Procedure Code Procedure Description Pricing Indicator Rate Type Mod1 Mod2 Mod3 Mod4 Max Fee Max Fee Eff. Date Max Fee End Date PA
0001A ADM SARSCOV2 30MCG/0.3ML 1ST OPXOVR DEF         NA NA NA N
0001A ADM SARSCOV2 30MCG/0.3ML 1ST MAXFEE DEF         37.66 1/1/2022 12/31/2299 N
0002A ADM SARSCOV2 30MCG/0.3ML 2ND OPXOVR DEF         NA NA NA N
0002A ADM SARSCOV2 30MCG/0.3ML 2ND MAXFEE DEF         37.66 1/1/2022 12/31/2299 N
0003A ADM SARSCOV2 30MCG/0.3ML 3RD OPXOVR DEF         NA NA NA N
0003A ADM SARSCOV2 30MCG/0.3ML 3RD MAXFEE DEF         37.66 1/1/2022 12/31/2299 N
0004A ADM SARSCOV2 30MCG/0.3ML BST OPXOVR DEF         NA NA NA N
0004A ADM SARSCOV2 30MCG/0.3ML BST MAXFEE DEF         37.66 1/1/2022 12/31/2299 N
0011A ADM SARSCOV2 100MCG/0.5ML1ST OPXOVR OPB         NA NA NA N
0011A ADM SARSCOV2 100MCG/0.5ML1ST MAXFEE DEF         37.66 1/1/2022 12/31/2299 N
0012A ADM SARSCOV2 100MCG/0.5ML2ND OPXOVR OPB         NA NA NA N
0012A ADM SARSCOV2 100MCG/0.5ML2ND MAXFEE DEF         37.66 1/1/2022 12/31/2299 N
0013A ADM SARSCOV2 100MCG/0.5ML3RD OPXOVR DEF         NA NA NA N
0013A ADM SARSCOV2 100MCG/0.5ML3RD MAXFEE DEF         37.66 1/1/2022 12/31/2299 N
0051A ADM SARSCV2 30MCG TRS-SUCR 1 OPXOVR DEF         NA NA NA N
0051A ADM SARSCV2 30MCG TRS-SUCR 1 MAXFEE DEF         37.66 1/3/2022 12/31/2299 N
0052A ADM SARSCV2 30MCG TRS-SUCR 2 OPXOVR DEF         NA NA NA N
0052A ADM SARSCV2 30MCG TRS-SUCR 2 MAXFEE DEF         37.66 1/3/2022 12/31/2299 N
0053A ADM SARSCV2 30MCG TRS-SUCR 3 OPXOVR DEF         NA NA NA N
0053A ADM SARSCV2 30MCG TRS-SUCR 3 MAXFEE DEF         37.66 1/3/2022 12/31/2299 N
0054A ADM SARSCV2 30MCG TRS-SUCR B OPXOVR DEF         NA NA NA N
0054A ADM SARSCV2 30MCG TRS-SUCR B MAXFEE DEF         37.66 1/3/2022 12/31/2299 N
0064A ADM SARSCOV2 50MCG/0.25MLBST OPXOVR OPB         NA NA NA N
0064A ADM SARSCOV2 50MCG/0.25MLBST MAXFEE DEF         37.66 1/1/2022 12/31/2299 N
0071A ADM SARSCV2 10MCG TRS-SUCR 1 OPXOVR OPB         NA NA NA N
0071A ADM SARSCV2 10MCG TRS-SUCR 1 MAXFEE DEF         37.66 1/1/2022 12/31/2299 N
0072A ADM SARSCV2 10MCG TRS-SUCR 2 OPXOVR OPB         NA NA NA N
0072A ADM SARSCV2 10MCG TRS-SUCR 2 MAXFEE DEF         37.66 1/1/2022 12/31/2299 N
0073A ADM SARSCV2 10MCG TRS-SUCR 3 OPXOVR DEF         NA NA NA N
0073A ADM SARSCV2 10MCG TRS-SUCR 3 MAXFEE DEF         37.66 1/3/2022 12/31/2299 N
0074A ADM SARSCV2 10MCG TRS-SUCR B OPXOVR DEF         NA NA NA N
0074A ADM SARSCV2 10MCG TRS-SUCR B MAXFEE DEF         37.66 5/17/2022 12/31/2299 N
0081A ADM SARSCV2 3MCG TRS-SUCR 1 OPXOVR DEF         NA NA NA N
0081A ADM SARSCV2 3MCG TRS-SUCR 1 MAXFEE DEF         37.66 6/17/2022 12/31/2299 N
0082A ADM SARSCV2 3MCG TRS-SUCR 2 OPXOVR DEF         NA NA NA N
0082A ADM SARSCV2 3MCG TRS-SUCR 2 MAXFEE DEF         37.66 6/17/2022 12/31/2299 N
0083A ADM SARSCV2 3MCG TRS-SUCR 3 OPXOVR DEF         NA NA NA N
