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					0.38	1/1/2010	12/31/2299	N
S5101	ADULT DAY CARE PER HALF DAY	MAXFEE	WVR					40.60	11/1/2021	12/31/2299	N
S5102	ADULT DAY CARE PER DIEM	MAXFEE	WVR					81.18	11/1/2021	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
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					8.68	1/1/2019	12/31/2299	N
S5170	HOMEDELIVERED PREPARED MEAL	MAXFEE	WVR					7.20	11/1/2021	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