101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN …

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101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 318.00: RATES FOR RADIOLOGY SERVICES

1

Section

318.01: General Provisions

318.02: General Definitions 318.03: General Rate Provisions

318.04: Maximum Allowable Fees – Radiology Services

318.05: Severability

318.01: General Provisions

(1) Scope, Purpose, and Effective Date. 101 CMR 318.00 governs the payment rates used by all

governmental units for radiology care and services provided to publicly aided patients. Rates for

services provided to individuals covered by M.G.L. c. 152 (the Workers’ Compensation Act) are

not set forth in 101 CMR 318.00, but are at 114.3 CMR 40.00: Rates for Services Under M.G.L. c. 152, Worker’s Compensation Act.

(2) Applicable Dates of Service. Rates contained in 101 CMR 318.00 apply for dates of service on or after August 1, 2021, except as otherwise noted.

(3) Coverage. (a) Payment rates in 101 CMR 318.00 are used to pay for radiology services rendered to

patients in a private medical office, licensed clinic, hospital, or other inpatient or outpatient

facility or department, independent diagnostic testing facility, patient’s residence, or other

appropriate setting by an individual eligible provider, when an eligible provider bills for the medical services rendered and no other payment method applies.

(b) The rates of payment under 101 CMR 318.00 are full compensation for patient care

rendered to publicly aided patients as well as for any related administrative or supervisory duties in connection with patient care. The rates of payment also reimburse all overhead

expenses associated with the service provided, without regard to where the care is rendered.

(4) Disclaimer of Authorization of Services. 101 CMR 318.00 is not authorization for or approval of the procedures for which rates are determined pursuant to 101 CMR 318.00.

Governmental units that purchase care are responsible for the definition, authorization, coverage

policies, and approval of care and services provided to publicly aided patients.

(5) Coding Updates and Corrections. EOHHS may publish procedure code updates and

corrections in the form of an administrative bulletin. Updates may reference coding systems including but not limited to the American Medical Association’s Current Procedural

Terminology (CPT).

(a) The publication of such updates and corrections will list 1. codes for which the code numbers change, with the corresponding cross references

between the new codes and the codes being replaced. Rates for such updated codes are

set at the rate of the code that is being replaced; 2. deleted codes for which there are no corresponding new codes; and

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3. codes for entirely new services that require pricing. EOHHS will list these codes and

apply individual consideration (I.C.) reimbursement for these codes until appropriate rates can be developed.

(b) For entirely new codes that require new pricing and have Medicare-assigned relative

value units (RVUs) (or, for applicable services, Medicare rates), EOHHS may list these codes

and price them according to the appropriate rate methodology used in setting physician rates.

When Medicare RVUs (or, for applicable services, Medicare rates) are not available, EOHHS

may apply individual consideration in reimbursing for these new codes until appropriate rates

can be developed.

(6) Administrative Bulletins. EOHHS may issue administrative bulletins to add, delete, or

otherwise update codes or modifiers, and to clarify its policy on and understanding of substantive

provisions of 101 CMR 318.00. EOHHS may also issue administrative bulletins to clarify to

which duly licensed or certified health care professionals or students the rate methods in this regulation apply.

318.02: General Definitions

Meaning of Terms. The five-digit procedure codes and two-digit modifiers included in 101 CMR

318.00, and their corresponding descriptions, utilize the Healthcare Common Procedure Code

System (HCPCS) for Level I and Level II coding. Level I CPT-4 codes are obtained from the Physicians’ 2020 Current Procedural Terminology (CPT), copyright 2019, by the American

Medical Association (AMA), unless otherwise specified. Level II codes are obtained from the

2020 HCPCS, maintained jointly by the Centers for Medicare & Medicaid Services (CMS), the Blue Cross and Blue Shield Association, and the Health Insurance Association of America.

HCPCS is a listing of descriptive terms and identifying codes and modifiers for reporting medical

services and procedures performed by physicians and other health care professionals, as well as associated nonphysician services. No fee schedules, basic unit value, relative value guides,

conversion factors, or scales are included in any part of the Physicians’ Current Procedure

Terminology. For code descriptions, see the radiology services code spreadsheet at

www.mass.gov/regulations/101-CMR-31800-radiology.

In addition, terms used in 101 CMR 318.00 have the meanings set forth in 101 CMR 318.02.

Eligible Provider. The rates established in these regulations apply in accordance with 101 CMR

318.01 to the following types of providers who meet conditions of participation of the

governmental unit purchasing such services, and to the extent specified by such governmental unit. Eligible providers must provide such services in accordance with generally accepted

professional standards and in accordance with state licensing requirements and certification by

national credentialing bodies as required by law.

A licensed physician (other than an intern, resident, fellow, or house officer), licensed podiatrist, licensed dentist, licensed chiropractor, and licensed optometrist.

A provider of therapeutic and diagnostic radiology services. Such radiology services may be

rendered by eligible providers such as, but not limited to, independent diagnostic testing facilities (IDTFs). These eligible providers must be independent of a hospital or a physician’s office.

http://www.mass.gov/regulations/101-CMR-31800-radiology

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A provider of radiation oncology services. Radiation oncology services may be rendered by

eligible providers such as, but not limited to, independent radiation oncology centers. These eligible providers must be independent of a hospital or a physician’s office.

A clinic licensed by the Massachusetts Department of Public Health in accordance with 105

CMR 140.000: Licensure of Clinics to provide radiology services. A freestanding birth center facility that is not operating under a hospital’s license, and is

licensed as a birth center by the Massachusetts Department of Public Health pursuant to 105

CMR 142.000: The Operation and Maintenance of Birth Centers.

An advanced practice registered nurse who is authorized by the Board of Registration in Nursing to practice as a certified nurse practitioner, certified nurse midwife, clinical nurse

specialist, psychiatric clinical nurse specialist, or a certified registered nurse anesthetist (CRNA).

A licensed physician assistant who is authorized by the Board of Registration for Physician Assistants to practice as a physician assistant.

EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A.