0083A ADM SARSCV2 3MCG TRS-SUCR 3 MAXFEE DEF         37.66 6/17/2022 12/31/2299 N
0091A ADM SARSCOV2 50 MCG/.5 ML1ST OPXOVR DEF         NA NA NA N
0091A ADM SARSCOV2 50 MCG/.5 ML1ST MAXFEE DEF         37.66 6/17/2022 12/31/2299 N
0092A ADM SARSCOV2 50 MCG/.5 ML2ND OPXOVR DEF         NA NA NA N
0092A ADM SARSCOV2 50 MCG/.5 ML2ND MAXFEE DEF         37.66 6/17/2022 12/31/2299 N
0093A ADM SARSCOV2 50 MCG/.5 ML3RD OPXOVR DEF         NA NA NA N
0093A ADM SARSCOV2 50 MCG/.5 ML3RD MAXFEE DEF         37.66 6/17/2022 12/31/2299 N
0094A ADM SARSCOV2 50 MCG/.5 MLBST OPXOVR DEF         NA NA NA N
0094A ADM SARSCOV2 50 MCG/.5 MLBST MAXFEE DEF         37.66 3/29/2022 12/31/2299 N
0111A ADM SARSCOV2 25MCG/0.25ML1ST OPXOVR DEF         NA NA NA N
0111A ADM SARSCOV2 25MCG/0.25ML1ST MAXFEE DEF         37.66 6/17/2022 12/31/2299 N
0112A ADM SARSCOV2 25MCG/0.25ML2ND OPXOVR DEF         NA NA NA N
0112A ADM SARSCOV2 25MCG/0.25ML2ND MAXFEE DEF         37.66 6/17/2022 12/31/2299 N
0113A ADM SARSCOV2 25MCG/0.25ML3RD OPXOVR DEF         NA NA NA N
0113A ADM SARSCOV2 25MCG/0.25ML3RD MAXFEE DEF         37.66 8/31/2022 12/31/2299 N
90460 IM ADMIN 1ST/ONLY COMPONENT OPXOVR DEF         NA NA NA N
90460 IM ADMIN 1ST/ONLY COMPONENT MAXFEE DEF         15 1/1/2016 12/31/2299 N
90461 IM ADMIN EACH ADDL COMPONENT OPXOVR DEF         NA NA NA N
90461 IM ADMIN EACH ADDL COMPONENT MAXFEE DEF         0 1/1/2011 12/31/2299 N
90471 IMMUNIZATION ADMIN OPXOVR DEF         NA NA NA N
90471 IMMUNIZATION ADMIN MAXFEE DEF         12.95 1/1/2022 12/31/2299 N
90472 IMMUNIZATION ADMIN EACH ADD OPXOVR DEF         NA NA NA N
90472 IMMUNIZATION ADMIN EACH ADD MAXFEE DEF         9.85 1/1/2022 12/31/2299 N
90480 ADMN SARSCOV2 VACC 1 DOSE OPXOVR OPB         NA NA NA N
90480 ADMN SARSCOV2 VACC 1 DOSE MAXFEE DEF         39.94 9/11/2023 12/31/2299 N
90611 SMALLPOX&MONKEYPOX VAC 0.5ML OPXOVR DEF         NA NA NA N
90611 SMALLPOX&MONKEYPOX VAC 0.5ML MAXFEE DEF         0.01 7/26/2022 12/31/2299 N
90622 VACCINIA VRS VAC 0.3 ML PERQ OPXOVR DEF         NA NA NA N
90622 VACCINIA VRS VAC 0.3 ML PERQ MAXFEE DEF         0.01 7/26/2022 12/31/2299 N
91300 SARSCOV2 VAC 30MCG/0.3ML IM OPXOVR DEF         NA NA NA N
91300 SARSCOV2 VAC 30MCG/0.3ML IM MAXFEE DEF         0.01 12/11/2020 12/31/2299 N
91301 SARSCOV2 VAC 100MCG/0.5ML IM OPXOVR DEF         NA NA NA N
91301 SARSCOV2 VAC 100MCG/0.5ML IM MAXFEE DEF         0.01 12/18/2020 12/31/2299 N
91304 SARSCOV2 VAC 5MCG/0.5ML IM OPXOVR DEF         NA NA NA N
91304 SARSCOV2 VAC 5MCG/0.5ML IM MAXFEE DEF         148.20 10/1/2023 12/31/2299 N
91305 SARSCOV2 VAC 30 MCG TRS-SUCR OPXOVR DEF         NA NA NA N
91305 SARSCOV2 VAC 30 MCG TRS-SUCR MAXFEE DEF         0.01 1/3/2022 12/31/2299 N
91306 SARSCOV2 VAC 50MCG/0.25ML IM OPXOVR OPB         NA NA NA N
91306 SARSCOV2 VAC 50MCG/0.25ML IM MAXFEE DEF         0.01 10/20/2021 12/31/2299 N
