Fee Schedule With Modifiers,V1,,,,,,,
Schedule Code,,MPGA ASD U7,,,,,,
Schedule Name,,GA MP Autism with U7 modifier,,,,,,
Table Name,,MPGA ASD U7,,,,,,
Table Type,,Base Table,,,,,,
Comment,,,,,,,,
Active,Version,Effective,Termination,Base Percent,Default Percent,,,
Y,CFG_FAC030220134242,1/1/2019,12/31/9999,1,0,,,
Procedure Code,Modifier,Description,Effective,Termination,Reimbursement Method,Allowed,Percent,Follow-up Days
97151,U1,,1/1/2019,12/31/9999,Allowed,74.09,0,0
97151,U2,,1/1/2019,12/31/9999,Allowed,46.76,0,0
97151,U3,,1/1/2019,12/31/9999,Allowed,36.68,0,0
97152,U1,,1/1/2019,12/31/9999,Allowed,74.09,0,0
97152,U2,,1/1/2019,12/31/9999,Allowed,46.76,0,0
97152,U3,,1/1/2019,12/31/9999,Allowed,36.68,0,0
97152,U4,,1/1/2019,12/31/9999,Allowed,24.36,0,0
97152,U5,,1/1/2019,12/31/9999,Allowed,18.15,0,0
0362T ,U1,,1/1/2019,12/31/9999,Allowed,74.09,0,0
0362T ,U2,,1/1/2019,12/31/9999,Allowed,46.76,0,0
0362T ,U3,,1/1/2019,12/31/9999,Allowed,36.68,0,0
0362T ,U4,,1/1/2019,12/31/9999,Allowed,24.36,0,0
0362T ,U5,,1/1/2019,12/31/9999,Allowed,18.15,0,0
97153,U1,,1/1/2019,12/31/9999,Allowed,74.09,0,0
97153,U2,,1/1/2019,12/31/9999,Allowed,46.76,0,0
97153,U3,,1/1/2019,12/31/9999,Allowed,36.68,0,0
97153,U4,,1/1/2019,12/31/9999,Allowed,24.36,0,0
97153,U5,,1/1/2019,12/31/9999,Allowed,18.15,0,0
97154,U1,,1/1/2019,12/31/9999,Allowed,74.09,0,0
97154,U2,,1/1/2019,12/31/9999,Allowed,46.76,0,0
97154,U3,,1/1/2019,12/31/9999,Allowed,36.68,0,0
97154,U4,,1/1/2019,12/31/9999,Allowed,24.36,0,0
97154,U5,,1/1/2019,12/31/9999,Allowed,18.15,0,0
97155,U1,,1/1/2019,12/31/9999,Allowed,74.09,0,0
97155,U2,,1/1/2019,12/31/9999,Allowed,46.76,0,0
97155,U3,,1/1/2019,12/31/9999,Allowed,36.68,0,0
97156,U1,,1/1/2019,12/31/9999,Allowed,26.72,0,0
97156,U2,,1/1/2019,12/31/9999,Allowed,20.78,0,0
97156,U3,,1/1/2019,12/31/9999,Allowed,16.51,0,0
97157,U1,,1/1/2019,12/31/9999,Allowed,30.97,0,0
97157,U2,,1/1/2019,12/31/9999,Allowed,20.78,0,0
97157,U3,,1/1/2019,12/31/9999,Allowed,16.51,0,0
97158,U1,,1/1/2019,12/31/9999,Allowed,30.97,0,0
97158,U2,,1/1/2019,12/31/9999,Allowed,20.78,0,0
97158,U3,,1/1/2019,12/31/9999,Allowed,16.51,0,0
0373T,U1,,1/1/2019,12/31/9999,Allowed,74.09,0,0
0373T,U2,,1/1/2019,12/31/9999,Allowed,46.76,0,0