Governmental Unit. The Commonwealth, any department, agency, board, or commission of the

Commonwealth and any political subdivision of the Commonwealth.

Individual Consideration (I.C.). Radiology services that are authorized but not listed in 101 CMR

318.00, radiology services performed in unusual circumstances, and services designated “I.C.”

are individually considered items. The governmental unit or purchaser analyzes the eligible provider’s report of services rendered and charges submitted under the appropriate unlisted

services or procedures category. The governmental unit or purchaser determines appropriate

payment for procedures designated I.C. in accordance with the following standards and criteria:

(a) the amount of time required to perform the service; (b) the degree of skill required to perform the service;

(c) the severity or complexity of the patient’s disease, disorder, or disability;

(d) any applicable relative value studies; (e) any complications or other circumstances that may be deemed relevant;

(f) the policies, procedures, and practices of other third party insurers;

(g) the payment rate for prescribed drugs as set forth in 101 CMR 331.00: Prescribed Drugs; and

(h) a copy of the current invoice from the supplier.

Modifiers. Listed services and procedures may be modified under certain circumstances. When applicable, the modifying circumstances should be identified by the addition of the appropriate

two-digit number.

Publicly Aided Individual (or Publicly Aided Patient). A person who receives health care and

services for which a governmental unit is in whole or in part liable under a statutory program of

public assistance.

Radiology Services. Radiology services including diagnostic ultrasound, radiation oncology, and

nuclear medicine provided for the assessment and/or treatment of a medical condition, injury, or

illness.

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Separate Procedure. Some of the listed procedures are commonly carried out as an integral part

of a total service, and as such do not warrant a separate identification. When, however, such a procedure is performed independently of, and is not immediately related to, other services, it may

be listed as a separate procedure in the procedure description. Thus, when a procedure that is

ordinarily a component of a larger procedure is performed alone for a specific purpose, it may be considered to be a separate procedure.

Supervision and Interpretation Only. When a procedure is performed by two eligible physicians,

the radiologic portion of the procedure is designated as "radiological supervision and interpretation." When an eligible physician performs both the procedure and the imaging

supervision and interpretation, a combination of procedure codes outside the 70000 series and

imaging supervision and interpretation codes are to be used. The radiological supervision and interpretation codes are not applicable to the Radiology Oncology subsection.

Unlisted Procedure or Service. A service or procedure that may be provided that is covered but not listed in 101 CMR 318.04. When reporting such a service, the appropriate "Unlisted

Procedure" code may be used to indicate the service.

318.03: General Rate Provisions

(1) Rate Determination. Rates of payment for services for which 101 CMR 318.00 applies are

the lowest of (a) the eligible provider's usual fee to patients other than publicly aided individuals;

(b) the eligible provider's actual charge submitted; or

(c) the schedule of allowable fees set forth in 101 CMR 318.04(3), taking into account

appropriate modifiers and any other applicable rate provision(s) in accordance with 101 CMR 318.03.

(2) Supplemental Payment (a) Eligibility. An eligible provider who is a physician, certified nurse practitioner, physician

assistant, or CRNA is eligible for a supplemental payment for services to publicly aided

individuals eligible under Titles XIX and XXI of the Social Security Act if the following conditions are met:

1. the eligible provider is employed by a nonprofit group practice that was established in

accordance with St.1997, c.163 and is affiliated with a Commonwealth-owned medical

school; 2. such nonprofit group practice must have been established on or before January 1, 2000,

in order to support the purposes of a teaching hospital affiliated with and appurtenant to a

Commonwealth-owned medical school; and 3. the services are provided at a teaching hospital affiliated with and appurtenant to a

Commonwealth-owned medical school.

(b) Payment Method. This supplemental payment may not exceed the difference between 1. payments to the eligible provider made pursuant to the rates applicable under 101

CMR 316.03(1), 101 CMR 317.03(1), and 101 CMR 318.03(1); and

2. the federal upper payment established by the Centers for Medicare & Medicaid

Services.

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(3) The sum of the professional and technical components of an individual procedure will not be

greater than the allowable global fee set forth in 101 CMR 318.04(3).

(4) Allowable Fee for Certain Eligible Providers. Payment for services provided by eligible

providers who are certified nurse practitioners, certified nurse midwives, psychiatric clinical

nurse specialists, clinical nurse specialists, and physician assistants as specified in 101 CMR

318.02, is 85% of the fees contained in 101 CMR 318.04.

(5) CPT Category III Codes. All radiology-related CPT category III codes are included as a part

of this regulation and have an assigned fee of I.C.

318.04: Maximum Allowable Fees – Radiology Services

(1) Unless otherwise specified, guidelines, notes, and definitions provided in the 2020 CPT

Coding Handbook are applicable to the use of the procedure codes and modifiers listed below, as

well as their corresponding descriptions. For code descriptions, see the radiology services code

spreadsheet at www.mass.gov/regulations/101-CMR-31800-radiology.

(2) Modifiers.

(a) 26: Professional Component. The component of a service or procedure representing the physician’s or other qualified health care professional’s work interpreting or performing the

service or procedure. (When the physician or other qualified health care professional component is reported separately, the addition of modifier 26 to the procedure code will allow payment of the professional component allowable fee (PC Fee) contained in 101 CMR

318.04(3), adjusted by 101 CMR 318.03 as applicable.)

(b) 51: Multiple Procedures. Most radiology services do not require modifier 51. Modifier 51

applies only to nuclear medicine procedure codes 78306, 78320, 78802, 78803, 78806, and 78807 and should be used only when a whole body bone, tumor, or infection study is

performed on the same day prior to a SPECT bone, tumor, or infection study, respectively.

Under these circumstances, the modifier must be used to report multiple procedures performed at the same session. The service code for the major procedure or service must be

reported without a modifier. The secondary, additional, or lesser procedure(s) must be

identified by adding modifier 51 to the end of the service code for the secondary

procedure(s). (The addition of modifier 51 to the second and subsequent procedure codes allows payment of 50% of the allowable fee contained in 101 CMR 318.04(3), adjusted by

101 CMR 318.03 as applicable, to the eligible provider. Note: This modifier should not be

used with designated “add-on” codes or with codes in which the narrative begins with “each additional.”)