91307 SARSCOV2 VAC 10 MCG TRS-SUCR OPXOVR OPB         NA NA NA N
91307 SARSCOV2 VAC 10 MCG TRS-SUCR MAXFEE DEF         0.01 10/29/2021 12/31/2299 N
91308 SARSCOV2 VAC 3 MCG TRS-SUCR OPXOVR DEF         NA NA NA N
91308 SARSCOV2 VAC 3 MCG TRS-SUCR MAXFEE DEF         0.01 6/17/2022 12/31/2299 N
91309 SARSCOV2 VAC 50MCG/0.5ML IM OPXOVR DEF         NA NA NA N
91309 SARSCOV2 VAC 50MCG/0.5ML IM MAXFEE DEF         0.01 3/29/2022 12/31/2299 N
91311 SARSCOV2 VAC 25MCG/0.25ML IM OPXOVR DEF         NA NA NA N
91311 SARSCOV2 VAC 25MCG/0.25ML IM MAXFEE DEF         0.01 6/17/2022 12/31/2299 N
91318 SARSCOV2 VAC 3MCG TRS-SUC IM OPXOVR OPB         NA NA NA N
91318 SARSCOV2 VAC 3MCG TRS-SUC IM MAXFEE DEF         65.55 1/1/2024 12/31/2299 N
91319 SARSCV2 VAC 10MCG TRS-SUC IM OPXOVR OPB         NA NA NA N
91319 SARSCV2 VAC 10MCG TRS-SUC IM MAXFEE DEF         87.78 10/1/2023 12/31/2299 N
91320 SARSCV2 VAC 30MCG TRS-SUC IM OPXOVR OPB         NA NA NA N
91320 SARSCV2 VAC 30MCG TRS-SUC IM MAXFEE DEF         131.10 10/1/2023 12/31/2299 N
91321 SARSCOV2 VAC 25 MCG/.25ML IM OPXOVR OPB         NA NA NA N
91321 SARSCOV2 VAC 25 MCG/.25ML IM MAXFEE DEF         145.92 10/1/2023 12/31/2299 N
91322 SARSCOV2 VAC 50 MCG/0.5ML IM OPXOVR OPB         NA NA NA N
91322 SARSCOV2 VAC 50 MCG/0.5ML IM MAXFEE DEF         145.92 10/1/2023 12/31/2299 N
96101 PSYCHO TESTING BY PSYCH/PHYS MAXFEE OPB         NA     S
96101 PSYCHO TESTING BY PSYCH/PHYS OPXOVR OPB         NA NA NA S
96111 DEVELOPMENTAL TEST EXTEND MAXFEE OPB         NA     S
96111 DEVELOPMENTAL TEST EXTEND OPXOVR OPB         NA NA NA S
96118 NEUROPSYCH TST BY PSYCH/PHYS MAXFEE OPB         NA     S
96118 NEUROPSYCH TST BY PSYCH/PHYS OPXOVR OPB         NA NA NA S
99201 OFFICE/OUTPATIENT VISIT NEW MAXFEE OPB         49.38 8/1/2017 12/31/2299 N
99201 OFFICE/OUTPATIENT VISIT NEW OPXOVR OPB         NA NA NA N
99343 HOME VISIT NEW PATIENT MAXFEE OPB         NA     N
99343 HOME VISIT NEW PATIENT OPXOVR OPB         NA NA NA N
99354 PROLNG SVC O/P 1ST HOUR MAXFEE OPB         NA     N
99354 PROLNG SVC O/P 1ST HOUR OPXOVR OPB         NA NA NA N
99355 PROLNG SVC O/P EA ADDL 30 MAXFEE OPB         NA     N
99355 PROLNG SVC O/P EA ADDL 30 OPXOVR OPB         NA NA NA N
G0312 IMMUNIZE COUNS < 21YR 5-15 M OPXOVR DEF         NA NA NA N
G0312 IMMUNIZE COUNS < 21YR 5-15 M MAXFEE DEF         26.21 6/8/2022 12/31/2299 N
G0313 IMMUNIZE COUNS < 21YR 6-30 M OPXOVR DEF         NA NA NA N
G0313 IMMUNIZE COUNS < 21YR 6-30 M MAXFEE DEF         39.90 6/8/2022 12/31/2299 N
G0378 HOSPITAL OBSERVATION PER HR MAXFEE OPB         NA     N
G0378 HOSPITAL OBSERVATION PER HR OPXOVR OPB         NA NA NA N
J3399 INJ ONASE ABEPAR-XIOI TREAT PRXOVR DEF         NA NA NA E
J3399 INJ ONASE ABEPAR-XIOI TREAT MANUAL DEF         NA NA NA E
J3490 DRUGS UNCLASSIFIED INJECTION PRXOVR DEF         NA NA NA Y
J3490 DRUGS UNCLASSIFIED INJECTION MANUAL DEF         NA NA NA Y