Procedure Code Procedure Description Pricing Indicator Rate Type Mod1 Mod2 Mod3 Mod4 Max Fee Max Fee Eff. Date Max Fee End Date PA
0403T DIABETES PREV STANDARD CURR PRXOVR DEF         NA NA NA N
0403T DIABETES PREV STANDARD CURR MAXFEE DEF         23 1/1/2022 12/31/2299 N
0488T DIABETES PREV ONLINE/ELEC PRXOVR DEF         NA NA NA N
0488T DIABETES PREV ONLINE/ELEC MAXFEE DEF         49 1/1/2022 12/31/2299 N
97802 MEDICAL NUTRITION INDIV IN PRXOVR DEF         NA NA NA S
97802 MEDICAL NUTRITION INDIV IN MAXFEE FAC         18.77 1/1/2024 12/31/2299 S
97802 MEDICAL NUTRITION INDIV IN MAXFEE FAC TH       18.77 1/1/2024 12/31/2299 S
97802 MEDICAL NUTRITION INDIV IN MAXFEE NFF         22.84 1/1/2024 12/31/2299 S
97802 MEDICAL NUTRITION INDIV IN MAXFEE NFF TH       22.84 1/1/2024 12/31/2299 S
97803 MED NUTRITION INDIV SUBSEQ PRXOVR DEF         NA NA NA S
97803 MED NUTRITION INDIV SUBSEQ MAXFEE FAC         16.06 1/1/2024 12/31/2299 S
97803 MED NUTRITION INDIV SUBSEQ MAXFEE FAC TH       16.06 1/1/2024 12/31/2299 S
97803 MED NUTRITION INDIV SUBSEQ MAXFEE NFF         19.95 1/1/2024 12/31/2299 S
97803 MED NUTRITION INDIV SUBSEQ MAXFEE NFF TH       19.95 1/1/2024 12/31/2299 S
97804 MEDICAL NUTRITION GROUP PRXOVR DEF         NA NA NA S
97804 MEDICAL NUTRITION GROUP MAXFEE FAC         8.61 1/1/2024 12/31/2299 S
97804 MEDICAL NUTRITION GROUP MAXFEE FAC TH       8.61 1/1/2024 12/31/2299 S
97804 MEDICAL NUTRITION GROUP MAXFEE NFF         9.97 1/1/2024 12/31/2299 S
97804 MEDICAL NUTRITION GROUP MAXFEE NFF TH       9.97 1/1/2024 12/31/2299 S
G0108 DIAB MANAGE TRN PER INDIV PRXOVR DEF         NA NA NA N
G0108 DIAB MANAGE TRN PER INDIV MAXFEE DEF         42.23 1/1/2024 12/31/2299 N
G0109 DIAB MANAGE TRN IND/GROUP PRXOVR DEF         NA NA NA N
G0109 DIAB MANAGE TRN IND/GROUP MAXFEE DEF         11.71 1/1/2024 12/31/2299 N