(c) 52: Reduced Services. Under certain circumstances, a service or procedure is partially

reduced or eliminated at the physician's or other qualified health care professional’s election. Under these circumstances, the service provided can be identified by its usual procedure

number and addition of modifier 52, signifying that the service is reduced. This provides a

means of reporting reduced services without disturbing the identification of the basic service.

(d) 59: Distinct Procedural Service. To identify a procedure distinct or independent from other services performed on the same day, add modifier 59 to the end of the appropriate

service code. Modifier 59 is used to identify services/procedures that are not normally

reported together, but are appropriate under certain circumstances, for example, different site


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or organ system. However, when another already established modifier is appropriate, it

should be used rather than modifier 59. (e) PA: Surgical or other invasive procedure performed on the wrong body part. This

modifier is applied to report Provider Preventable Conditions in accordance with 42 CFR

447.26 and results in nonpayment for services. (f) PB: Surgical or other invasive procedure performed on the wrong patient. This modifier

is applied to report Provider Preventable Conditions in accordance with 42 CFR 447.26 and

results in nonpayment for services.

(g) PC: Wrong surgical or other invasive procedure performed on a patient. This modifier is applied to report Provider Preventable Conditions in accordance with 42 CFR 447.26 and

results in nonpayment for services.

(h) SA: Nurse Practitioner rendering service in collaboration with a physician. This modifier is to be applied to service codes billed by a physician that were performed by a certified nurse

practitioner employed by the physician (the physician employer must be practicing as an

individual and not practicing as a professional corporation or as a member of a group practice). A certified nurse practitioner billing under his/her own individual provider number,

or a group practice, should not use this modifier.

(i) TC: Technical component. The component of a service or procedure representing the cost

of rent, equipment, utilities, supplies, administrative and technical salaries and benefits, and other overhead expenses of the service or procedures, excluding the physician’s or other

qualified health care professional’s professional component. (When the technical component

is reported separately, the addition of modifier TC to the procedure code will allow payment of the technical component allowable fee (TC Fee) contained in 101 CMR 318.04(3),

adjusted by 101 CMR 318.03 as applicable.)

(j) XE: Separate encounter. A service that is distinct because it occurred during a separate

encounter.

(k) XS: Separate structure. A service that is distinct because it was performed on a separate

organ/structure. (l) XP: Separate practitioner. A service that is distinct because it was performed by a

different practitioner.

(m) XU: Unusual non-overlapping service. The use of a service that is distinct because it

does not overlap usual components of the main service.

(3) Fee Schedule

(a) NFAC – “Nonfacility.” These amounts apply when the service is performed in a nonfacility setting.

(b) FAC – “Facility.” These amounts, also known as the Facility Setting Fee, apply when

the service is performed in a facility setting. (c) Global Fee. These amounts apply when no site of service differential rate is specified.

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Code NFAC FAC Global PC TC

Description (see radiology

services code spreadsheet at

www.mass.gov/regulations/101-

CMR-31800-radiology)

70010 - - $46.52 - -

70015 - - $130.09 $45.79 $84.30

70030 - - $24.71 $6.49 $18.21

70100 - - $29.32 $7.05 $22.27

70110 - - $33.79 $9.78 $24.01

70120 - - $29.32 $7.05 $22.27

70130 - - $47.72 $13.28 $34.45

70134 - - $45.16 $13.61 $31.55

70140 - - $24.95 $7.89 $17.06

70150 - - $36.66 $10.33 $26.33

70160 - - $29.06 $6.78 $22.27

70170 - - - $11.39 $187.19

70190 - - $30.70 $8.71 $21.98

70200 - - $37.19 $10.86 $26.33

70210 - - $24.71 $6.78 $17.92

70220 - - $29.22 $8.69 $20.53

70240 - - $26.69 $7.60 $19.08

70250 - - $28.45 $7.92 $20.53

70260 - - $35.16 $11.15 $24.01

70300 - - $10.97 $4.35 $6.62

70310 - - $31.40 $5.94 $25.46

70320 - - $44.58 $8.98 $35.60

70328 - - $26.71 $7.05 $19.66

70330 - - $41.35 $9.51 $31.84

70332 - - $64.87 $20.86 $44.01

70336 - - $298.41 $56.87 $241.54

70350 - - $13.69 $7.07 $6.62

70355 - - $15.07 $8.16 $6.91

70360 - - $24.39 $7.05 $17.35

70370 - - $71.29 $11.34 $59.95

70371 - - $85.44 $32.74 $52.70



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70380 - - $28.77 $6.49 $22.27

