| Procedure Code | Procedure Description | Pricing Indicator | Rate Type | Mod1 | Mod2 | Mod3 | Mod4 | Max Fee | Max Fee Eff. Date | Max Fee End Date | PA |
| PT512 | ENHANCED ADULT DAY SERVICE- 15 MINUTES | MAXFEE | WVR | 1.94 | 11/1/2021 | 12/31/2299 | N | ||||
| PT514 | INTENSIVE ADULT DAY SERVICE- 15 MINUTES | MAXFEE | WVR | 2.54 | 11/1/2021 | 12/31/2299 | N | ||||
| PT516 | ENHANCED ADULT DAY SERVICE | MAXFEE | WVR | 61.74 | 11/1/2021 | 12/31/2299 | N | ||||
| PT517 | ENHANCED ADULT DAY SERVICE - HALF DAY | MAXFEE | WVR | 30.88 | 11/1/2021 | 12/31/2299 | N | ||||
| PT518 | INTENSIVE ADULT DAY SERVICE | MAXFEE | WVR | 81.05 | 11/1/2021 | 12/31/2299 | N | ||||
| PT519 | INTENSIVE ADULT DAY SERVICE - HALF DAY | MAXFEE | WVR | 40.51 | 11/1/2021 | 12/31/2299 | N | ||||
| PT523 | ADULT DAY SERVICE TRANS.PER MILE | MAXFEE | WVR | 2.78 | 11/1/2021 | 12/31/2299 | N | ||||
| PT524 | ADULT DAY SERVICE ONE WAY TRIP | MAXFEE | WVR | 20.69 | 11/1/2021 | 12/31/2299 | N | ||||
| PT525 | ADULT DAY SERVICE ROUND TRIP TRANS | MAXFEE | WVR | 25.50 | 11/1/2021 | 12/31/2299 | N | ||||
| PT530 | WAIVER NURSING - RN | MAXFEE | WVR | 53.92 | 11/1/2021 | 12/31/2299 | N | ||||
| PT530 | WAIVER NURSING - RN | MAXFEE | OVR | 17.84 | 11/1/2021 | 12/31/2299 | N | ||||
| PT531 | WAIVER NURSING - LPN | MAXFEE | WVR | 45.62 | 11/1/2021 | 12/31/2299 | N | ||||
| PT531 | WAIVER NURSING - LPN | MAXFEE | OVR | 14.46 | 11/1/2021 | 12/31/2299 | N | ||||
| PT546 | MEALS: HOME DELIVERED | MAXFEE | WVR | 7.20 | 11/1/2021 | 12/31/2299 | N | ||||
| PT548 | HOME DELIVERED MEAL SERVICES | MAXFEE | WVR | 8.68 | 1/1/2019 | 12/31/2299 | N | ||||
| PT570 | HOMEMAKER SERVICE-15 MINUTES | MAXFEE | WVR | 4.07 | 11/1/2021 | 12/31/2299 | N | ||||
| PT598 | SOCIAL WORK COUNSELING SERVICE-15 MINUTE | MAXFEE | WVR | 16.26 | 7/1/2013 | 12/31/2299 | N | ||||
| PT600 | NUTRITIONAL CONSULTATION SERVICE-15 MIN | MAXFEE | WVR | 13.34 | 7/1/2013 | 12/31/2299 | N | ||||
| PT624 | PERSONAL CARE SERVICE-15 MINUTES | MAXFEE | WVR | 4.92 | 11/1/2021 | 12/31/2299 | N | ||||
| PT624 | PERSONAL CARE SERVICE-15 MINUTES | MAXFEE | OVR | 7.95 | 11/1/2021 | 12/31/2299 | N | ||||
| PT672 | HOME MED EQ&SUPP: AMBULATORY-SECOND ONE | MAXFEE | WVR | 5224.93 | 7/1/2013 | 12/31/2299 | N | ||||
| PT673 | HOME MED EQ&SUPP: AMBULATORY- THIRD ONE | MAXFEE | WVR | 5224.93 | 7/1/2013 | 12/31/2299 | N | ||||
| PT674 | HOME MED EQ&SUPP: NON-AMBULATORY-2ND ONE | MAXFEE | WVR | 5224.93 | 7/1/2013 | 12/31/2299 | N | ||||
| PT675 | HOME MED EQ&SUPP: NON-AMBULATORY-3RD ONE | MAXFEE | WVR | 5224.93 | 7/1/2013 | 12/31/2299 | N | ||||
| PT680 | HOME CARE ATTENDANT - NURSING | MAXFEE | WVR | 27.53 | 11/1/2021 | 12/31/2299 | N | ||||
| PT680 | HOME CARE ATTENDANT - NURSING | MAXFEE | OVR | 11.70 | 11/1/2021 | 12/31/2299 | N | ||||
| PT681 | HOME CARE ATTENDANT - PERSONAL CARE | MAXFEE | WVR | 3.13 | 11/1/2021 | 12/31/2299 | N | ||||
