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Arkansas Medicaid 2021 Ambulatory Surgical CenterFee ScheduleThis fee schedule does not address the various coverage limitations routinely applied by Arkansas Medicaidbefore final payment is determined (e.g., beneficiary and provider eligibility, benefit limits, billing instructions,frequency of services, third party liability, age restrictions, prior authorization,co-payments/coinsurance where applicable). Procedure codes and/or fee schedule amounts listed do notguarantee payment, coverage or amount allowed.Although every effort is made to ensure the accuracy of this information, discrepancies may occur. This feeschedule may be changed or updated at any time to correct such discrepancies. The reimbursement ratesreflected in this fee schedule are in effect in calendar year 2021. The reimbursement rate applied to a claimdepends on the claim’s date of service because Arkansas Medicaid’s reimbursement rates are date-of-serviceeffective. This fee schedule reflects only procedure codes that are currently payable. Rates that are listed at 0 represent a requirement of manual pricing or a packaged service/item that allows no separatereimbursement.The payment made to an Ambulatory Surgical Center (ASC) for surgical procedures is calculated as theclaim is processed for payment. Each county is assigned a County Code based on the regional location. Theprocedure codes reimbursed each have a base rate used in the calculation. This base rate is reflected in theArkansas Medicaid ASC Fee Schedule. The base rate is equal to 95% of the Medicare rate. The wage indexis only applied to half of the base rate. See example below:(Base Rate x Wage Index) Base Rate ( 10 x 0.8197 x 50%) 4.10 ( 10 x 50%) 5.00 RegionCode 9.10 Medicaid RateRegional LocationWageIndex1Garland0.81972Craighead, Poinsett counties0.79773Faulkner, Grant, Lonoke, Perry, Pulaski, Saline counties0.82884Crittenden county, TN-MS-AR metro area0.86705Miller county AR (Texarkana, AR); Bowie county TX (Texarkana, TX)0.85586Crawford, Franklin, Sebastian counties AR; LeFlore, Sequoyah counties OK0.82757Rural Arkansas (if not specifically listed then use)0.71028Benton, Madison, Washington counties AR; McDonald county MO0.84059Cleveland, Jefferson, Lincoln counties0.7685RegionCode % of Level III PricingASC pricing description10.8197Hot Springs20.7977Jonesboro30.8288Little Rock area40.8670West Memphis and Tennessee50.8558Texarkana60.8275Fort Smith and Oklahoma70.7102Rural Arkansas80.8405Fayetteville and Springdale90.7685Pine Bluff
168St. ad771Van Buren730Hot ce774Woodruff733Izard775Yell734Jackson776Pulaski (North)735Jefferson991State of Louisiana736Johnson792State of Missouri837Lafayette793State of Mississippi438Lawrence794State of Oklahoma639Lee795State of Tennessee440Lincoln996State of Texas5797All other States741Little River
Please note that Arkansas Medicaid will reimburse the lesser of the amount billed or the Medicaidmaximum. For a full explanation of the revenue codes, procedure codes, and modifiers listed here,refer to your Arkansas Medicaid provider manual and provider notices.Run Date 3/29/21Provider Type: 28RevenueCode360Mod 1Mod 2Mod 3Mod 4MedicaidMaximumAllowedAmount 297.00361 250.00369 320.00509 1011Mod GSGSGMod 2Mod 3Mod 4MedicaidMaximumAllowedAmount 0.00 300.12 0.00 224.75 0.00 300.12 0.00 300.12 0.00 59.73 300.12 0.00 0.00 0.00 71.43 107.76 185.65 225.06 99.45 567.37 101.91 76.35 950.46 32.63 0.00 