70390 - - $90.52 $14.63 $75.89

70450 - - $91.84 $32.76 $59.08

70460 - - $129.99 $43.37 $86.62

70470 - - $152.50 $48.78 $103.72

70480 - - $139.14 $49.05 $90.09

70481 - - $179.26 $43.37 $135.89

70482 - - $194.77 $48.49 $146.28

70486 - - $111.26 $33.05 $78.21

70487 - - $133.18 $43.37 $89.80

70488 - - $162.64 $48.78 $113.86

70490 - - $130.74 $49.34 $81.40

70491 - - $161.50 $53.15 $108.35

70492 - - $195.27 $62.57 $132.70

70496 - - $213.45 $67.18 $146.28

70498 - - $213.45 $67.18 $146.28

70540 - - $277.15 $51.48 $225.67

70542 - - $431.34 $62.57 $368.77

70543 - - $471.81 $82.14 $389.67

70544 - - $295.37 $46.06 $249.31

70545 - - $317.29 $46.06 $271.23

70546 - - $488.62 $57.16 $431.46

70547 - - $296.18 $46.35 $249.83

70548 - - $350.24 $57.69 $292.55

70549 - - $501.87 $69.37 $432.50

70551 - - $265.46 $57.16 $208.30

70552 - - $331.04 $68.55 $262.49

70553 - - $465.47 $88.08 $377.39

70554 - - $370.32 $81.07 $289.25

70555 - - - $96.74 -

70557 - - - $123.41 $386.60



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70558 - - - $132.71 $146.32

70559 - - - $126.37 $146.32

71045 - - $20.34 $7.05 $13.29

71046 - - $26.03 $8.40 $17.63

71047 - - $32.87 $10.60 $22.27

71048 - - $35.67 $12.53 $23.14

71100 - - $28.35 $8.69 $19.66

71101 - - $32.58 $10.31 $22.27

71110 - - $34.27 $11.42 $22.85

71111 - - $40.86 $12.50 $28.36

71120 - - $26.08 $7.87 $18.21

71130 - - $31.83 $8.69 $23.14

71250 - - $125.86 $44.46 $81.40

71260 - - $156.63 $47.99 $108.64

71270 - - $185.56 $52.86 $132.70

71271 - - $209.27 $41.23 $168.04

71275 - - $216.18 $69.90 $146.28

71550 - - $333.21 $56.34 $276.87

71551 - - $621.66 $66.36 $555.30

71552 - - $538.57 $86.21 $452.36

71555 - - $370.10 $68.77 $301.33

72020 - - $19.23 $6.23 $13.00

72040 - - $30.38 $8.69 $21.69

72050 - - $40.40 $10.60 $29.81

72052 - - $47.58 $11.68 $35.89

72070 - - $25.21 $7.87 $17.35

72072 - - $30.65 $8.95 $21.69

72074 - - $34.37 $9.49 $24.88

72080 - - $27.22 $8.42 $18.79

72081 - - $33.18 $10.33 $22.85

72082 - - $54.17 $12.48 $41.69



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72083 - - $63.06 $14.12 $48.94

72084 - - $74.80 $16.00 $58.79

72100 - - $30.38 $8.69 $21.69

72110 - - $38.69 $10.04 $28.65

72114 - - $47.58 $11.68 $35.89

72120 - - $31.54 $8.69 $22.85

72125 - - $124.22 $38.48 $85.75

72126 - - $156.10 $46.88 $109.22

72127 - - $184.38 $48.78 $135.60

72128 - - $124.22 $38.48 $85.75

72129 - - $157.26 $46.88 $110.38

72130 - - $184.67 $48.78 $135.89

72131 - - $123.64 $38.48 $85.17

72132 - - $156.39 $46.88 $109.51

72133 - - $183.51 $48.49 $135.02

72141 - - $263.11 $57.16 $205.95

72142 - - $436.30 $68.84 $367.46

72146 - - $263.24 $57.16 $206.08

72147 - - $435.23 $68.55 $366.68

72148 - - $263.11 $57.16 $205.95

72149 - - $434.44 $68.55 $365.89

72156 - - $466.25 $88.08 $378.17

72157 - - $466.51 $88.08 $378.43

72158 - - $465.86 $88.08 $377.78

72159 - - $379.29 $69.37 $309.92

72170 - - $22.68 $6.78 $15.90

72190 - - $32.34 $9.78 $22.56

72191 - - $215.05 $68.77 $146.28

72192 - - $115.60 $41.73 $73.86

72193 - - $190.78 $44.46 $146.32

72194 - - $193.15 $46.88 $146.28



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72195 - - $296.77 $56.34 $240.43

72196 - - $442.99 $66.65 $376.34

72197 - - $480.76 $84.04 $396.72

72198 - - $371.26 $68.21 $303.05

72200 - - $25.58 $6.78 $18.79

72202 - - $30.36 $8.95 $21.40

72220 - - $25.00 $6.78 $18.21

72240 - - $88.50 $35.22 $53.28

72255 - - $89.82 $36.53 $53.28

72265 - - $81.74 $31.36 $50.39

72270 - - $112.35 $51.82 $60.53

72275 - - $104.81 $30.37 $74.44

72285 - - $96.83 $45.57 $51.26

72295 - - $85.22 $32.81 $52.42

73000 - - $25.02 $6.52 $18.50

73010 - - $22.10 $7.07 $15.03

73020 - - $16.93 $5.96 $10.97

73030 - - $26.42 $7.34 $19.08

73040 - - $96.75 $21.15 $75.60

73050 - - $24.97 $7.34 $17.63

73060 - - $25.02 $6.52 $18.50

73070 - - $22.70 $6.52 $16.19

73080 - - $24.71 $6.78 $17.92

73085 - - $90.57 $22.51 $68.07

73090 - - $22.99 $6.52 $16.48

73092 - - $24.15 $6.23 $17.92

73100 - - $26.18 $6.52 $19.66

73110 - - $31.08 $6.78 $24.30

73115 - - $101.68 $21.73 $79.95

73120 - - $24.15 $6.52 $17.63

73130 - - $27.90 $6.78 $21.11



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73140 - - $28.57 $5.43 $23.14

73200 - - $128.57 $38.48 $90.09

73201 - - $178.32 $44.46 $133.86

73202 - - $193.15 $46.88 $146.28

73206 - - $215.05 $68.77 $146.28

73218 - - $312.99 $52.06 $260.93

73219 - - $461.80 $62.86 $398.94

73220 - - $507.37 $82.43 $424.94

73221 - - $265.83 $52.84 $212.99

73222 - - $591.26 $62.86 $528.40

73223 - - $496.52 $82.43 $414.09

73225 - - $380.30 $66.94 $313.36

73501 - - $25.26 $7.34 $17.92

73502 - - $36.18 $8.69 $27.49

73503 - - $44.75 $10.60 $34.16

73521 - - $31.83 $8.69 $23.14

73522 - - $41.51 $11.42 $30.10

73523 - - $47.26 $12.24 $35.02

73525 - - $98.98 $22.79 $76.18

73551 - - $23.28 $6.52 $16.77

73552 - - $27.58 $7.05 $20.53

73560 - - $26.76 $6.52 $20.24

73562 - - $31.35 $7.34 $24.01

73564 - - $35.02 $8.69 $26.33

73565 - - $31.11 $6.81 $24.30

73580 - - $109.70 $22.22 $87.49

73590 - - $24.44 $6.23 $18.21

73592 - - $24.15 $6.23 $17.92

73600 - - $25.31 $6.52 $18.79

73610 - - $27.90 $6.78 $21.11

73615 - - $103.03 $22.51 $80.53



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73620 - - $22.12 $5.94 $16.19

