Proc Code	Proc Mod	Amount*	Effective Date	Pricing Method	Add'l Criteria	Attachment Required
	90460		**	1/1/2013	MAX FEE		N
	90461		**	1/1/2013	MAX FEE		N
	90471		**	1/1/2013	MAX FEE		N
	90472		**	1/1/2013	MAX FEE		N
	90473		**	1/1/2013	MAX FEE		N
	90474		**	1/1/2013	MAX FEE		N
	99201		$41.35	1/1/2013	MAX FEE		N
	99202		$70.59	1/1/2013	MAX FEE		N
	99203		$102.27	1/1/2013	MAX FEE		N
	99204		$157.00	1/1/2013	MAX FEE		N
	99205		$194.95	1/1/2013	MAX FEE		N
	99211		$19.12	1/1/2013	MAX FEE		N
	99212		$41.35	1/1/2013	MAX FEE		N
	99213		$68.88	1/1/2013	MAX FEE		N
	99214		$101.49	1/1/2013	MAX FEE		N
	99215		$136.51	1/1/2013	MAX FEE		N
	99217		$68.39	1/1/2013	MAX FEE		N
	99218		$93.94	1/1/2013	MAX FEE		N
	99219		$127.92	1/1/2013	MAX FEE		N
	99220		$175.15	1/1/2013	MAX FEE		N
	99221		$95.83	1/1/2013	MAX FEE		N
	99222		$130.21	1/1/2013	MAX FEE		N
	99223		$191.74	1/1/2013	MAX FEE		N
	99224		$37.62	1/1/2013	MAX FEE		N
	99225		$68.20	1/1/2013	MAX FEE		N
	99226		$98.28	1/1/2013	MAX FEE		N
	99231		$37.04	1/1/2013	MAX FEE		N
	99232		$68.16	1/1/2013	MAX FEE		N
	99233		$98.23	1/1/2013	MAX FEE		N
	99234		$127.25	1/1/2013	MAX FEE		N
	99235		$159.60	1/1/2013	MAX FEE		N
	99236		$206.22	1/1/2013	MAX FEE		N
	99238		$68.43	1/1/2013	MAX FEE		N
	99239		$101.01	1/1/2013	MAX FEE		N
	99281		$19.98	1/1/2013	MAX FEE		N
	99282		$39.23	1/1/2013	MAX FEE		N
	99283		$58.63	1/1/2013	MAX FEE		N
	99284		$111.81	1/1/2013	MAX FEE		N
	99285		$164.32	1/1/2013	MAX FEE		N
	99291		$261.08	1/1/2013	MAX FEE		N
	99292		$116.76	1/1/2013	MAX FEE		N
	99304		$88.23	1/1/2013	MAX FEE		N
	99305		$125.36	1/1/2013	MAX FEE		N
	99306		$158.61	1/1/2013	MAX FEE		N
	99307		$42.03	1/1/2013	MAX FEE		N
	99308		$65.23	1/1/2013	MAX FEE		N
	99309		$85.71	1/1/2013	MAX FEE		N
	99310		$127.48	1/1/2013	MAX FEE		N
	99315		$69.01	1/1/2013	MAX FEE		N
	99316		$99.20	1/1/2013	MAX FEE		N
	99318		$90.50	1/1/2013	MAX FEE		N
	99324		$52.66	1/1/2013	MAX FEE		N
	99325		$75.94	1/1/2013	MAX FEE		N
	99326		$131.78	1/1/2013	MAX FEE		N
	99327		$176.12	1/1/2013	MAX FEE		N
	99328		$204.50	1/1/2013	MAX FEE		N
	99334		$57.19	1/1/2013	MAX FEE		N
	99335		$89.61	1/1/2013	MAX FEE		N
	99336		$126.94	1/1/2013	MAX FEE		N
	99337		$182.37	1/1/2013	MAX FEE		N
	99339		$73.53	1/1/2013	MAX FEE		N
	99340		$103.08	1/1/2013	MAX FEE		N
	99341		$52.35	1/1/2013	MAX FEE		N
	99342		$75.28	1/1/2013	MAX FEE		N
	99343		$124.23	1/1/2013	MAX FEE		N
	99344		$172.44	1/1/2013	MAX FEE		N
	99345		$207.50	1/1/2013	MAX FEE		N
	99347		$52.62	1/1/2013	MAX FEE		N
	99348		$79.79	1/1/2013	MAX FEE		N
	99349		$120.92	1/1/2013	MAX FEE		N
	99350		$168.08	1/1/2013	MAX FEE		N
	99360		$58.23	1/1/2013	MAX FEE		N
	99366		$40.34	1/1/2013	MAX FEE		N
	99367		$53.29	1/1/2013	MAX FEE		N
	99368		$34.79	1/1/2013	MAX FEE		N
	99374		$66.25	1/1/2013	MAX FEE		N
	99381		$104.58	1/1/2013	MAX FEE		N
	99382		$108.99	1/1/2013	MAX FEE		N
	99383		$113.62	1/1/2013	MAX FEE		N
	99384		$128.45	1/1/2013	MAX FEE		N
	99385		$124.77	1/1/2013	MAX FEE		N
	99391		$93.98	1/1/2013	MAX FEE		N
	99392		$100.26	1/1/2013	MAX FEE		N
	99393		$99.95	1/1/2013	MAX FEE		N
	99394		$109.61	1/1/2013	MAX FEE		N
	99395		$111.95	1/1/2013	MAX FEE		N
	99406		$13.15	1/1/2013	MAX FEE		N
	99407		$26.02	1/1/2013	MAX FEE		N
	99460		$86.70	1/1/2013	MAX FEE		N
	99461		$94.56	1/1/2013	MAX FEE		N
	99462		$39.49	1/1/2013	MAX FEE		N
	99463		$109.23	1/1/2013	MAX FEE		N
	99464		$72.61	1/1/2013	MAX FEE		N
	99465		$139.36	1/1/2013	MAX FEE		N
	99466		$251.40	1/1/2013	MAX FEE		N
	99467		$116.23	1/1/2013	MAX FEE		N
	99468		$905.41	1/1/2013	MAX FEE		N
	99469		$374.95	1/1/2013	MAX FEE		N
	99471		$809.04	1/1/2013	MAX FEE		N
	99472		$385.80	1/1/2013	MAX FEE		N
	99475		$535.20	1/1/2013	MAX FEE		N
	99476		$330.92	1/1/2013	MAX FEE		N
	99477		$333.34	1/1/2013	MAX FEE		N
	99478		$133.65	1/1/2013	MAX FEE		N
	99479		$121.44	1/1/2013	MAX FEE		N
	99480		$113.67	1/1/2013	MAX FEE		N
							
	"* Eligibility for the ACA Primary Care rates depends on a number of factors, please check the provider "						
	  secure site for rates specific to your facility.						
							
	** Vaccine administration codes are dependent on the provider and the member; please 						
	    refer to the provider secure site for individual pricing information.