300.12 Packaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 950.46 166.88 252.93 567.37 0.00 0.00 0.00 0.00 0.00 58.81 72.66 0.00 90.52 0.00 110.84 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 86.64 0.00 81.28 86.64 101.60 111.76 87.74 99.45 107.45 116.99 567.37 567.37 83.44 96.99 107.45 116.69 567.37 950.46 96.37 107.14 115.45 127.78 567.37 950.46 950.46 950.46Packaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 950.46 950.46 950.46 950.46 128.38 140.09 147.48 158.56 300.12 567.37 128.38 140.39 149.94 164.10 567.37 950.46 131.46 144.09 156.09 170.88 567.37 950.46 0.00 0.00 0.00 0.00 0.00 0.00 95.45 74.20 121.92 170.26 0.00 950.46 950.46 950.46 0.00 0.00 118.85 130.24 0.00 42.18 53.57 68.35 75.43 1,699.54 3,621.33 950.46 72.05 0.00Packaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesASC Family PlanningPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 0.00 0.00 0.00 0.00 0.00 0.00 166.88 166.88 86.64 0.00 0.00 0.00 86.64 166.88 166.88 86.64 252.93 166.88 166.88 166.88 166.88 166.88 252.93 827.72 166.88 166.88 252.93 252.93 252.93 827.72 166.88 166.88 166.88 166.88 166.88 166.88 166.88 252.93 252.93 0.00 252.93 252.93 0.00 166.88 252.93 0.00 252.93 252.93 0.00 827.72Packaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 827.72 827.72 827.72 827.72 827.72 827.72 827.72 827.72 1,699.54 0.00 827.72 827.72 0.00 252.93 0.00 827.72 252.93 827.72 0.00 827.72 0.00 827.72 0.00 1,699.54 0.00 827.72 0.00 1,699.54 0.00 827.72 0.00 0.00 1,699.54 0.00 0.00 827.72 0.00 827.72 0.00 827.72 0.00 827.72 0.00 827.72 0.00 1,699.54 0.00 827.72 0.00 827.72Packaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 0.00 827.72 1,699.54 827.72 827.72 1,699.54 827.72 827.72 827.72 827.72 1,699.54 1,699.54 1,699.54 1,699.54 827.72 1,699.54 827.72 1,699.54 827.72 1,699.54 1,699.54 1,699.54 827.72 166.88 166.88 0.00 487.99 300.12 315.58 166.88 0.00 0.00 0.00 252.93 0.00 0.00 827.72 827.72 827.72 827.72 827.72 827.72 1,699.54 1,699.54 1,699.54 1,699.54 2,149.18 950.46 950.46 950.46Packaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 950.46 950.46 950.46 950.46 950.46 1,699.54 1,699.54 827.72 1,699.54 0.00 252.93 70.81 0.00 0.00 1,699.54 1,699.54 827.72 1,699.54 950.46 1,699.54 950.46 950.46 1,699.54 1,699.54 827.72 827.72 950.46 950.46 1,699.54 827.72 827.72 567.37 950.46 827.72 1,699.54 827.72 1,699.54 0.00 0.00 86.64 166.88 166.88 0.00 0.00 104.06 166.88 240.15 312.19 0.00 0.00Packaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 0.00 0.00 0.00 0.00 0.00 120.38 132.70 86.64 86.64 0.00 118.53 132.70 147.16 0.00 102.83 115.77 129.62 142.86 170.56 252.93 0.00 252.93 0.00 0.00 0.00 0.00 252.93 69.58 0.00 567.37 0.00 567.37 0.00 567.37 0.00 567.37 0.00 567.37 1,123.19 1,625.49 1,123.19 1,123.19 1,123.19 1,123.19 0.00 0.00 0.00 0.00 0.00 0.00Packaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 0.00 0.00 0.00 0.00 4,088.77 0.00 2,149.18 1,123.19 1,123.19 2,149.18 2,149.18 2,149.18 2,149.18 2,149.18 2,662.57 1,123.19 1,123.19 2,149.18 2,662.57 1,123.19 1,123.19 5,352.91 1,123.19 1,123.19 2,149.18 1,123.19 218.28 827.72 827.72 300.12 1,268.34 567.37 950.46 567.37 567.37 567.37 950.46 950.46 1,268.34 2,797.03 64.96 0.00 133.93 950.46 39.41 42.18 24.94 26.17 25.86 30.17Packaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 1,268.34 24.02 43.42 25.24 46.18 30.17 52.03 32.95 155.48 1,268.34 690.89 690.89 1,268.34 130.39 567.37 950.46 3,984.71 8,656.19 2,797.03 690.89 10,255.79 