73630 - - $26.16 $6.49 $19.66

73650 - - $22.41 $6.23 $16.19

73660 - - $22.49 $5.14 $17.35

73700 - - $123.64 $38.48 $85.17

73701 - - $154.84 $44.46 $110.38

73702 - - $186.82 $46.59 $140.24

73706 - - $218.30 $72.03 $146.28

73718 - - $290.63 $51.77 $238.86

73719 - - $330.25 $62.57 $267.68

73720 - - $479.65 $82.14 $397.51

73721 - - $265.05 $52.06 $212.99

73722 - - $592.17 $62.86 $529.31

73723 - - $496.39 $82.43 $413.96

73725 - - $371.39 $69.03 $302.36

74018 - - $23.23 $7.05 $16.19

74019 - - $28.62 $8.95 $19.66

74021 - - $33.16 $10.31 $22.85

74022 - - $38.54 $12.21 $26.33

74150 - - $118.49 $45.79 $72.70

74160 - - $195.39 $49.07 $146.32

74170 - - $200.16 $53.88 $146.28

74174 - - $324.38 $83.95 $240.43

74175 - - $215.89 $69.61 $146.28

74176 - - $158.45 $66.91 $91.54

74177 - - $261.97 $70.19 $191.78

74178 - - $294.55 $76.97 $217.58

74181 - - $284.10 $56.34 $227.76

74182 - - $371.04 $66.65 $304.39

74183 - - $409.75 $84.04 $325.71

74185 - - $373.61 $68.50 $305.11



Final Adoption

July 23, 2021



14






74190 - - - $17.82 $386.60

74210 - - $75.47 $22.76 $52.70

74220 - - $76.89 $23.03 $53.86

74221 - - $86.79 $26.84 $59.95

74230 - - $104.06 $20.35 $83.72

74235 - - - $45.79 -

74240 - - $96.02 $31.14 $64.88

74246 - - $110.56 $34.66 $75.89

74248 - - $65.39 $26.84 $38.55

74250 - - $96.57 $31.41 $65.17

74251 - - $191.29 $44.97 $146.32

74261 - - $182.25 $92.16 $90.09

74262 - - $242.29 $95.97 $146.32

74263 - - $606.91 $88.19 $518.72

74270 - - $122.96 $39.83 $83.14

74280 - - $177.45 $48.23 $129.22

74283 - - $197.47 $79.85 $117.63

74290 - - $66.08 $12.21 $53.86

74300 - - - $13.81 -

74301 - - - $8.13 -

74328 - - - $27.42 -

74329 - - - $27.42 -

74330 - - - $35.24 -

74340 - - - $20.86 -

74355 - - - $29.50 -

74360 - - - $21.64 -

74363 - - - $33.55 -

74400 - - $103.00 $18.71 $84.30

74410 - - $104.74 $18.42 $86.33

74415 - - $122.71 $18.71 $104.01

74420 - - $58.87 $19.50 $39.37



Final Adoption

July 23, 2021



15






74425 - - $104.69 $19.24 $85.46

74430 - - $31.88 $12.21 $19.66

74440 - - $74.04 $14.09 $59.95

74445 - - - $42.28 $90.09

74450 - - - $12.48 $187.19

74455 - - $78.51 $12.48 $66.04

74470 - - - $20.28 $386.60

74485 - - $90.24 $30.87 $59.37

74710 - - $31.49 $13.28 $18.21

74712 - - $340.28 $114.94 $225.34

74713 - - $212.15 $71.28 $140.87

74740 - - $72.55 $14.63 $57.92

74742 - - - $23.58 -

74775 - - - $23.85 $187.19

75557 - - $296.43 $88.89 $207.54

75559 - - $457.20 $109.16 $348.04

75561 - - $409.25 $97.84 $311.41

75563 - - $553.55 $113.00 $440.55

75565 - - $50.73 $9.49 $41.24

75571 - - $83.90 $22.21 $61.69

75572 - - $198.43 $66.64 $131.78

75573 - - $243.53 $97.29 $146.23

75574 - - $237.07 $90.80 $146.28

75600 - - $162.15 $19.01 $143.13

75605 - - $103.12 $42.01 $61.11

75625 - - $109.22 $53.33 $55.89

75630 - - $133.60 $74.52 $59.08

75635 - - $236.98 $90.71 $146.28

75705 - - $198.52 $89.05 $109.47

75710 - - $128.86 $65.72 $63.14

75716 - - $137.40 $72.85 $64.54



Final Adoption

July 23, 2021



16






75726 - - $145.10 $75.00 $70.10

75731 - - $130.21 $43.93 $86.28

75733 - - $140.47 $49.02 $91.45

75736 - - $119.89 $41.43 $78.46

75741 - - $113.14 $48.26 $64.88

75743 - - $127.26 $61.51 $65.75

75746 - - $114.80 $42.43 $72.37

75756 - - $130.47 $42.74 $87.73

75774 - - $85.18 $37.11 $48.07

75801 - - - $33.17 $506.30

75803 - - - $45.01 $1,309.72

75805 - - - $31.41 $1,309.72

75807 - - - $42.65 $2,225.31

75809 - - $73.15 $18.13 $55.02

75810 - - - $37.71 $1,309.72

75820 - - $86.08 $26.41 $59.66

75822 - - $100.13 $39.60 $60.53

75825 - - $99.51 $42.16 $57.34

75827 - - $103.52 $42.41 $61.11

75831 - - $103.99 $41.43 $62.56

75833 - - $124.42 $55.24 $69.18

75840 - - $112.00 $43.93 $68.07

75842 - - $136.17 $57.72 $78.46

75860 - - $109.50 $42.88 $66.62

75870 - - $146.01 $48.67 $97.34

75872 - - $112.00 $43.93 $68.07

75880 - - $94.91 $26.84 $68.07

75885 - - $118.03 $52.00 $66.04

75887 - - $118.90 $52.58 $66.33

75889 - - $107.31 $41.28 $66.04

75891 - - $109.05 $42.15 $66.91



Final Adoption

July 23, 2021



