| 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 | 16.91 | 1/1/2014 | 12/31/2299 | S | ||||
| 97802 | MEDICAL NUTRITION INDIV IN | MAXFEE | NFF | 20.58 | 1/1/2014 | 12/31/2299 | S | ||||
| 97803 | MED NUTRITION INDIV SUBSEQ | PRXOVR | DEF | NA | NA | NA | S | ||||
| 97803 | MED NUTRITION INDIV SUBSEQ | MAXFEE | FAC | 14.47 | 1/1/2014 | 12/31/2299 | S | ||||
| 97803 | MED NUTRITION INDIV SUBSEQ | MAXFEE | NFF | 17.97 | 1/1/2014 | 12/31/2299 | S | ||||
| 97804 | MEDICAL NUTRITION GROUP | PRXOVR | DEF | NA | NA | NA | S | ||||
| 97804 | MEDICAL NUTRITION GROUP | MAXFEE | FAC | 7.76 | 1/1/2014 | 12/31/2299 | S | ||||
| 97804 | MEDICAL NUTRITION GROUP | MAXFEE | NFF | 8.98 | 1/1/2014 | 12/31/2299 | S | ||||
| G0108 | DIAB MANAGE TRN PER INDIV | PRXOVR | DEF | NA | NA | NA | N | ||||
| G0108 | DIAB MANAGE TRN PER INDIV | MAXFEE | DEF | 40.22 | 1/1/2022 | 12/31/2299 | N | ||||
| G0109 | DIAB MANAGE TRN IND/GROUP | PRXOVR | DEF | NA | NA | NA | N | ||||
| G0109 | DIAB MANAGE TRN IND/GROUP | MAXFEE | DEF | 11.15 | 1/1/2022 | 12/31/2299 | N |