NA     N
90817 PSYTX HOSP 20-30 MIN W/E&M PRXOVR DEF         NA NA NA N
90817 PSYTX HOSP 20-30 MIN W/E&M MAXFEE DEF         NA     N
90818 PSYTX HOSP 45-50 MIN PRXOVR DEF         NA NA NA N
90818 PSYTX HOSP 45-50 MIN MAXFEE DEF         NA     N
90819 PSYTX HOSP 45-50 MIN W/E&M PRXOVR DEF         NA NA NA N
90819 PSYTX HOSP 45-50 MIN W/E&M MAXFEE DEF         NA     N
90821 PSYTX HOSP 75-80 MIN PRXOVR DEF         NA NA NA N
90821 PSYTX HOSP 75-80 MIN MAXFEE DEF         NA     N
90822 PSYTX HOSP 75-80 MIN W/E&M PRXOVR DEF         NA NA NA N
90822 PSYTX HOSP 75-80 MIN W/E&M MAXFEE DEF         NA     N
90823 INTAC PSYTX HOSP 20-30 MIN PRXOVR DEF         NA NA NA N
90823 INTAC PSYTX HOSP 20-30 MIN MAXFEE DEF         NA     N
90824 INTAC PSYTX HSP 20-30 W/E&M PRXOVR DEF         NA NA NA N
90824 INTAC PSYTX HSP 20-30 W/E&M MAXFEE DEF         NA     N
90826 INTAC PSYTX HOSP 45-50 MIN PRXOVR DEF         NA NA NA N
90826 INTAC PSYTX HOSP 45-50 MIN MAXFEE DEF         NA     N
90827 INTAC PSYTX HSP 45-50 W/E&M PRXOVR DEF         NA NA NA N
90827 INTAC PSYTX HSP 45-50 W/E&M MAXFEE DEF         NA     N
90828 INTAC PSYTX HOSP 75-80 MIN PRXOVR DEF         NA NA NA N
90828 INTAC PSYTX HOSP 75-80 MIN MAXFEE DEF         NA     N
90829 INTAC PSYTX HSP 75-80 W/E&M PRXOVR DEF         NA NA NA N
90829 INTAC PSYTX HSP 75-80 W/E&M MAXFEE DEF         NA     N
90832 PSYTX W PT 30 MINUTES PRXOVR DEF         NA NA NA S
90832 PSYTX W PT 30 MINUTES MAXFEE FAC         35.58 1/1/2024 12/31/2299 S
90832 PSYTX W PT 30 MINUTES MAXFEE NFF         56.93 1/1/2024 12/31/2299 S
90833 PSYTX W PT W E/M 30 MIN PRXOVR DEF         NA NA NA S
90833 PSYTX W PT W E/M 30 MIN MAXFEE FAC         36.85 1/1/2024 12/31/2299 S
90833 PSYTX W PT W E/M 30 MIN MAXFEE NFF         58.96 1/1/2024 12/31/2299 S
90834 PSYTX W PT 45 MINUTES PRXOVR DEF         NA NA NA S
90834 PSYTX W PT 45 MINUTES MAXFEE FAC         49.43 1/1/2024 12/31/2299 S
90834 PSYTX W PT 45 MINUTES MAXFEE NFF         74.01 1/1/2024 12/31/2299 S
90836 PSYTX W PT W E/M 45 MIN PRXOVR DEF         NA NA NA S
90836 PSYTX W PT W E/M 45 MIN MAXFEE FAC         47.45 1/1/2024 12/31/2299 S
90836 PSYTX W PT W E/M 45 MIN MAXFEE NFF         74.90 1/1/2024 12/31/2299 S
90837 PSYTX W PT 60 MINUTES PRXOVR DEF         NA NA NA S
90837 PSYTX W PT 60 MINUTES MAXFEE FAC         75.77 1/1/2024 12/31/2299 S
90837 PSYTX W PT 60 MINUTES MAXFEE NFF         108.57 1/1/2024 12/31/2299 S
90838 PSYTX W PT W E/M 60 MIN PRXOVR DEF         NA NA NA S
90838 PSYTX W PT W E/M 60 MIN MAXFEE FAC         76.91 1/1/2024 12/31/2299 S
90838 PSYTX W PT W E/M 60 MIN MAXFEE NFF         98.80 1/1/2024 12/31/2299 S
90839 PSYTX CRISIS INITIAL 60 MIN PRXOVR DEF         NA NA NA S