17






75893 - - $92.60 $20.77 $71.83

75894 - - - $54.92 -

75898 - - - $68.93 $1,309.72

75901 - - $176.82 $18.08 $158.74

75902 - - $68.42 $14.56 $53.86

75956 - - - $261.22 -

75957 - - - $223.53 -

75958 - - - $148.26 -

75959 - - - $130.34 -

75970 - - - $30.49 -

75984 - - $78.83 $26.70 $52.13

75989 - - $96.09 $44.83 $51.26

76000 - - $33.28 $11.88 $21.40

76010 - - $22.94 $7.05 $15.90

76080 - - $46.90 $19.99 $26.91

76098 - - $34.17 $12.19 $21.98

76100 - - $78.01 $23.86 $54.15

76101 - - $78.27 $20.69 $57.59

76102 - - $114.28 $24.24 $90.05

76120 - - $87.58 $14.58 $72.99

76125 - - - $10.31 -

76140 - - I.C. - -

76145 - - $703.38 - -

76376 - - $18.26 $7.58 $10.68

76377 - - $56.63 $30.59 $26.04

76380 - - $113.94 $37.08 $76.86

76390 - - $422.96 $54.26 $368.70

76391 - - $256.61 $42.87 $213.74

76496 - - - - $64.01

76497 - - - - $64.01

76498 - - - - $76.86



Final Adoption

July 23, 2021



18






76499 - - I.C. - -

76506 - - $92.38 $24.60 $67.78

76510 - - $72.39 $37.07 $35.31

76511 - - $49.06 $27.95 $21.11

76512 - - $41.72 $24.38 $17.35

76513 - - $79.73 $27.90 $51.84

76514 - - $9.42 $6.28 $3.14

76516 - - $38.35 $17.81 $20.53

76519 - - $53.07 $24.13 $28.94

76529 - - $66.62 $25.51 $41.11

76536 - - $93.22 $21.68 $71.54

76604 - - $63.00 $22.18 $40.82

76641 - - $85.56 $27.93 $57.63

76642 - - $69.74 $26.02 $43.72

76700 - - $98.31 $31.41 $66.91

76705 - - $72.86 $22.47 $50.39

76706 - - $91.51 $21.12 $70.38

76770 - - $90.46 $28.19 $62.27

76775 - - $46.51 $22.21 $24.30

76776 - - $125.64 $29.50 $96.14

76800 - - $113.69 $44.75 $68.94

76801 - - $97.29 $38.21 $59.08

76802 - - $49.42 $31.74 $17.68

76805 - - $111.78 $38.21 $73.57

76810 - - $72.39 $37.95 $34.45

76811 - - $140.18 $72.74 $67.44

76812 - - $157.87 $68.11 $89.76

76813 - - $95.96 $45.28 $50.68

76814 - - $61.73 $38.01 $23.72

76815 - - $66.91 $24.93 $41.98

76816 - - $90.19 $32.56 $57.63



Final Adoption

July 23, 2021



19






76817 - - $76.23 $28.75 $47.49

76818 - - $93.71 $40.18 $53.53

76819 - - $68.94 $29.57 $39.37

76820 - - $36.90 $19.26 $17.63

76821 - - $72.05 $26.60 $45.46

76825 - - $219.05 $63.21 $155.84

76826 - - $130.48 $31.45 $99.03

76827 - - $58.44 $21.96 $36.47

76828 - - $41.10 $21.43 $19.66

76830 - - $98.70 $26.57 $72.12

76831 - - $95.44 $27.66 $67.78

76856 - - $87.68 $26.28 $61.40

76857 - - $38.34 $18.97 $19.37

76870 - - $84.04 $24.38 $59.66

76872 - - $115.84 $25.75 $90.09

76873 - - $139.68 $60.31 $79.37

76881 - - $61.79 $24.16 $37.63

76882 - - $45.33 $18.71 $26.62

76885 - - $92.49 $28.48 $64.01

76886 - - $84.38 $23.85 $60.53

76932 - - - $26.53 -

76936 - - $214.93 $74.45 $140.48

76937 - - $29.03 $11.06 $17.97

76940 - - - $78.97 -

76941 - - - $51.55 -

76942 - - $45.13 $24.31 $20.82

76945 - - - $25.51 -

76946 - - $25.35 $14.38 $10.97

76948 - - $60.53 $25.51 $35.02

76965 - - $72.96 $52.42 $20.53

76975 - - - $32.12 $187.19



Final Adoption

July 23, 2021



20






76977 - - $5.58 $2.15 $3.43

76978 - - $262.51 $61.99 $200.52

76979 - - $179.03 $33.00 $146.03

76981 - - $86.48 $22.76 $63.72

76982 - - $76.92 $22.76 $54.15

76983 - - $47.08 $19.26 $27.82

76998 - - - $48.28 -

76999 - - I.C. - -

77001 - - $77.43 $14.29 $63.14

77002 - - $86.89 $21.44 $65.46

77003 - - $80.95 $23.03 $57.92

77011 - - $187.00 $49.08 $137.92

77012 - - $119.34 $56.78 $62.56

77013 - - - $146.35 -

77014 - - $97.73 $34.88 $62.85

77021 - - $375.64 $56.04 $319.60

77022 - - - $166.16 -

77046 - - $267.96 $55.79 $212.17

77047 - - $273.28 $61.50 $211.78

77048 - - $361.54 $80.52 $281.02

77049 - - $367.98 $88.34 $279.64

77053 - - $45.35 $13.81 $31.55

77054 - - $58.76 $17.35 $41.40

77061 - - I.C. - -

77062 - - I.C. - -

77063 - - $43.32 $23.03 $20.29

77065 - - $107.30 $31.41 $75.89

77066 - - $135.24 $38.48 $96.76

77067 - - $148.95 $42.79 $106.16

77071 - - $42.11 - -

77072 - - $20.02 $7.31 $12.71



Final Adoption

July 23, 2021



21






77073 - - $35.17 $10.58 $24.59

77074 - - $50.38 $17.09 $33.29

77075 - - $76.15 $21.41 $54.73

77076 - - $82.15 $26.84 $55.31

