Fee Schedule With Modifiers,V1,,,,,,,
Schedule Code,,MPGA ASD U6,,,,,,
Schedule Name,,GA MP Autism with U6 modifier,,,,,,
Table Name,,MPGA ASD U6,,,,,,
Table Type,,Base Table,,,,,,
Comment,,,,,,,,
Active,Version,Effective,Termination,Base Percent,Default Percent,,,
Y,CFG_FAC030220133905,1/1/2019,12/31/9999,1,0,,,
Procedure Code,Modifier,Description,Effective,Termination,Reimbursement Method,Allowed,Percent,Follow-up Days
97151,U1,,1/1/2019,12/31/9999,Allowed,58.21,0,0
97151,U2,,1/1/2019,12/31/9999,Allowed,38.97,0,0
97151,U3,,1/1/2019,12/31/9999,Allowed,30.01,0,0
97152,U1,,1/1/2019,12/31/9999,Allowed,58.21,0,0
97152,U2,,1/1/2019,12/31/9999,Allowed,38.97,0,0
97152,U3,,1/1/2019,12/31/9999,Allowed,30.01,0,0
97152,U4,,1/1/2019,12/31/9999,Allowed,20.3,0,0
97152,U5,,1/1/2019,12/31/9999,Allowed,15.13,0,0
0362T ,U1,,1/1/2019,12/31/9999,Allowed,58.21,0,0
0362T ,U2,,1/1/2019,12/31/9999,Allowed,38.97,0,0
0362T ,U3,,1/1/2019,12/31/9999,Allowed,30.01,0,0
0362T ,U4,,1/1/2019,12/31/9999,Allowed,20.3,0,0
0362T ,U5,,1/1/2019,12/31/9999,Allowed,15.13,0,0
97153,U1,,1/1/2019,12/31/9999,Allowed,58.21,0,0
97153,U2,,1/1/2019,12/31/9999,Allowed,38.97,0,0
97153,U3,,1/1/2019,12/31/9999,Allowed,30.01,0,0
97153,U4,,1/1/2019,12/31/9999,Allowed,20.3,0,0
97153,U5,,1/1/2019,12/31/9999,Allowed,15.13,0,0
97154,U1,,1/1/2019,12/31/9999,Allowed,58.21,0,0
97154,U2,,1/1/2019,12/31/9999,Allowed,38.97,0,0
97154,U3,,1/1/2019,12/31/9999,Allowed,30.01,0,0
97154,U4,,1/1/2019,12/31/9999,Allowed,20.3,0,0
97154,U5,,1/1/2019,12/31/9999,Allowed,15.13,0,0
97155,U1,,1/1/2019,12/31/9999,Allowed,58.21,0,0
97155,U2,,1/1/2019,12/31/9999,Allowed,38.97,0,0
97155,U3,,1/1/2019,12/31/9999,Allowed,30.01,0,0
97156,U1,,1/1/2019,12/31/9999,Allowed,21.9,0,0
97156,U2,,1/1/2019,12/31/9999,Allowed,17.01,0,0
97156,U3,,1/1/2019,12/31/9999,Allowed,13.21,0,0
97157,U1,,1/1/2019,12/31/9999,Allowed,25.34,0,0
97157,U2,,1/1/2019,12/31/9999,Allowed,17,0,0
97157,U3,,1/1/2019,12/31/9999,Allowed,13.21,0,0
97158,U1,,1/1/2019,12/31/9999,Allowed,25.34,0,0
97158,U2,,1/1/2019,12/31/9999,Allowed,17,0,0
97158,U3,,1/1/2019,12/31/9999,Allowed,13.21,0,0
0373T,U1,,1/1/2019,12/31/9999,Allowed,58.21,0,0
0373T,U2,,1/1/2019,12/31/9999,Allowed,38.97,0,0
0373T,U3,,1/1/2019,12/31/9999,Allowed,30.01,0,0
0373T,U4,,1/1/2019,12/31/9999,Allowed,20.3,0,0
0373T,U5,,1/1/2019,12/31/9999,Allowed,15.13,0,0