Procedure Code Procedure Description Pricing Indicator Rate Type Mod1 Mod2 Mod3 Mod4 Max Fee Max Fee Eff. Date Max Fee End Date PA
H0045 RESPITE NOT-IN-HOME PER DIEM MAXFEE WVR         199.82 1/1/2010 12/31/2299 N
S0215 NONEMERG TRANSP MILEAGE MAXFEE WVR         0.48 1/1/2024 12/31/2299 N
S5101 ADULT DAY CARE PER HALF DAY MAXFEE WVR         53.11 1/1/2024 12/31/2299 N
S5102 ADULT DAY CARE PER DIEM MAXFEE WVR         106.26 1/1/2024 12/31/2299 N
S5121 CHORE SERVICES PER DIEM BILLED DEF         NA NA NA N
S5135 ADULT COMPANIONCARE PER 15M MAXFEE WVR         3.93 1/1/2024 12/31/2299 N
S5160 EMER RESPONSE SYS INSTAL&TST MAXFEE WVR         32.95 1/1/2019 12/31/2299 N
S5161 EMER RSPNS SYS SERV PERMONTH MAXFEE WVR         32.95 1/1/2019 12/31/2299 N
S5165 HOME MODIFICATIONS PER SERV BILLED DEF         NA NA NA N
S5170 HOMEDELIVERED PREPARED MEAL MAXFEE OTH         10.61 1/1/2024 12/31/2299 N
S5170 HOMEDELIVERED PREPARED MEAL MAXFEE WVR         8.80 1/1/2024 12/31/2299 N
T2029 SPECIAL MED EQUIP; NOSWAIVER BILLED DEF         NA NA NA 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