77077 - - $36.44 $13.30 $23.14

77078 - - $73.49 $9.49 $64.01

77080 - - $31.59 $7.58 $24.01

77081 - - $25.79 $7.87 $17.92

77084 - - $362.09 $61.79 $300.30

77085 - - $42.65 $11.39 $31.26

77086 - - $27.61 $6.49 $21.11

77261 - - $55.53 - -

77262 - - $84.06 - -

77263 - - $131.24 - -

77280 - - $225.62 $29.16 $196.46

77285 - - $378.24 $45.02 $333.22

77290 - - $403.90 $64.30 $339.60

77293 - - $364.67 $82.50 $282.16

77295 - - $388.49 $175.45 $213.05

77299 - - I.C. - -

77300 - - $52.83 $25.34 $27.49

77301 - - $1,543.26 $326.63 $1,216.63

77306 - - $118.85 $57.49 $61.35

77307 - - $229.82 $118.75 $111.07

77316 - - $174.94 $57.49 $117.45

77317 - - $229.40 $75.43 $153.97

77318 - - $327.36 $118.46 $208.90

77321 - - $75.07 $39.47 $35.60

77331 - - $51.01 $35.70 $15.32

77332 - - $37.60 $18.51 $19.08

77333 - - $96.81 $30.77 $66.04



Final Adoption

July 23, 2021



22






77334 - - $101.54 $47.38 $54.15

77336 - - $64.94 - -

77338 - - $387.82 $175.45 $212.38

77370 - - $101.24 - -

77371 - - I.C. - -

77372 - - $858.11 - -

77373 - - $987.48 - -

77385 - - I.C. - -

77386 - - I.C. - -

77387 - - I.C. - -

77399 - - I.C. - -

77401 - - $19.95 - -

77402 - - I.C. - -

77407 - - I.C. - -

77412 - - I.C. - -

77417 - - $9.23 - -

77423 - - I.C. - -

77424 - - I.C. - -

77425 - - I.C. - -

77427 - - $148.27 - -

77431 - - $82.50 - -

77432 - - $330.47 - -

77435 - - $499.16 - -

77469 - - $247.74 - -

77470 - - $104.41 $83.59 $20.82

77499 - - I.C. - -

77520 - - I.C. - -

77522 - - I.C. - -

77523 - - I.C. - -

77525 - - I.C. - -

77600 - - $378.00 $55.35 $322.65



Final Adoption

July 23, 2021



23






77605 - - $689.46 $79.30 $610.17

77610 - - $555.43 $53.66 $501.77

77615 - - $869.35 $75.70 $793.65

77620 - - $496.21 $65.45 $430.76

77750 - - $302.61 $204.29 $98.32

77761 - - $321.26 $157.49 $163.78

77762 - - $423.90 $236.15 $187.74

77763 - - $597.05 $354.66 $242.39

77767 - - $193.48 $43.28 $150.20

77768 - - $290.54 $57.49 $233.05

77770 - - $270.26 $80.06 $190.20

77771 - - $481.53 $155.29 $326.24

77772 - - $726.12 $219.49 $506.63

77778 - - $688.25 $358.14 $330.12

77789 - - $102.10 $47.41 $54.69

77790 - - $12.42 - -

77799 - - I.C. - -

78012 - - $66.88 $7.31 $59.57

78013 - - $158.03 $13.83 $144.20

78014 - - $197.28 $18.68 $178.60

78015 - - $184.36 $25.46 $158.89

78016 - - $231.90 $26.06 $205.85

78018 - - $257.22 $31.66 $225.56

78020 - - $67.04 $21.33 $45.70

78070 - - $243.46 $29.78 $213.67

78071 - - $289.92 $44.94 $244.98

78072 - - $365.41 $58.99 $306.42

78075 - - $369.35 $28.48 $340.87

78099 - - I.C. - -

78102 - - $139.57 $20.30 $119.28

78103 - - $177.54 $26.76 $150.78



Final Adoption

July 23, 2021



24






78104 - - $204.62 $29.78 $174.84

78110 - - $57.03 $6.15 $50.88

78111 - - $60.43 $7.24 $53.19

78120 - - $58.38 $7.51 $50.88

78121 - - $63.67 $10.47 $53.19

78122 - - $78.42 $16.24 $62.18

78130 - - $102.28 $19.62 $82.67

78140 - - $90.69 $19.62 $71.07

78185 - - $140.19 $12.89 $127.30

78191 - - $102.28 $19.62 $82.67

78195 - - $290.79 $44.65 $246.13

78199 - - I.C. - -

78201 - - $156.85 $16.22 $140.63

78202 - - $168.86 $18.37 $150.49

78215 - - $160.50 $18.42 $142.08

78216 - - $105.23 $20.83 $84.41

78226 - - $269.69 $27.90 $241.79

78227 - - $364.52 $34.37 $330.14

78230 - - $143.30 $17.35 $125.94

78231 - - $85.98 $16.65 $69.33

78232 - - $84.37 $15.03 $69.33

78258 - - $177.28 $26.79 $150.49

78261 - - $167.30 $22.03 $145.27

78262 - - $196.80 $25.73 $171.07

78264 - - $273.62 $29.81 $243.82

78265 - - $323.45 $37.08 $286.38

78266 - - $353.73 $37.79 $315.94

78267 - - I.C. - -

78268 - - I.C. - -

78278 - - $286.08 $37.63 $248.45

78282 - - - $12.35 $295.59



Final Adoption

July 23, 2021



25






78290 - - $271.57 $25.44 $246.13

78291 - - $208.97 $32.97 $175.99

78299 - - I.C. - -

78300 - - $188.34 $23.85 $164.49

78305 - - $228.02 $31.65 $196.37

78306 - - $247.28 $32.73 $214.54

78315 - - $284.27 $38.72 $245.55

78350 - - $25.74 $8.40 $17.35

78351 - - $11.93 - -

78399 - - I.C. - -

78414 - - - $16.82 -

