Proc Code	Proc Mod	Amount*	Effective Date	Pricing Method	Add'l Criteria	Attachment Required
	90460		**	7/1/2013	MAX FEE		N
	90461		**	7/1/2013	MAX FEE		N
	90471		**	7/1/2013	MAX FEE		N
	90472		**	7/1/2013	MAX FEE		N
	90473		**	7/1/2013	MAX FEE		N
	90474		**	7/1/2013	MAX FEE		N
	99201		$42.14	7/1/2013	MAX FEE		N
	99202		$72.13	7/1/2013	MAX FEE		N
	99203		$104.93	7/1/2013	MAX FEE		N
	99204		$161.03	7/1/2013	MAX FEE		N
	99205		$200.20	7/1/2013	MAX FEE		N
	99211		$19.41	7/1/2013	MAX FEE		N
	99212		$42.14	7/1/2013	MAX FEE		N
	99213		$70.80	7/1/2013	MAX FEE		N
	99214		$104.29	7/1/2013	MAX FEE		N
	99215		$140.01	7/1/2013	MAX FEE		N
	99217		$70.51	7/1/2013	MAX FEE		N
	99218		$97.12	7/1/2013	MAX FEE		N
	99219		$132.23	7/1/2013	MAX FEE		N
	99220		$181.37	7/1/2013	MAX FEE		N
	99221		$99.33	7/1/2013	MAX FEE		N
	99222		$134.84	7/1/2013	MAX FEE		N
	99223		$198.45	7/1/2013	MAX FEE		N
	99224		$38.88	7/1/2013	MAX FEE		N
	99225		$70.51	7/1/2013	MAX FEE		N
	99226		$101.90	7/1/2013	MAX FEE		N
	99231		$38.30	7/1/2013	MAX FEE		N
	99232		$70.46	7/1/2013	MAX FEE		N
	99233		$101.55	7/1/2013	MAX FEE		N
	99234		$131.50	7/1/2013	MAX FEE		N
	99235		$164.97	7/1/2013	MAX FEE		N
	99236		$213.18	7/1/2013	MAX FEE		N
	99238		$70.55	7/1/2013	MAX FEE		N
	99239		$104.47	7/1/2013	MAX FEE		N
	99281		$20.73	7/1/2013	MAX FEE		N
	99282		$40.69	7/1/2013	MAX FEE		N
	99283		$60.85	7/1/2013	MAX FEE		N
	99284		$116.37	7/1/2013	MAX FEE		N
	99285		$170.62	7/1/2013	MAX FEE		N
	99291		$268.85	7/1/2013	MAX FEE		N
	99292		$120.49	7/1/2013	MAX FEE		N
	99304		$90.95	7/1/2013	MAX FEE		N
	99305		$129.26	7/1/2013	MAX FEE		N
	99306		$163.99	7/1/2013	MAX FEE		N
	99307		$43.29	7/1/2013	MAX FEE		N
	99308		$67.15	7/1/2013	MAX FEE		N
	99309		$88.28	7/1/2013	MAX FEE		N
	99310		$131.68	7/1/2013	MAX FEE		N
	99315		$71.13	7/1/2013	MAX FEE		N
	99316		$102.35	7/1/2013	MAX FEE		N
	99318		$93.34	7/1/2013	MAX FEE		N
	99324		$54.33	7/1/2013	MAX FEE		N
	99325		$78.77	7/1/2013	MAX FEE		N
	99326		$136.44	7/1/2013	MAX FEE		N
	99327		$181.86	7/1/2013	MAX FEE		N
	99328		$211.59	7/1/2013	MAX FEE		N
	99334		$58.97	7/1/2013	MAX FEE		N
	99335		$92.47	7/1/2013	MAX FEE		N
	99336		$131.33	7/1/2013	MAX FEE		N
	99337		$188.31	7/1/2013	MAX FEE		N
	99339		$75.60	7/1/2013	MAX FEE		N
	99340		$106.07	7/1/2013	MAX FEE		N
	99341		$54.02	7/1/2013	MAX FEE		N
	99342		$78.11	7/1/2013	MAX FEE		N
	99343		$128.43	7/1/2013	MAX FEE		N
	99344		$178.05	7/1/2013	MAX FEE		N
	99345		$214.59	7/1/2013	MAX FEE		N
	99347		$54.28	7/1/2013	MAX FEE		N
	99348		$82.37	7/1/2013	MAX FEE		N
	99349		$124.79	7/1/2013	MAX FEE		N
	99350		$173.52	7/1/2013	MAX FEE		N
	99360		$60.52	7/1/2013	MAX FEE		N
	99366		$42.01	7/1/2013	MAX FEE		N
	99367		$55.42	7/1/2013	MAX FEE		N
	99368		$35.98	7/1/2013	MAX FEE		N
	99374		$68.08	7/1/2013	MAX FEE		N
	99381		$107.07	7/1/2013	MAX FEE		N
	99382		$111.65	7/1/2013	MAX FEE		N
	99383		$116.44	7/1/2013	MAX FEE		N
	99384		$132.07	7/1/2013	MAX FEE		N
	99385		$127.95	7/1/2013	MAX FEE		N
	99391		$96.25	7/1/2013	MAX FEE		N
	99392		$103.05	7/1/2013	MAX FEE		N
	99393		$102.75	7/1/2013	MAX FEE		N
	99394		$112.43	7/1/2013	MAX FEE		N
	99395		$114.85	7/1/2013	MAX FEE		N
	99406		$13.86	7/1/2013	MAX FEE		N
	99407		$26.85	7/1/2013	MAX FEE		N
	99460		$90.20	7/1/2013	MAX FEE		N
	99461		$96.65	7/1/2013	MAX FEE		N
	99462		$40.88	7/1/2013	MAX FEE		N
	99463		$112.77	7/1/2013	MAX FEE		N
	99464		$75.09	7/1/2013	MAX FEE		N
	99465		$144.22	7/1/2013	MAX FEE		N
	99466		$259.65	7/1/2013	MAX FEE		N
	99467		$120.21	7/1/2013	MAX FEE		N
	99468		$936.94	7/1/2013	MAX FEE		N
	99469		$388.82	7/1/2013	MAX FEE		N
	99471		$836.47	7/1/2013	MAX FEE		N
	99472		$399.36	7/1/2013	MAX FEE		N
	99475		$554.47	7/1/2013	MAX FEE		N
	99476		$342.42	7/1/2013	MAX FEE		N
	99477		$345.26	7/1/2013	MAX FEE		N
	99478		$138.22	7/1/2013	MAX FEE		N
	99479		$125.58	7/1/2013	MAX FEE		N
	99480		$117.65	7/1/2013	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.