690.89 690.89 2,797.03 2,797.03 252.93 1,699.54 827.72 827.72 2,797.03 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 300.12 2,797.03 2,797.03 0.00 0.00 2,797.03 2,797.03 0.00 1,033.52 234.60 567.37Packaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 298.34 950.46 950.46 950.46 2,279.17 2,279.17 1,033.52 270.01 245.69 241.99 2,279.17 1,033.52 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 228.45 334.36 787.56 563.11 674.26 629.00 579.12 574.20 640.40 102.11 594.82 594.82 1,033.52 2,279.17 490.78 0.00 2,279.17 1,033.52 2,279.17 1,033.52 2,279.17 2,279.17 1,033.52 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17Packaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 3,424.05 2,279.17 2,279.17 2,279.17 1,193.04 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 11,068.16 3,130.81 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 3,540.62 2,279.17 2,279.17 1,033.52 1,033.52 490.78 1,033.52 99.49 490.78 1,033.52 1,033.52 2,279.17 1,033.52 1,268.34 1,033.52 3,316.51 2,279.17 1,033.52 490.78 2,279.17 1,033.52 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17 2,279.17
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 2,279.17 218.28 490.78 2,279.17 2,279.17 2,279.17 1,033.52 506.77 2,279.17 292.08 490.78 2,997.23 2,279.17 3,097.69 3,075.39 3,250.05 3,051.99 3,163.27 99.49 490.78 1,033.52 490.78 950.46 1,268.34 567.37 950.46 950.46 567.37 950.46 950.46 950.46 2,797.03 950.46 1,268.34 2,279.17 2,797.03 1,268.34 300.12 1,268.34 1,268.34 99.49 170.88 567.37 567.37 567.37 950.46 950.46 950.46 950.46 2,797.03
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 2,797.03 2,797.03 0.00 99.49 1,268.34 690.89 1,268.34 1,268.34 0.00 2,797.03 2,797.03 0.00 8,130.92 0.00 8,080.45 0.00 8,196.57 0.00 0.00 0.00 0.00 0.00 0.00 11,277.57 0.00 0.00 11,747.70 0.00 9,740.92 0.00 950.46 950.46 567.37 950.46 950.46 950.46 950.46 1,268.34 950.46 950.46 690.89 1,268.34 1,268.34 128.38 950.46 567.37 950.46 567.37 950.46 950.46Packaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged ServicesPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 950.46 1,268.34 1,268.34 2,797.03 1,268.34 2,797.03 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 2,797.03 1,268.34 2,797.03 2,797.03 1,268.34 1,268.34 2,797.03 2,797.03 2,797.03 2,797.03 1,268.34 2,797.03 300.12 950.46 950.46 0.00 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 3,948.68 3,760.07 2,797.03 2,797.03 2,797.03 2,797.03 8,485.26 8,149.37 2,797.03 7,855.26 2,797.03 7,459.68Packaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 99.49 690.89 3,836.49 690.89 99.49 2,797.03 3,864.13 99.49 99.49 2,797.03 3,723.22 99.49 690.89 2,797.03 99.49 690.89 8,033.24 10,782.15 99.49 690.89 2,797.03 99.49 690.89 2,797.03 690.89 2,797.03 690.89 8,756.04 690.89 2,797.03 5,601.15 827.72 950.46 567.37 1,268.34 1,268.34 1,268.34 167.49 950.46 950.46 950.46 567.37 950.46 950.46 950.46 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 2,797.03 2,797.03 1,268.34 1,268.34 4,525.58 1,268.34 2,797.03 1,268.34 2,797.03 1,268.34 2,797.03 1,268.34 2,797.03 2,797.03 2,797.03 1,268.34 1,268.34 1,268.34 141.32 950.46 0.00 690.89 2,797.03 1,268.34 1,268.34 2,797.03 2,797.03 2,797.03 1,268.34 2,797.03 2,797.03 2,797.03 1,268.34 3,650.05 2,797.03 5,601.15 1,268.34 1,268.34 1,268.34 3,616.18 11,598.02 8,935.65 11,462.39 8,298.59 8,646.43 7,690.30 10,303.58 2,797.03 5,601.15 2,797.03Packaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 7,817.82 7,799.37 1,268.34 2,797.03 7,503.63 99.49 690.89 7,646.34 7,817.82 99.49 690.89 2,797.03 7,892.16 10,423.05 99.49 690.89 690.89 7,684.87 99.49 690.89 7,377.20 2,797.03 5,601.15 8,440.77 99.49 690.89 2,797.03 690.89 3,870.36 54.49 99.49 690.89 2,797.03 8,680.61 99.49 690.89 3,696.66 2,797.03 5,601.15 1,268.34 2,797.03 690.89 1,268.34 690.89 1,268.34 1,268.34 690.89 1,268.34 690.89 2,797.03