78428 - - $151.43 $28.96 $122.47

78429 - - - $64.10 $11.55

78430 - - - $60.84 $11.55

78431 - - - $70.91 $1,807.37

78432 - - - $75.42 $2,208.79

78433 - - - $82.45 $2,208.79

78434 - - - $23.87 -

78445 - - $160.74 $19.44 $141.30

78451 - - $275.27 $51.46 $223.82

78452 - - $384.64 $60.68 $323.97

78453 - - $248.09 $38.19 $209.91

78454 - - $356.14 $51.22 $304.93

78456 - - $252.82 $37.12 $215.70

78457 - - $143.34 $28.70 $114.64

78458 - - $167.85 $34.95 $132.90

78459 - - - $58.14 $1,021.63

78466 - - $163.82 $27.15 $136.67

78468 - - $157.37 $29.78 $127.59

78469 - - $182.59 $34.71 $147.88

78472 - - $185.92 $37.08 $148.84



Final Adoption

July 23, 2021



26






78473 - - $235.34 $54.42 $180.92

78481 - - $143.02 $37.08 $105.94

78483 - - $195.73 $55.00 $140.72

78491 - - - $56.52 $1,158.72

78492 - - - $66.61 $1,158.72

78494 - - $184.15 $44.68 $139.48

78496 - - $34.29 $18.68 $15.61

78499 - - I.C. - -

78579 - - $153.92 $18.42 $135.51

78580 - - $194.13 $27.90 $166.23

78582 - - $273.43 $40.33 $233.09

78597 - - $164.30 $27.05 $137.25

78598 - - $249.71 $31.40 $218.31

78599 - - I.C. - -

78600 - - $151.06 $16.80 $134.26

78601 - - $178.13 $19.24 $158.89

78605 - - $163.88 $20.35 $143.53

78606 - - $271.96 $24.09 $247.87

78608 - - - $54.93 $1,158.72

78609 - - $58.56 $58.56 -

78610 - - $143.13 $11.39 $131.74

78630 - - $277.95 $25.73 $252.22

78635 - - $278.12 $23.58 $254.54

78645 - - $267.25 $21.12 $246.13

78650 - - $226.91 $19.62 $207.30

78660 - - $151.22 $20.35 $130.87

78699 - - I.C. - -

78700 - - $140.40 $16.77 $123.62

78701 - - $179.63 $18.42 $161.21

78707 - - $190.22 $35.97 $154.26

78708 - - $143.24 $45.21 $98.03



Final Adoption

July 23, 2021



27






78709 - - $300.41 $52.25 $248.16

78725 - - $88.74 $13.80 $74.93

78730 - - $62.48 $6.01 $56.47

78740 - - $178.27 $20.83 $157.44

78761 - - $173.54 $27.40 $146.14

78799 - - I.C. - -

78800 - - $212.55 $24.58 $187.97

78801 - - $233.39 $27.84 $205.56

78802 - - $256.50 $29.49 $227.01

78803 - - $319.17 $40.28 $278.89

78804 - - $543.81 $37.87 $505.94

78808 - - $32.51 - -

78811 - - - $57.88 $1,021.63

78812 - - - $71.13 $1,158.72

78813 - - - $71.34 $1,158.72

78814 - - - $81.43 $1,158.72

78815 - - - $91.28 $1,158.72

78816 - - - $92.00 $1,158.72

78830 - - $403.64 $55.20 $348.45

78831 - - $584.58 $67.34 $517.24

78832 - - $761.47 $78.44 $683.03

78835 - - $84.21 $17.31 $66.91

78999 - - I.C. - -

79005 - - $108.75 $67.68 $41.07

79101 - - $117.34 $75.69 $41.65

79200 - - $106.81 $63.43 $43.39

79300 - - - $50.81 -

79403 - - $150.20 $83.67 $66.53

79440 - - $95.80 $63.43 $32.37

79445 - - - $87.52 -

79999 - - I.C. - -



Final Adoption

July 23, 2021



28






0394T - - I.C. - -

0395T - - I.C. - -

A4641 - - I.C. - -

A9500 - - I.C. - -

A9502 - - I.C. - -

A9503 - - I.C. - -

A9505 - - I.C. - -

A9512 - - I.C. - -

A9537 - - I.C. - -

A9552 - - I.C. - -

A9586 - - I.C. - -

A9587 - - I.C. - -

A9588 - - I.C. - -

A9591 - - I.C. - -

G0279 - - $43.32 $23.03 $20.29

G0297 - - $191.42 $39.30 $152.12

G6001 - - $94.38 $24.86 $69.52

G6002 - - $60.40 $15.81 $44.59

G6003 - - $152.41 - -

G6004 - - $115.31 - -

G6005 - - $115.31 - -

G6006 - - $115.31 - -

G6007 - - $216.46 - -

G6008 - - $159.07 - -

G6009 - - $157.92 - -

G6010 - - $157.92 - -

G6011 - - $213.85 - -

G6012 - - $210.96 - -

G6013 - - $211.24 - -

G6014 - - $211.24 - -

G6015 - - $296.86 - -



Final Adoption

July 23, 2021



29






G6016 - - $295.88 - -

G6017 - - $60.40 $15.81 $44.59

R0075 - - I.C. - -

318.05: Severability

The provisions of 101 CMR 318.00 are hereby declared to be severable, and if any such provisions or the application of such provisions to any person or circumstances shall be held to be invalid or

unconstitutional, such invalidity shall not be construed to affect the validity or constitutionality of any

remaining provisions to eligible providers or circumstances other than those held invalid.

REGULATORY AUTHORITY

101 CMR 318.00: M.G.L. c. 118E.



Documents

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN …