Proc Code Proc Mod Amount* Effective Date Pricing Method Add'l Criteria Attachment Required 90460 ** 1/1/2014 MAX FEE N 90471 ** 1/1/2014 MAX FEE N 90472 ** 1/1/2014 MAX FEE N 90473 ** 1/1/2014 MAX FEE N 90474 ** 1/1/2014 MAX FEE N 99201 $39.95 1/1/2014 MAX FEE N 99202 $69.19 1/1/2014 MAX FEE N 99203 $100.73 1/1/2014 MAX FEE N 99204 $155.92 1/1/2014 MAX FEE N 99205 $194.97 1/1/2014 MAX FEE N 99211 $18.31 1/1/2014 MAX FEE N 99212 $40.26 1/1/2014 MAX FEE N 99213 $68.14 1/1/2014 MAX FEE N 99214 $100.89 1/1/2014 MAX FEE N 99215 $135.58 1/1/2014 MAX FEE N 99217 $69.32 1/1/2014 MAX FEE N 99218 $95.75 1/1/2014 MAX FEE N 99219 $130.74 1/1/2014 MAX FEE N 99220 $178.89 1/1/2014 MAX FEE N 99221 $97.77 1/1/2014 MAX FEE N 99222 $132.84 1/1/2014 MAX FEE N 99223 $195.81 1/1/2014 MAX FEE N 99224 $38.47 1/1/2014 MAX FEE N 99225 $69.89 1/1/2014 MAX FEE N 99226 $100.82 1/1/2014 MAX FEE N 99231 $37.87 1/1/2014 MAX FEE N 99232 $69.55 1/1/2014 MAX FEE N 99233 $100.20 1/1/2014 MAX FEE N 99234 $130.10 1/1/2014 MAX FEE N 99235 $163.04 1/1/2014 MAX FEE N 99236 $210.56 1/1/2014 MAX FEE N 99238 $69.35 1/1/2014 MAX FEE N 99239 $102.51 1/1/2014 MAX FEE N 99281 $20.51 1/1/2014 MAX FEE N 99282 $40.28 1/1/2014 MAX FEE N 99283 $60.22 1/1/2014 MAX FEE N 99284 $114.83 1/1/2014 MAX FEE N 99285 $169.00 1/1/2014 MAX FEE N 99291 $260.20 1/1/2014 MAX FEE N 99292 $117.78 1/1/2014 MAX FEE N 99304 $89.03 1/1/2014 MAX FEE N 99305 $126.94 1/1/2014 MAX FEE N 99306 $161.19 1/1/2014 MAX FEE N 99307 $42.57 1/1/2014 MAX FEE N 99308 $65.64 1/1/2014 MAX FEE N 99309 $86.54 1/1/2014 MAX FEE N 99310 $128.97 1/1/2014 MAX FEE N 99315 $69.95 1/1/2014 MAX FEE N 99316 $100.67 1/1/2014 MAX FEE N 99318 $91.95 1/1/2014 MAX FEE N 99324 $53.38 1/1/2014 MAX FEE N 99325 $77.93 1/1/2014 MAX FEE N 99326 $134.34 1/1/2014 MAX FEE N 99327 $179.07 1/1/2014 MAX FEE N 99328 $207.98 1/1/2014 MAX FEE N 99334 $58.04 1/1/2014 MAX FEE N 99335 $91.06 1/1/2014 MAX FEE N 99336 $128.58 1/1/2014 MAX FEE N 99337 $185.56 1/1/2014 MAX FEE N 99339 $74.16 1/1/2014 MAX FEE N 99340 $103.89 1/1/2014 MAX FEE N 99341 $53.07 1/1/2014 MAX FEE N 99342 $76.96 1/1/2014 MAX FEE N 99343 $126.01 1/1/2014 MAX FEE N 99344 $175.25 1/1/2014 MAX FEE N 99345 $211.35 1/1/2014 MAX FEE N 99347 $53.33 1/1/2014 MAX FEE N 99348 $80.93 1/1/2014 MAX FEE N 99349 $122.33 1/1/2014 MAX FEE N 99350 $170.71 1/1/2014 MAX FEE N 99360 $59.89 1/1/2014 MAX FEE N 99366 $41.59 1/1/2014 MAX FEE N 99367 $54.76 1/1/2014 MAX FEE N 99368 $35.83 1/1/2014 MAX FEE N 99374 $66.60 1/1/2014 MAX FEE N 99381 $103.69 1/1/2014 MAX FEE N 99382 $108.26 1/1/2014 MAX FEE N 99383 $113.09 1/1/2014 MAX FEE N 99384 $128.22 1/1/2014 MAX FEE N 99385 $124.40 1/1/2014 MAX FEE N 99391 $93.42 1/1/2014 MAX FEE N 99392 $99.95 1/1/2014 MAX FEE N 99393 $99.64 1/1/2014 MAX FEE N 99394 $109.35 1/1/2014 MAX FEE N 99395 $111.77 1/1/2014 MAX FEE N 99406 $13.30 1/1/2014 MAX FEE N 99407 $26.37 1/1/2014 MAX FEE N 99460 $91.78 1/1/2014 MAX FEE N 99461 $91.66 1/1/2014 MAX FEE N 99462 $40.76 1/1/2014 MAX FEE N 99463 $110.18 1/1/2014 MAX FEE N 99464 $69.18 1/1/2014 MAX FEE N 99465 $142.82 1/1/2014 MAX FEE N 99466 $250.85 1/1/2014 MAX FEE N 99467 $118.93 1/1/2014 MAX FEE N 99468 $901.86 1/1/2014 MAX FEE N 99469 $383.71 1/1/2014 MAX FEE N 99471 $822.17 1/1/2014 MAX FEE N 99472 $389.15 1/1/2014 MAX FEE N 99475 $556.56 1/1/2014 MAX FEE N 99476 $336.22 1/1/2014 MAX FEE N 99477 $336.58 1/1/2014 MAX FEE N 99478 $133.32 1/1/2014 MAX FEE N 99479 $120.93 1/1/2014 MAX FEE N 99480 $116.39 1/1/2014 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.