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 1,268.34 169.34 950.46 567.37 950.46 567.37 567.37 950.46 950.46 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 690.89 690.89 690.89 690.89 1,268.34 690.89 1,268.34 1,268.34 690.89 1,268.34 1,268.34 2,797.03 2,797.03 1,268.34 1,268.34 1,268.34 2,797.03 1,268.34 1,268.34 1,268.34 1,268.34 0.00 690.89 690.89 1,268.34 690.89 1,268.34 2,797.03 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34Packaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 2,797.03 2,797.03 2,797.03 1,268.34 1,268.34 2,797.03 3,942.71 1,268.34 2,797.03 5,601.15 1,268.34 1,268.34 3,849.50 7,978.43 2,797.03 2,797.03 1,268.34 3,915.07 3,855.19 4,147.03 3,995.82 2,797.03 1,723.09 1,268.34 2,797.03 2,797.03 8,892.78 11,867.17 4,173.85 8,687.66 4,204.21 12,199.56 1,268.34 2,797.03 1,268.34 1,268.34 2,797.03 5,601.15 1,268.34 99.49 690.89 3,757.64 690.89 3,682.30 2,797.03
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 99.49 99.49 3,680.67 99.49 690.89 3,986.61 3,889.87 99.49 690.89 1,268.34 4,010.18 4,002.32 4,019.67 99.49 690.89 2,797.03 99.49 690.89 1,268.34 99.49 1,268.34 3,635.42 99.49 4,355.41 1,268.34 99.49 2,797.03 99.49 2,797.03 690.89 2,797.03 3,822.67 3,977.12 7,925.26 3,822.94 3,863.86 2,797.03 1,268.34 2,797.03 690.89 827.72 1,268.34 86.64 567.37 1,268.34 1,268.34 1,268.34 690.89 1,268.34 1,268.34
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 690.89 1,268.34 690.89 690.89 690.89 1,268.34 690.89 1,268.34 1,268.34 690.89 567.37 567.37 567.37 567.37 950.46 950.46 1,268.34 1,268.34 0.00 1,268.34 1,268.34 690.89 690.89 690.89 690.89 690.89 690.89 690.89 2,797.03 690.89 1,268.34 1,268.34 690.89 690.89 1,268.34 1,268.34 690.89 567.37 690.89 70.51 1,268.34 2,797.03 1,268.34 1,268.34 2,797.03 1,268.34 2,797.03 1,268.34 3,729.18 2,797.03Packaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 690.89 1,268.34 1,268.34 1,268.34 690.89 1,268.34 1,268.34 1,268.34 690.89 1,268.34 1,268.34 1,268.34 690.89 1,268.34 1,268.34 1,268.34 1,268.34 690.89 690.89 1,268.34 690.89 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 2,797.03 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 2,797.03 1,268.34 690.89 3,677.16 4,075.49 1,268.34 3,834.87 1,268.34
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 1,268.34 1,268.34 1,268.34 2,797.03 1,268.34 1,268.34 2,797.03 690.89 1,268.34 1,268.34 1,268.34 1,268.34 2,797.03 1,268.34 1,268.34 690.89 1,268.34 1,268.34 1,268.34 99.49 99.49 1,268.34 1,268.34 1,268.34 99.49 690.89 1,268.34 1,268.34 99.49 690.89 1,268.34 1,268.34 1,268.34 99.49 690.89 1,268.34 1,268.34 99.49 99.49 1,268.34 1,268.34 99.49 690.89 1,268.34 99.49 99.49 1,268.34 1,268.34 99.49 116.38