| PT681 | HOME CARE ATTENDANT - PERSONAL CARE | MAXFEE | OVR | 4.41 | 11/1/2021 | 12/31/2299 | N | ||||
| PT690 | PERSONAL EMERGENCY RESPONSE SYSTEMS | MAXFEE | WVR | 32.95 | 1/1/2019 | 12/31/2299 | N | ||||
| PT691 | EMER RESP SYSTEM SERVICES DEVICE | MAXFEE | WVR | 101.46 | 7/1/2013 | 12/31/2299 | N | ||||
| PT722 | HOME MED EQ&SUPP: HYG & DISPOS- 2ND ONE | MAXFEE | WVR | 5224.93 | 7/1/2013 | 12/31/2299 | N | ||||
| PT728 | HOME MED EQ&SUPP: HYG & DISPOS- 3RD ONE | MAXFEE | WVR | 5224.93 | 7/1/2013 | 12/31/2299 | N | ||||
| PT737 | HOME MED EQ & SUPP: EQUIPMENT REPAIR | MAXFEE | WVR | 5224.93 | 7/1/2013 | 12/31/2299 | N | ||||
| PT739 | MINOR HOME MOD: $1 UNIT | MAXFEE | WVR | 10000 | 1/1/2019 | 12/31/2299 | N | ||||
| PT749 | HOME MED EQ&SUPP: NUTRITION SUPLMNT&SUPP | MAXFEE | WVR | 5224.93 | 7/1/2013 | 12/31/2299 | N | ||||
| PT760 | OUT-OF-HOME RESPITE | MAXFEE | WVR | 199.82 | 7/1/2014 | 12/31/2299 | N | ||||
| PT761 | CHOICES-HOME CARE ATTENDANT SERVICE | MAXFEE | WVR | 6.25 | 3/1/2014 | 12/31/2299 | N | ||||
| PT761 | CHOICES-HOME CARE ATTENDANT SERVICE | MAXFEE | OVR | 11.03 | 1/1/2016 | 12/31/2299 | N | ||||
| PT779 | ALTERNATIVE MEALS SERVICE | MAXFEE | WVR | 31.35 | 7/1/2013 | 12/31/2299 | N | ||||
| PT806 | PERSONAL EMER RESP SYSTEM SRVICES DEVICE | MAXFEE | WVR | 101.46 | 7/1/2013 | 12/31/2299 | N | ||||
| PT816 | PERSONAL EMERGENCY RESPONSE SYSTEMS | MAXFEE | WVR | 32.95 | 1/1/2019 | 12/31/2299 | N | ||||
| PT818 | PASSPORT TRANSPORTATION ONE WAY | MAXFEE | WVR | 653.11 | 7/1/2013 | 12/31/2299 | N | ||||
| PT819 | PASSPORT TRANSPORTATION ROUND TRIP | MAXFEE | WVR | 1306.24 | 7/1/2013 | 12/31/2299 | N | ||||
| PT821 | PASSPORT TRANSPORTATION NONMEDICAL RT | MAXFEE | WVR | 1306.24 | 7/1/2013 | 12/31/2299 | N | ||||
| PT822 | PASSPORT TRANSPORTATION NONMEDICAL 1 WAY | MAXFEE | WVR | 653.11 | 7/1/2013 | 12/31/2299 | N | ||||
| PT823 | ENHANCED COMMUNITY LIVING 15 MINUTES | MAXFEE | WVR | 5.83 | 3/23/2020 | 12/31/2299 | N | ||||
| PT824 | PASSPORT PERSONAL CARE (IND) > 15 MINUTE | MAXFEE | WVR | 5.16 | 11/1/2021 | 12/31/2299 | N | ||||
| PT831 | HOME MED EQ & SUPPLIES: AMBULATORY | MAXFEE | WVR | 5224.93 | 7/1/2013 | 12/31/2299 | N | ||||
| PT832 | HOME MED EQ & SUPPLIES: NON-AMBULATORY | MAXFEE | WVR | 5224.93 | 7/1/2013 | 12/31/2299 | N | ||||
| PT833 | HOME MED EQ & SUPPLIES: HYGIENE & DISPOS | MAXFEE | WVR | 5224.93 | 7/1/2013 | 12/31/2299 | N | ||||
| S5121 | CHORE SERVICES PER DIEM | BILLED | DEF | NA | NA | NA | N | ||||
| S5135 | ADULT COMPANIONCARE PER 15M | MAXFEE | WVR | 3.50 | 7/1/2019 | 12/31/2299 | N | ||||
| T2033 | RES; NOS WAIVER PER DIEM | MAXFEE | WVR | 113.19 | 7/1/2017 | 12/31/2299 | N | ||||
| T2038 | COMM TRANS WAIVER/SERVICE | MAXFEE | WVR | 2000 | 7/1/2019 | 12/31/2299 | N | ||||
| T2039 | VEHICLE MOD WAIVER/SERVICE | BILLED | DEF | NA | NA | NA | N |