90839 PSYTX CRISIS INITIAL 60 MIN MAXFEE FAC         97.31 1/1/2024 12/31/2299 S
90839 PSYTX CRISIS INITIAL 60 MIN MAXFEE NFF         154.87 1/1/2024 12/31/2299 S
90840 PSYTX CRISIS EA ADDL 30 MIN PRXOVR DEF         NA NA NA S
90840 PSYTX CRISIS EA ADDL 30 MIN MAXFEE FAC         46.85 1/1/2024 12/31/2299 S
90840 PSYTX CRISIS EA ADDL 30 MIN MAXFEE NFF         73.92 1/1/2024 12/31/2299 S
90846 FAMILY PSYTX W/O PT 50 MIN PRXOVR DEF         NA NA NA N
90846 FAMILY PSYTX W/O PT 50 MIN MAXFEE FAC         57.66 1/1/2024 12/31/2299 N
90846 FAMILY PSYTX W/O PT 50 MIN MAXFEE NFF         92.26 1/1/2024 12/31/2299 N
90847 FAMILY PSYTX W/PT 50 MIN PRXOVR DEF         NA NA NA S
90847 FAMILY PSYTX W/PT 50 MIN MAXFEE FAC         67.71 1/1/2024 12/31/2299 S
90847 FAMILY PSYTX W/PT 50 MIN MAXFEE NFF         90.85 1/1/2024 12/31/2299 S
90849 MULTIPLE FAMILY GROUP PSYTX PRXOVR DEF         NA NA NA S
90849 MULTIPLE FAMILY GROUP PSYTX MAXFEE FAC         22.92 1/1/2024 12/31/2299 S
90849 MULTIPLE FAMILY GROUP PSYTX MAXFEE NFF         36.67 1/1/2024 12/31/2299 S
90853 GROUP PSYCHOTHERAPY PRXOVR DEF         NA NA NA S
90853 GROUP PSYCHOTHERAPY MAXFEE DEF         29.85 1/1/2024 12/31/2299 S
90857 INTAC GROUP PSYTX PRXOVR DEF         NA NA NA S
90857 INTAC GROUP PSYTX MAXFEE DEF         NA     S
90862 MEDICATION MANAGEMENT PRXOVR DEF         NA NA NA N
90862 MEDICATION MANAGEMENT MAXFEE DEF         NA     N
90863 PHARMACOLOGIC MGMT W/PSYTX PRXOVR DEF         NA NA NA S
90863 PHARMACOLOGIC MGMT W/PSYTX MAXFEE FAC         20.15 1/1/2014 12/31/2299 S
90863 PHARMACOLOGIC MGMT W/PSYTX MAXFEE NFF         25.95 1/1/2024 12/31/2299 S
90870 ELECTROCONVULSIVE THERAPY PRXOVR DEF         NA NA NA N
90870 ELECTROCONVULSIVE THERAPY MAXFEE FAC         53.64 1/1/2024 12/31/2299 N
90870 ELECTROCONVULSIVE THERAPY MAXFEE NFF         88.42 1/1/2024 12/31/2299 N
90899 UNLISTED PSYC SVC/THERAPY PRXOVR DEF         NA NA NA N
90899 UNLISTED PSYC SVC/THERAPY MANUAL DEF         NA NA NA N
96101 PSYCHO TESTING BY PSYCH/PHYS PRXOVR DEF         NA NA NA S
96101 PSYCHO TESTING BY PSYCH/PHYS MAXFEE DEF         NA     S
J1230 METHADONE INJECTION PRXOVR DEF         NA NA NA N
J1230 METHADONE INJECTION MAXFEE DEF         20.61 4/1/2024 12/31/2299 N
J2358 OLANZAPINE LONG-ACTING INJ PRXOVR DEF         NA NA NA N
J2358 OLANZAPINE LONG-ACTING INJ MAXFEE DEF         2.92 10/1/2022 12/31/2299 N
J2426 INJ; INVEGA SUSTENNA; 1 MG PRXOVR DEF         NA NA NA N
J2426 INJ; INVEGA SUSTENNA; 1 MG MAXFEE DEF         14.28 4/1/2024 12/31/2299 N
J2794 INJ RISPERDAL CONSTA; 0.5 MG PRXOVR DEF         NA NA NA N
J2794 INJ RISPERDAL CONSTA; 0.5 MG MAXFEE DEF         12.18 4/1/2024 12/31/2299 N