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 1,268.34 1,268.34 3,899.63 2,797.03 2,797.03 3,786.62 4,341.59 2,797.03 2,797.03 1,268.34 0.00 1,268.34 0.00 1,268.34 1,268.34 1,268.34 1,268.34 690.89 690.89 1,268.34 2,797.03 1,268.34 2,797.03 2,797.03 1,268.34 567.37 567.37 950.46 950.46 950.46 950.46 950.46 690.89 690.89 690.89 950.46 2,797.03 1,268.34 2,797.03 1,268.34 2,797.03 1,268.34 950.46 1,268.34 0.00 0.00 1,268.34 1,268.34 2,797.03 1,268.34Packaged ServicesPackaged ServicesPackaged ServicesPackaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 4,121.01 1,268.34 8,391.39 2,797.03 99.49 99.49 99.49 1,268.34 99.49 99.49 2,797.03 690.89 99.49 99.49 690.89 99.49 690.89 99.49 690.89 1,268.34 690.89 12,325.35 950.46 1,268.34 1,268.34 1,268.34 1,268.34 567.37 950.46 768.43 768.43 567.37 950.46 950.46 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 2,797.03 950.46 950.46 1,268.34 1,268.34 1,268.34 2,797.03 1,268.34 5,601.15 2,797.03 0.00Packaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 1,268.34 950.46 0.00 950.46 2,797.03 3,680.14 2,797.03 2,797.03 1,268.34 1,268.34 1,268.34 2,797.03 2,797.03 1,268.34 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 9,655.72 2,797.03 2,797.03 2,797.03 2,797.03 2,797.03 1,268.34 3,693.14 5,601.15 9,846.19 2,797.03 1,268.34 2,797.03 7,746.74 7,685.96 5,601.15 8,211.77 7,820.52 8,222.62 8,335.49 2,797.03 4,253.25 2,797.03 2,797.03 1,268.34 1,268.34 690.89 2,797.03Packaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 99.49 99.49 690.89 690.89 99.49 4,026.17 690.89 99.49 690.89 99.49 2,797.03 99.49 1,268.34 99.49 99.49 690.89 99.49 99.49 2,797.03 690.89 1,268.34 1,268.34 1,268.34 1,268.34 950.46 1,268.34 690.89 1,268.34 1,268.34 1,268.34 1,268.34 159.17 950.46 950.46 950.46 567.37 950.46 1,268.34 1,268.34 1,268.34 1,268.34 950.46 950.46 1,268.34 2,797.03 2,797.03 1,268.34 1,268.34 1,268.34 0.00Packaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 2,797.03 3,938.64 2,797.03 1,268.34 1,268.34 2,797.03 2,797.03 2,797.03 1,268.34 2,797.03 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 2,797.03 2,797.03 0.00 2,797.03 2,797.03 2,797.03 3,627.29 1,268.34 3,629.47 1,268.34 7,369.06 4,035.66 4,506.88 3,771.19 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 3,890.95 99.49 690.89 2,797.03 7,895.41 7,700.61 99.49 690.89 2,797.03 99.49 690.89 2,797.03 99.49 690.89 2,797.03 99.49Packaged Services
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 99.49 3,731.35 99.49 690.89 3,753.02 99.49 690.89 3,755.46 3,716.45 99.49 690.89 3,720.78 7,957.28 7,904.10 3,787.98 99.49 1,268.34 3,862.50 99.49 690.89 2,797.03 3,670.65 1,268.34 8,276.34 8,613.32 1,268.34 2,797.03 1,268.34 2,797.03 1,268.34 158.87 690.89 1,268.34 1,268.34 1,268.34 111.14 690.89 1,268.34 1,268.34 690.89 768.43 950.46 950.46 567.37 950.46 950.46 950.46 1,268.34 1,268.34 1,268.34
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 768.43 1,268.34 1,268.34 2,797.03 1,268.34 690.89 1,268.34 1,268.34 690.89 690.89 1,268.34 2,797.03 3,957.07 1,268.34 2,797.03 3,878.22 690.89 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 271.55 1,268.34 2,797.03 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 690.89 165.02 567.37 567.37 1,268.34 2,797.03 1,268.34 2,797.03 258.00 1,268.34 1,268.34 1,268.34 253.38 235.22
SGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSGSG 690.89 2,797.03 1,268.34 1,268.34 1,268.34 690.89 2,797.03 690.89 1,268.34 225.99 1,268.34 1,268.34 1,268.34 1,268.34 1,268.34 4,219.38 1,268.34 1,268.34 1,268.34 4,084.71 3,614.56 2,797.03 3,938.92 2,797.03 2,797.03 4,015.06 2,797.03 2,797.03 1,268.34 3,790.42 2,797.03 1,268.34 1,268.34 1,268.34 8,205.81 3,885.54 1,268
Revenue Code Mod 1 Mod 2 Mod 3 Mod 4 Medicaid Maximum Allowed Amount Reimbursement Indicator 360 297.00 361 250.00 369 320.00 509 363.00 Procedure
