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					11.06	1/1/2017	12/31/2299	N
90791	PSYCH DIAGNOSTIC EVALUATION	PRXOVR	DEF					NA	NA	NA	S
90791	PSYCH DIAGNOSTIC EVALUATION	MAXFEE	FAC					73.47	1/1/2014	12/31/2299	S
90791	PSYCH DIAGNOSTIC EVALUATION	MAXFEE	NFF					103.07	1/1/2014	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					83.14	1/1/2014	12/31/2299	S
90792	PSYCH DIAG EVAL W/MED SRVCS	MAXFEE	NFF					86.17	1/1/2014	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					30.90	1/1/2014	12/31/2299	S
90832	PSYTX W PT 30 MINUTES	MAXFEE	NFF					42.99	1/1/2014	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					28.30	1/1/2014	12/31/2299	S
90833	PSYTX W PT W E/M 30 MIN	MAXFEE	NFF					28.81	1/1/2014	12/31/2299	S
90834	PSYTX W PT 45 MINUTES	PRXOVR	DEF					NA	NA	NA	S
90834	PSYTX W PT 45 MINUTES	MAXFEE	FAC					47.08	1/1/2014	12/31/2299	S
90834	PSYTX W PT 45 MINUTES	MAXFEE	NFF					55.89	1/1/2014	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					45.19	1/1/2019	12/31/2299	S
90836	PSYTX W PT W E/M 45 MIN	MAXFEE	NFF					46.74	1/1/2019	12/31/2299	S
90837	PSYTX W PT 60 MINUTES	PRXOVR	DEF					NA	NA	NA	S
90837	PSYTX W PT 60 MINUTES	MAXFEE	FAC					72.16	1/1/2014	12/31/2299	S
90837	PSYTX W PT 60 MINUTES	MAXFEE	NFF					81.99	1/1/2014	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					73.25	1/1/2014	12/31/2299	S
90838	PSYTX W PT W E/M 60 MIN	MAXFEE	NFF					75.29	1/1/2014	12/31/2299	S
90839	PSYTX CRISIS INITIAL 60 MIN	PRXOVR	DEF					NA	NA	NA	S
90839	PSYTX CRISIS INITIAL 60 MIN	MAXFEE	FAC					92.68	4/1/2015	12/31/2299	S
90839	PSYTX CRISIS INITIAL 60 MIN	MAXFEE	NFF					93.37	4/1/2015	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					44.62	4/1/2015	12/31/2299	S
90840	PSYTX CRISIS EA ADDL 30 MIN	MAXFEE	NFF					44.85	4/1/2015	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					52.35	1/1/2014	12/31/2299	N
90846	FAMILY PSYTX W/O PT 50 MIN	MAXFEE	NFF					55.86	1/1/2014	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					64.49	1/1/2014	12/31/2299	S
90847	FAMILY PSYTX W/PT 50 MIN	MAXFEE	NFF					68.61	1/1/2014	12/31/2299	S
90849	MULTIPLE FAMILY GROUP PSYTX	PRXOVR	DEF					NA	NA	NA	S
90849	MULTIPLE FAMILY GROUP PSYTX	MAXFEE	FAC					16.12	1/1/2014	12/31/2299	S
90849	MULTIPLE FAMILY GROUP PSYTX	MAXFEE	NFF					21.31	1/1/2014	12/31/2299	S
90853	GROUP PSYCHOTHERAPY	PRXOVR	DEF					NA	NA	NA	S
90853	GROUP PSYCHOTHERAPY	MAXFEE	DEF					19.27	7/1/2008	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					31.99	1/1/2014	12/31/2299	S
90870	ELECTROCONVULSIVE THERAPY	PRXOVR	DEF					NA	NA	NA	N
90870	ELECTROCONVULSIVE THERAPY	MAXFEE	FAC					40.92	1/1/2014	12/31/2299	N
90870	ELECTROCONVULSIVE THERAPY	MAXFEE	NFF					76.24	1/1/2014	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					17.52	10/1/2023	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					14.34	10/1/2023	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					12.15	10/1/2023	12/31/2299	N